As
Part B News readers know, CMS is considering making some much-needed revisions to the 1995 and 1997 E/M documentation guidelines (
see our coverage of the 2018 physician fee schedule).
So when CMS deputy director Marge Watchorn asked a roomful of coding veterans at this week’s AMA CPT Symposium in Chicago what they would change about the guidelines, she got an earful.
Here’s an unedited version of what the coders told her:
- [Address] the difference between expanded problem-focused and detailed exam in the 1995 guidelines (applause).
[Note: here are those definitions:
“Expanded Problem Focused -- a limited examination of the affected body area or organ system and other symptomatic or related organ system(s).
“Detailed -- an extended examination of the affected body area(s) and other symptomatic or related organ system(s).”]
- I’m wondering if we can move pieces of the history into decision-making.
- It’s all about medical decision-making (light applause). EHRs capture history and exam to the minutiae that it’s useless. Physicians need to document what they’re thinking – and that’s where medical decision-making supports their work.
- Expanding on the table of risk and including more specialties and differences in specialties.
- Medical decision-making is the key component; it is the driving force. Almost no payer pays attention to the history and physical. I would suggest that there are two components – the nature of the presenting problem – the presenting condition – comorbidities, signs, symptoms, medications, relevant histories – some focus on HPI that includes comorbidities – and complexity of medical decision-making. Clarity and focus on the nature of the present problem.
- I’d like to see in the MDM a way to differentiate between the patient who has two to three chronic conditions and the patient who has 8-10 conditions or comorbidities.
- For the table of risk, if you flip the table of risk to show high to low – I think that would be a good idea.
- With all the cutting and pasting … it really comes down to the nature of the presenting problem, which is going to drive MDM. (CMS drafted papers around 2000.) Auditors are tired of looking at 8 to 10 pages. Physicians are tired of looking through the pages too.
- Many EHRs today are taking the H&P and putting them at the top. The community is finding a way to get through all of that stuff. I’ve seen a level 5 highly complex new patient go to a level 1 because social history is missing. I’d like to reiterate the MDM – the Marshfield Clinic tool – kind of takes that subjectivity out if you do it correctly. Some of the MACs put it on their website, but there’s no continuity among the MACs.
- If you’re going to continue requiring some history, for patients who are unconscious … some methodology for credit for that section … with that section, the whole visit implodes.
- Our MAs are doing a lot more than RNs – a little more specificity about who can do what with E/M.
- I think it’s super important for CMS to understand that there could be critical difference between the MDM and medical necessity.
- MACs have different guidelines. There’s not a consistent way to report E/M in different regions.
- The MDM came out of the 95 and 97 guidelines. Our MAC uses the Marshfield tool. But I see more often than not that people who lack experience with pathology … My concern is that we not put MDM as the same definition as the same overarching criteria for medical necessity.
- Be cautious about the revaluation about the work component. When the 97 guidelines went in, there was not a lot of attention to the value of the work compared to the extra work required in the guidelines.
- As far as established patient E/M … two of three required … how do you justify lower MDM?
- In the wake of EHRs … in regard to 95 guidelines, if you do keep history, update your guidelines to reflect operations and processes for review and re-review of that data. Second comment is in regards to time. I refer to many specialists as talkers. My recommendation for time would be to expand that … because that seems to be for a lot of different specialties how they calculate E/M services.
- Can we perhaps add some elements that we can reference? How do we report and weigh chronic conditions?
- E/M is not unique to medical necessity … Simplifying the definition of the codes rather than focusing on elements would help capture the correct leveling and reduce gray areas. Get rid of the elements.
- As you take in all these comments … I plead with you, once you make changes, please make it that MACs can make no changes to this so that these guidelines are universal (applause).
- The first point is prescription management. It would be great if the guidelines really clarified Rx management. Is it that they document? Change? It is an ongoing area that’s confusing. The second issue is detailed exam. 95 guidelines … 2-7 on problem-focused … it would be better if a detailed exam ... was really fine tuned.
- Decision to obtain records from another and summarize that info. I would like to see what you expect in preventive visits – what type of documentation?
- Can CMS offer guidelines on how they look at copy and paste?
Do you have an idea about how the documentation guidelines could be improved? Join the conversation by commenting below!