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Overall, proposed documentation guidelines from the Baltimore-based Health Care Financing Administration (HCFA) will be easier to comply with than the current rules, reports Mason Smith, MD, FACEP, president and CEO of Lynx Medical Systems, a Bellevue-WA-based consulting firm specializing in coding and reimbursement for emergency medicine.
The total amount of documentation required is essentially unchanged, says Smith. "For example, a Level 5 service still requires documentation of approximately 35 elements."
The difference is there is less review of systems, and medical decision making has been simplified, he reports. Here are eight key changes in the proposed documentation guidelines:
1. The definition of the extended history of the present illness (HPI) has changed. The new guidelines define this as including four discreet elements of the history of the present illness. "In the original version, it was defined as at least one element in four of eight categories of the HPI," Smith notes. "What that means is that I can meet the requirements for an extended HPI with fewer than four categories included. That is actually a fairly common occurrence."
2. For a comprehensive history, only five organ systems are required to be reviewed, not 10. The organ systems can be considered covered by HPI questions, but an element cannot be counted twice, so elements count as review of systems or HPI, but not both, says Smith. Under current rules, you can count one element twice. "You now have more stringent requirements, because you needed four separate categories and 10 systems," he explains. "So you now can have a complete history of illness and a comprehensive review of systems, with a total of nine elements, as opposed to a minimum of 10 under the existing rules."
3. The number of physical exam elements has changed. Instead of using organ systems, the exam elements now include individual components of those systems. "So instead of using the neurology system, there is individual credit given for each element of the neurologic examination, including each of the cranial nerves, instead of at a system level," Smith explains.
A minimum of six data elements are required for an expanded examination. "Anything less than that falls into lowest category," he says. From seven through 11 elements is an expanded exam, from 12 through 17 elements is a detailed exam, and 18 or more is now a comprehensive exam.
A complete neurologic examination of cranial nerve counts as nine elements, but you have to record them individually, not as a system, he says. "It’s actually not too difficult, it just requires a more detailed approach to documentation. It does lend itself to structured records."
4. Medical decision making is reduced from three calculations to a single table. "The basic thrust of it remains the same, but there are some differences," says Smith. "Emer gency hospitalization is recognized as high-complexity medical decision making, but routine hospitalization is considered a moderate level. We expect that anyone admitted from the ED will be considered emergency hospitalization."
5. The number of prescription drug management levels was decreased. There will be only three levels now: low, moderate, and high," he says. "Currently there is a fourth level, called straightforward,’ which was combined with low."
6. Elements have been added to the history requirements. There was concern that HCFA’s guidelines might be adopted by other payers, whose covered members could include pediatric patients. Examina tion components were added to the examination to account for that possibility, says Peter Sawchuk, MD, JD, MBA, representative from the American College of Emergency Physicians to the American Medical Association advisory committee that developed the recommendations.
For example, measuring head circumference is very unusual in an adult visit, so this element was added for pediatric patients. "This element of the exam could be used to substantiate the level of exam," says Sawchuk. "HCFA is appropriately focused on adult examination, and if these guidelines are adopted by other payers with pediatric patients, and they didn’t address this issue, then ED physicians would have difficulty meeting the requirements for pediatric patients."
7. It will be more difficult for ED physicians to designate patients at high risk. The current guidelines are based on three areas: the diagnosis or management options based on the presenting problem, the data obtained and reviewed, and the patient’s risk.
"That risk is based upon a risk table that has been published," says Sawchuk. "Under the new guidelines, the first two will essentially no longer be there. So it will be structured almost entirely on the risk table."
This approach is problematic for the ED, he says. "For example, in the data obtained and reviewed, one of the designators of high risk would be evaluations of diagnostic results that takes 20 minutes or more," he explains. "This is problematic in the ED setting because there is a premium on doing things quickly. Since ED physicians address a number of patients within the same time frame, it makes it difficult."
There are items that ED physicians might not be able to utilize as indicators of risk, simply because of the way they practice medicine. "It limits the options for ED physicians to appropriately indicate medical decision making under the new proposal," Sawchuk says.
8. It will be easier to identify the level of history appropriately if the patient is unable to give an adequate history. Currently, appropriate reimbursement in this situation is possible only for patients of the highest severity, so ED physicians can identify a Level 5 service.
"Currently, it’s very difficult to obtain the required level of history for a patient who can’t give a history but is not of high severity," says Sawchuk. "But there are now ways of addressing that on the record, so it allows more leeway for submitting a less-than-required history."