Are changes coming to the E/M documentation guidelines?

Do you remember that CMS is talking about changing the documentation requirements for E/M services?  If it slipped your mind in the course of your busy work weeks, you can read my article about that here.

CMS E/M listening call

March 21, CMS held its E/M listening session and I joined in. First you might want to know what did CMS say?  Well, not much. They listened. They posed a series of questions and listened to the responses from people on the line.

They stated that they particularly wanted to hear from physicians and other practitioners. I think about 50 or 60% of the callers were practitioners.  The rest were consultants, compliance officers, coders and administrators. There was representation from some but not all specialties.

When are the E/M guidelines changing?

What will happen next and when? CMS stated that you could look to the proposed rule, which is released at the end of June for its next thoughts on changing the documentation guidelines for E/M services.

After the proposed rule, there is a comment period and the final rule is released at the end of October.  While it is possible that there will be changes in 2019, I think that is unlikely.  CMS said in the 2018 final rule that they thought it would be a multi-year process.

Here’s what participants said about the E/M guidelines:

Many callers said that the data entry for clinicians related to history and exam was repetitive, not useful, and burdensome. Some advocated for letting a staff member document the HPI.  Callers pointed out that because the history is readily available in the electronic health record, it shouldn’t need to be added into each note and be required for higher levels of service.

Different specialists had different opinions:

• An ophthalmologist suggested that history wasn’t important at all, only the exam.
• A pediatrics specialist and an endocrinologist both suggested that history was very important.
• In family practice, a physician said that the guidelines don’t recognize the importance of team-based care and team based documentation.
• There was some suggestion that the number of levels of services be decreased.
• A family physician advocated eliminating the requirements for new and established patients, and for allowing all members of the team to document.
• A pediatrician pointed out that Medicare rules have a large effect on Medicaid rules and it is important for CMS to consider pediatrics in the guidelines as well.
• An emergency physician said that for ED visits, history is important and that it is critical for the history and exam to paint a picture of the patient.

Medical decision-making

Everyone pointed to the importance of medical decision-making.

What did they suggest?

• One physician suggested that history, exam, and data be one component and medical decision-making the second.
• Someone suggested reducing the levels of medical decision-making to three levels, low, moderate, and high.
• Simplifying MDM was advocated.

My input regarding MDM:

• I said that comorbidities were important in selecting a level of service for the same presenting problem.
• I also pointed out that some specialists are treating only one problem, often a significant one. If that one problem is in good control, medical decision-making for the visit can be low.
• And, I said we need a 99214-and-a-half, for patients with multiple chronic problems that don’t reach a 99215.  That was out of step with others saying we needed fewer levels.

Other comments about changing E/M guidelines

Use caution
There was a physician on the call who was part of the unsuccessful process to change the guidelines back in 2000. He urged caution. He suggested that the guidelines need to be changed in concert with the CPT code definitions. He suggested that those working on the guidelines today talk to participants who were involved in the failed attempt in 2000.  He said changing medical decision-making would be hard.

Address inconsistency
A fellow consultant pointed out that each MAC is allowed to interpret the E/M guidelines in any way they please.

Simplify
Another consultant said that the guidelines were overly complex and it made it difficult to both audit and teach. No one disagreed with her.

What next?

We wait.  We read the proposed rule, and comment.

If the CPT descriptions are going to change to match the guidelines that might indicate that significant change will wait until 2020.

But it is not out of the question that even without that, there could be changes to the documentation guidelines in 2019. We’ll have to wait and see.

Read the full transcript of the listening call.

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