Part B Insider (Multispecialty) Coding Alert

Published on Fri Sep 17, 2004 PDF

AMA will not replace E/M documentation guidelines with clinical examples

The 1995 and 1997 evaluation and management documentation guidelines are here for the long haul - and some doctors prefer it that way.

The American Medical Association's move to replace those guidelines with "clinical examples" wasn't just doomed because of poor performance in tests (although that didn't help). A shift in the "political environment" since the late 1990s also made a difference: Many doctors now view documentation guidelines as an objective way of documenting and as protection against audits, according to a summary of E/M discussions the AMA recently submitted to the Practicing Physicians Advisory Council.

"As long as we continue to look at the medical record as a metric for the value of the service provided, we're going to have a hard time simplifying the documentation guidelines," concluded William Rogers, director of the Physicians Regulatory Issues Team. 

According to the AMA, the CPT Editorial Panel is still actively considering changes to descriptors and guidelines for follow-up inpatient consultations, confirmatory consultations and nursing facility services. The Panel tabled a motion from the E/M coding task force to adopt broad "principles of medical record documentation" which are less specific than the 1995/1997 guidelines, but consistent with them. The Panel will discuss this issue with members of the CPT/HCPAC Advisory Committee in November.

But the Panel rejected a suggestion to revise the descriptors and guidelines for a number of E/M codes to clarify that you only need two out of three key components (history, medical decision making or physical exam) to document the service. Also, the Panel rejected a suggestion to replace the clinical examples in Appendix C of the CPT book with more detailed clinical examples for levels three and five for services with five levels, or level two for services with three levels.