New evaluation guidelines draw praise for minimizing counting’ methods

New system won’t be tested until 2002

At a June 22 "town hall" meeting at its Baltimore headquarters, the Health Care Financing Administration (HCFA) finally unveiled the latest version of its much-contested evaluation and management (E/M) documentation guidelines. The E/M protocols are used to document the level of service physicians provide individual Medicare patients.

Because it will be at least January 2002 before this latest E/M proposal is pilot-tested and vetted, practices are free to continue using the 1995/ 1997 guidelines for documentation purposes. Meanwhile, the June 1999 draft guidelines have been ditched permanently. The June 2000 guidelines, which are based on HCFA’s 1995/ 1997 documentation guidance, represent the agency’s latest attempt to clarify the requirements for the E/M’s history-taking component. They attempt to minimize — but not entirely eliminate — the often criticized "counting" method used for the E/M’s exam and medical decision making sections.

Compared to the consternation caused by the 1997 proposed protocol, the first-blush reaction to this edition of E/M changes is generally positive. The highest praise from physicians goes to HCFA’s decision to eliminate most of the so-called counting methodology.

As part of the June proposal, HCFA says it will develop specialty-specific vignettes for multisystem exams, single-system exams, and medical decision making that physicians can use as a guide for designing their own personal documentation to go with exam findings, assessments, and the plan of treatment parts of the E/M process.

HCFA is planing two pilot studies of the June 2000 guidelines before making them official."We want to make it as easy as possible for physicians to do their jobs and provide appropriate, quality care to their patients,’’ said HCFA administrator Nancy-Ann DeParle. "These simpler guidelines should make it easier for physicians to focus on patient care while ensuring that Medicare pays them appropriately for their services."

In 1995, HCFA and the American Medical Association issued the first set of documenta-tion guidelines. These were updated in 1997 in a response to requests from specialists wanting more detailed E/Ms that recognized the narrower focus of the clinical services they provide. However, many physicians rebelled against the 1997 rewrite, calling them too cumbersome and hard to understand. "Physicians helped develop these guidelines, and we want physicians to tell us whether the revisions being tested are, in fact, better for them in the real world of day-to-day clinical practice," DeParle said.

A shorter format

Last June’s version of the suggested E/M coding guidelines is similar to the earlier 1995/1997 proposals, except it tries to minimize the use of counting when it comes to exam and medical decision making.

The exam section is collapsed into three levels: brief, detailed, and comprehensive. A brief exam consists of one to two areas or organ systems; a detailed exam has three to eight areas, and a comprehensive one includes nine or more areas. Single-specialty exams will be determined by vignettes that are still being written.

Medical decision-making protocols also contain three levels: low, moderate, and high and will be based upon a series of future vignettes.

The history section contains clarifications relating to inclusion of medication lists and the review of stable chronic illnesses. Instead of the two to nine systems previously used for a detailed history of present illness, the review of systems section has been revised to include three to eight systems.

In another change, medical histories are only measured by the actual information obtained from the patient. No allowances, such as considering a history to be complete even if unable to obtain any data, will be granted.