Cardiology Coding Alert


CMS Recommends Updating 1995 and 1997 E/M Documentation Guidelines

2018 Proposed MPFS advocates reviewing the history and exam components.

Via the 2018 proposed Medicare Physician Fee Schedule (MPFS), CMS recommends revising the 1995 and 1997 Evaluation and Management (E/M) Documentation Guidelines to "reduce clinical burden and improve documentation."

According to stakeholders, both sets of Guidelines are "administratively burdensome and outdated with respectto the practice of medicine." In the 2018 proposed MPFS, CMS agrees with stakeholders and maintains that the E/M Guidelines "may be an unnecessary burden" and they are "potentially outdated," especially in respect to the history and physical exam requirements.

Read on to see how this potential revision to the E/M Guidelines could impact how you code for E/M visits in your cardiology practice.

Dig Into Possible E/M Comment Areas

Take a look at the proposed public comment areas CMS introduced in the proposed MPFS:

Area #1: CMS is debating if they should eliminate history and exam documentation requirements for all E/M visits at all levels.

CMS proposes this alternative - making medical decision-making (MDM) and/or time the dominant factor in determining visit levels.

According to the proposed MPFS, MDM and time are the more significant factors in distinguishing visit levels.

"The need for extended histories and exams is being replaced by population-based screening and intervention, at least for some specialties," the proposed MPFS maintains.

As far as using MDM as the dominant factor to determining visit levels, Suzan Hauptman, MPM, CPC, CEMC, CEDC, AAPC Fellow, senior principal of ACE Med in Pittsburgh, offers the following example: The physician sees a diabetic for his six-month checkup. The physician must take both a robust history and a robust exam. Then, his MDM may look something like "I checked your A1C levels, and you are doing great. Keep up with it. Here is your script for your insulin. Here is a script for more test strips."

In this case, the decision-making may be quite limited, Hauptman says. With this proposal, the physician's level of care is called into question because the history and the exam he took does not count towards the level of service since it's just being based upon the decision-making.

If CMS decides to go this route, Hauptman recommends adding some of the history and exam elements into the MDM.

Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, AAPC Fellow, AHIMA-approved ICD-10 CM/PCS trainer, and president of Maggie Mac-Medical Practice Consulting in Clearwater, Florida, adds her thoughts about making MDM the dominant factor for determining service levels.

"I strongly believe there needs to be a history of present illness to support and to understand the level of medical decision-making," Mac says. "You cannot understand a medical decision-making level unless you've got history behind it."

In the documentation, the physician needs to mention all of the relevant information to set the scene and to give a background about what's going on with the patient, Mac says.

"It's like going to a show on Broadway; you probably want to know what kind of show it is before you buy tickets," Mac adds. "You watch the show, you have this wonderful finale, and you either go away happy or not."

In this case, a patient will have a finale based on what his symptoms are and how long he experiences them, according to Mac. You must gather this information.

Area #2: CMS is contemplating if they should leave it up to individual physicians' discretion to what extent they should perform and document the history and physical exam.

Hauptman doesn't agree with this method because she says physicians will not know what CMS is looking for. There should be a basis for which to gauge the patient's condition with the type of documentation to support the service being rendered.

When CMS says, "We are going to take money back," there needs to be reasoning behind why they are taking money back, Hauptman adds.

Hauptman offers the following example: "I know a doctor, and he is one of the most unique physicians I've ever met. He has a unique patient base; he deals with high-risk hepatocellular carcinoma (HCC). He operates on patients who could be considerednon-operable. But in his notes, he always writes, 'Mr. Jones is here for a routine follow-up.' The word 'routine' means something very different for him than it means for other physicians. He said, 'I have patients come in on a very regimented schedule. I go through 15 items at this visit and 22 items at this next visit. Then we go through all these very specific elements. This is my routine protocol.' And I had to tell him there was nothing 'routine' about that."

So, if it's left up to the physician, some physicians may just bill one level of service all the time, no matter what, Hauptman says. Or some may bill all high levels because their patients are specialized. Or some may bill just low levels because they don't know what CMS wants.

The current sets of guidelines do need to be revised, butnot in such a drastic way, Hauptman continues. They can be changed to reflect the changes in technology, but keeping a core structure will help everyone in the long run.

Mac agrees that as far as the history, CMS should not leave it up to the physician's discretion.

The physician needs to do complete documentation of the HPI, Mac says. However, Mac does believe that CMS should leave it up to the physician's discretion whether or not he needs to document the ROS or the past family and social history.

Assigning points, perhaps, to the past, family and social history components, might help, Hauptman adds. A family history may truly not be necessary; however, a comprehensive social or past might. Physicians should be given the appropriate credit for the work that is being done to take care of a patient in the best way possible.

The exam should also be left to the physician's discretion, Mac says.

The physician may have seen the patient a week ago or maybe he hasn't seen him for a year. The physician may need to do a complete exam. Or the patient's symptoms may have worsened, and the physician needs to perform a re-exam.

"I think it's up to the physician's discretion based on the patient's clinical background and history or when the patient was seen last and what symptoms the patient presents with," Mac says.

Mac also voices her concerns about potential medical legal problems.

"Medical legal doesn't care what the physician billed," Mac says. "Did the patient have an exam for this problem, and the physician didn't write down the findings because it wasn't pertinent or it was negative? Therefore, the physician didn't do it, so the patient is going to sue because the physician should have performed and documented the exam element, and the physician may be charged with a missed diagnosis as a result of not performing a 'standard of care' examination based on the presenting symptoms."

So, leave it up to the physician's discretion with the caveat that you need to be concerned with medical legal as well as the level of service, Mac recommends.