I hope you’re sitting down, because there is big news! The proposed physician fee schedule rule was released in mid July and includes a section about E/M (evaluation and management services).
CMS is asking for comments about changing the documentation guidelines! The current guidelines were developed in 1995 and 1997, prior to the adoption of electronic health records by most medical practices. Let me start this article by quoting the proposed rule.
Here’s what CMS had to say.
“In general, we agree that there may be unnecessary burden with these guidelines and that they are potentially outdated, and believe this is especially true for the requirements of the history and physical exam.”
“While CMS conducts few audits on E/M visits relative to the volume of PFS services they comprise, we have repeatedly heard from practitioners that compliance with the guidelines is a source of significant audit vulnerability and administrative burden.”
“We continue to agree with stakeholders that the E/M guidelines should be substantially revised. We believe that a comprehensive reform of E/M documentation guidelines would require a multi-year, collaborative effort among stakeholders.”
“We are also specifically seeking comment on whether it would be appropriate to remove our documentation requirements for history and physical exam for all E/M visits at all levels. We believe medical decision-making and time are the more significant factors in distinguishing visit levels, and the need for extended histories and exams is being replaced by population– based screening and intervention, at least for some specialties.”
“We also welcome comments on specific ideas that stakeholders may have on how to update MDM guidelines to foster appropriate documentation for patient care commensurate with the level of patient complexity, while avoiding burdensome documentation requirements and/ or inappropriate upcoding.”
The current guidelines are a joint work product of the AMA and CMS
These guidelines were developed when entries into the medical record were mostly hand written or dictated. There was little opportunity to import information from a prior note. We used forms for the review of systems and past family medical and social history, and some documentation was made on preprinted forms.
Now that most practices have switched to electronic medical records, practitioners complain about the number of clicks required to document the encounter, the difficulty of finding relevant and important information in overly long notes and that the systems seem to be designed for billing and coding not patient care. Coders complain that it was difficult to know what to credit in a note when the note was either heavily templated or large parts of it were imported from a previous encounter.
Physicians and other practitioners will probably agree with CMS that complexity and medical decision-making, along with time, should drive the level of service.
Don’t throw away your E/M audit sheets this year
CMS believes that this will be a multi-year project.
They also comment on the fact that they don’t review many E/M services relative to their volume. In 2012, the Office of Inspector General released a report called Coding trends of Medicare evaluation and management services. (May 2012 OEI-04-10-00180) It can be difficult to find these old reports, so you can download this report here.
The report noted that the level of E/M services submitted by all specialties providers and in all categories of codes had increased over the years, and suggested that CMS provide education to physicians about E/M services.
It also recommended that CMS instruct MACs to review these types of notes particularly for clinicians who consistently bill high-level services. While CMS agreed with some of the OIG recommendations, they also had this comment about the effectiveness of auditing E/M services for compliance:
“based on the findings in this report, the average E/M error was approximately $43.00. The average cost to review an E/M claim can range from $30.00 to $55.00. Therefore, CMS and the MACs must weigh the cost benefit of these services against more costly Part B services.”
 CMS did agree, however, to look at the 1,700 providers in the study who billed exclusively high level services.
Send comments to CMS
You have until Sept 11, 2017 to send comments in this first round. There will be more opportunities as CMS works with stakeholders to update the guidelines. It can’t come soon enough, although whether we’ll like the new guidelines more than the current ones remains to be seen.
And fellow coders, I know you work with a doctor or other provider who has strong opinions about the E/M guidelines. Show them this article! Now is the time to tell CMS what the guidelines should be.
Go to www.regulations.gov, and search for CMS-1676-P. Select the rule and submit your comments. Alternatively, you can write a letter to CMS, HHS, Attention CMS-1676-P, P.O. Box 8016, Baltimore MD 21244-8013.
In the meantime, we are still coding and auditing E/M services. I have put together a webinar on the topic. “To Credit or Not to Credit.” You can sign up for it here, and as always, webinars are free to CodingIntel members.
Medicare enrollment, CPT modifiers and healthcare compliance
And, don’t forget that practices that were asked to return large sums of money to the government typically fell afoul of provider number issues, incident-to billing and the use of modifiers. If you haven’t read my article about two unfortunate practices that each returned $4M to the government, now is a good time to do that here.
And, if you want to review the proposed rule for yourself, you can download it here.
 HHS OIG Report “Coding Trends of Medicare Evaluation and Management Services,” May 2012, OEI-04-10-00180. Appendix G, page 37.
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