Coding Corner: Make the most of revised E/M coding guidelines

December 01, 2013
Area(s) of Interest: Electronic Health Records Health Information Technology Payor Issues and Reimbursement Practice Management 

CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.

 Recent changes in how the Centers for Medicare & Medicaid Services (CMS) allows you to calculate evaluation and management (E/M) service levels are a benefit to providers, especially those who manage patients with multiple chronic conditions.

The background

E/M services may be provided at various levels of intensity, with more intensive services garnering higher reimbursement. E/M service levels (and the codes that describe them) are assigned according the elements of patient history, exam and medical decision-making documented in the provider’s encounter notes.

CMS allows you to choose between two sets of guidelines when translating provider documentation into E/M codes: The 1995 Documentation Guidelines for Evaluation and Management Services and the 1997 Documentation Guidelines for Evaluation and Management Services. The guidelines differ in how they define the history and exam portions of an E/M service (the guidelines are identical regarding medical decision-making).

The 1995 guidelines define the exam component such that specialist providers found it difficult to report higher-level E/M codes, even when services warranted doing so. The 1997 guidelines addressed this issue by providing bullet points for single organ system examinations, thereby allowing specialists to report higher level services for intensive, problem-specific exams. The 1997 exam requirements tend not to work as well for general practitioners, however.

The 1997 guidelines also differ in the history component, and allow “the status of three or more chronic conditions” to qualify as an “extended” history of present illness (HPI). Under the 1995 guidelines, providers must document four or more HPI “elements” (location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms) to attain an extended HPI.

Each set of guidelines has its advantages and disadvantages. For many providers, the ideal guideline would combine the 1995 exam requirements (which are more subjective, as compared to the 1997 exam requirements) with the 1997 history element (which are more flexible than the 1995 guidelines when defining HPI). Historically, however, such “mixing and matching” of the guidelines has not been allowed.

The big change

Effective September 10, 2013, CMS has revised its E/M Documentation Guidelines to allow an extended HPI, as defined by the 1997 guidelines, with the other elements of the 1995 guidelines. As a result, “the status of three or more chronic conditions” qualifies as an Extended HPI for either the 1997 or 1995 guidelines.

CMS announced the change as a “Question and Answer” on its website:

Q. Can a provider use both the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services to document their choice of evaluation and management HCPCS code?

A. For billing Medicare, a provider may choose either version of the documentation guidelines, not a combination of the two, to document a patient encounter. However, beginning for services performed on or after September 10, 2013, physicians may use the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 guidelines to document an evaluation and management service.

CMS will also update its Evaluation and Management Services Guide to reflect the new policy.

Ask your coding staff if they are aware of this change, and if they are measuring E/M services against the revised guidelines. Those physicians who manage patients with multiple chronic conditions, especially, may find that the new rules allow their coding and billing to better reflect the documented level of service provided, thereby legitimately boosting E/M levels and reimbursement levels. What’s more exciting is that if providers are already documenting their services well, they won’t have to change how they document to realize an advantage from these revised E/M guidelines. 


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