Deciphering the new E/M guidelines

Experts provide guidelines on how they work

The new evaluation and management (E/M) rules published by the Health Care Financing Administration (HFCA) that go into effect Jan. 1 establish a new, higher level of documentation requirements needed to support the E/M services a physician claims he or she provided.

"This new system is more intellectual and rule-driven. And I expect it is also going to cause a lot of short-term frustration for many physicians," notes Catherine Fischer, a reimbursement policy expert with Marshfield (WI) Clinic and a member of Physician Payment Update’s editorial board.

With the new E/M standards, Medicare has defined in detail the two ways to document physical examinations: the General Multi-System Exam and the Single Organ System Exam. One major difference from the old rules is that any physician, regardless of specialty, may utilize either pathway.

Also included in the new requirements is a list of 14 different organ systems/body areas, along with a checklist of 59 total examination elements for the various systems, which the documentation guidelines call "bullets" (see chart on p. 6 and p. 13 for a list of the different body systems, areas, and bullets associated with the new multi-system E/M documentation guidelines).

For instance, for the neck area there are two exam elements or bullets: examination of neck and examination of thyroid.

Also new is a four-tier classification system for determining the intensity of the Multi-System exam based on the number of elements/bullets included and documented. These are:

— Problem Focused, which includes the performance and documentation of one to five exam elements/bullets in one or more organ system(s) or body area(s).

— Expanded Problem Focused, which includes performance and documentation of at least six exam elements/bullets in one or more organ system(s) or body area(s).

— Detailed exams, which include examination of at least six organ systems or body areas. For each system/area selected for examination, auditors will expect to see at least two elements/bullets performed and documented.

— Comprehensive exams, which must include at least nine organ systems/body areas. All of the exam elements/bullets for each system/body area must be performed and documented, unless there is specific reason and direction not to perform certain exam elements.

By contrast, the single organ system exams vary in the number of systems or body area categories (boxes) listed, the number of shaded boxes, and the number of bulleted items listed in each box on HCFA’s exam chart template used for single organ exams, says M. Ray Painter, MD, FACS, president of Denver-based Physician Reimbursement Systems.

The first two levels (problem focused and expanded) are identical to the General Multi-System exam. In the single organ system, the third level (detailed) does not require the examination of two organ systems, but does require documentation of at least 12 elements. In the comprehensive level, you must document everything in the "shaded boxes" and at least one element in each of the boxes that are unshaded, although you have to perform all elements identified by a bullet.

One result of this new system is that physicians will have to be more precise in how they document E/M services. This, in turn, is going to leave a more detailed paper trail for Medicare auditors to follow.

"This makes it even more important not to do something just to get a certain code, because it is going to be easier for auditors to notice this kind of behavior," stresses Fischer.

The new documentation guidelines:

— define the multi-system examinations with greater clinical specificity;

— change the documentation requirements for the general multi-system exam;

— define content and documentation requirements for 10 organ system exams;

— change the documentation requirements for the four levels of physical examinations.

Keep in mind, however, that an auditor will judge you by compliance with documentation requirements, Painter says. You must document the required number of bulleted elements of the examination according to the documentation requirements referenced earlier in this article.