Recently the Health Care Financing Administration (HCFA, aka Medicare) began using more definitive criteria for evaluating the level of Evaluation & Management (E&M) services (e.g., CPT 99281-85 in an emergency department) provided from August 1, 1995 onward. These criteria are called the Documentation Guidelines (DGs). The DGs were developed by HCFA in concert with the American Medical Association (AMA) so as to correspond with the AMA's Current Procedural Terminology (CPT) system. Ostensibly, the DGs were developed in response to physicians' concerns that the 1992 CPT E&M requirements were too amorphous and therefore susceptible to erroneous interpretation by entities responsible for making health care payments.
A comprehensive exploration of the DGs' intricacies is not really feasible in a limited time. Therefore the following is meant as a broad overview of the DGs relationship to E&M services provided in an emergency department (ED). These services are encompassed by CPT codes 99281, 99282, 99283, 99284, and 99285 (referred to as Levels 1 through 5).
As should become apparent, correct utilization of the DGs depends upon appropriate (i.e., with regard to both content and legibility) documentation. The DGs relate to the respective CPT E&M services by defining criteria for the particular key components of history, (physical) examination, and decision making:
HISTORY is subdivided into History of Present Illness (HPI), Review of Systems (ROS), and Past, Family, and/or Social History (PFSH):
HPI: 8 elements of HPI are defined: location, quality, severity, duration, timing, context, modifying factors, and associated signs or symptoms. A "Brief" HPI is one which addresses 1-3 of these elements. An "Extended" HPI is one which addresses 4 or more of these elements.
ROS: 14 "systems" are defined for ROS: constitutional (e.g., fever, weight loss), eyes, ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary, neurologic, psychiatric, endocrine, hematologic/lymphatic, and allergic/immunologic. A "Problem Pertinent" ROS addresses the system directly related to the problem(s) in the HPI. An "Extended" ROS addresses pertinent positive or negative responses for 2-9 of the systems. A "Complete" ROS addresses the pertinent positive or negative responses for 10 or more of the systems.
PFSH: A "Pertinent" PFSH is one which addresses 1 item from the patient's past, or family, or social history. A "Complete" PFSH is one which addresses 1 item from each of 2 of the 3 PFSH areas.
EXAMINATION: there are 10 body areas (A) defined: head, neck, chest, abdomen, genitalia, back, and each of the four extremities; and 12 organ systems (S) defined: constitutional (e.g., vital signs, appearance), eyes, ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, skin, neurologic, psychiatric, hematologic/lymphatic/immunologic. A "Problem Focused" examination is one which addresses the affected A or S. An "Expanded Problem Focused" examination is one which addresses the affected A/S and other symptomatic or related S. A "Detailed" examination is one which addresses an extended examination of A/S's. {Ironically, a "detailed" examination is the most amorphous!} A "Comprehensive" general multi-system examination is one which addresses 8 or more of the defined systems.
It is important to note that while all the other levels of examination contain references to an amalgam of body areas and organ systems, "comprehensive" multi-system examination refers solely to organ systems. It is also important to note that it is possible to examine all 10 body areas but still address only a single organ system (e.g., skin).
DECISION MAKING: Decision Making takes into account the number of possible diagnoses or management options, the amount and/or complexity of data to be reviewed, and the risk of complications and/or morbidity or mortality. All these elements can vary substantially by patient, presentation, and physician.
The DGs are vague regarding how to assess the first and second Decision Making subcomponents. However, HCFA has developed a methodology for delineating these two items and has distributed it to its carriers (i.e., regional Medicare payors). The following incorporates both the HCFA methodology and the DGs' stipulations:
Number of Diagnoses or Management Options:
HCFA identifies 5 types of problems and assigns a "value" to each:
Self-limited/minor = 1
Established, stable/improved = 1
Established, worsening = 2
New, no additional work up planned = 3
New, additional work up planned = 4
The following total scores for this subcomponent would qualify for the listed coding level (i.e., Levels 1-5):
Score of 1 = Level 1
Score of 2 = Level 2
Score of 3 = Level 3 or 4
Score of 4 or greater = Level 5
The overall documentation should delineate the patient's problem(s) as best as possible.
Amount and/or Complexity of Data to be Reviewed:
Again HCFA has identified a number of categorical items and assigned a "value" to each:
The following total scores for this subcomponent would qualify for the listed coding level (i.e., Levels 1-5):
Score of 1 = Level 1
Score of 2 = Level 2
Score of 3 = Level 3 or 4
Score of 4 or greater = Level 5
The overall documentation must sufficiently substantiate the appropriate coding level for this subcomponent.
Risk of Significant Complications, Morbidity, and/or Mortality :
The DGs contains a "Table of Risk", consisting of various "Presenting Problem(s)", "Diagnostic Procedure(s) Ordered", and "Management Options Selected" whereby the risk associated with the patient encounter can be determined. The DGs identifies 4 types of risk, which would qualify for the following Coding Levels for this subcomponent:
Minimal Risk = Level 1
Low Risk = Level 2
Moderate Risk = Level 3 or 4
High Risk = Level 5
The overall documentation must sufficiently delineate the items from these various categories so that the appropriate code is substantiated.
As stated earlier, the foregoing is only a limited treatment of the Documentation Guidelines and CPT. In order to appropriately use both, a much more in depth understanding is necessary. But it is absolutely mandatory to remember one thing above all others, no matter the extent of documentation provided, the E&M code selected can never be at a level of service greater than that actually required for the patient's illness and/or injury.
Peter L. Sawchuk, MD, MBA
Doctor Sawchuk has 15 years of experience in emergency physician billing. Presently, he is the American College of Emergency Physicians' (ACEP) representative to both the AMA CPT Advisory Committee and the AMA Relative Values Update Committee's Advisory Panel. He also serves as the emergency medicine Delegate to the New Jersey Carrier Advisor Committee.