Documentation Guidelines for Evaluation and Management Services, AMA/Health Care Financing Administration, May 1997

It's understandable to want to avoid reading articles dealing with government health care regulations, but those who refuse to learn and comply with those regulations open themselves to many problems. We hope this article will be positive and of value to you and your patients.

Based on the amount of e-mail and letters we receive from practitioners about current Medicare/Medicaid guidelines as prescribed by the Health Care Financing Administration (HCFA), confusion continues to exist about what must be included in the examination of Medicare/Medicaid patients. Based on what Medicare representatives told us at the time this article was prepared, we will be required to follow these same guidelines to qualify for payment of examination charges submitted to other third-party payers.

The guidelines were jointly developed by the American Medica lAssociation (AMA) and the HCFA. Other participating advisory committees were the Practicing Physicians Advisory Council, the CPT Editorial Panel, the CPT Advisory Committees, and the Medicare Contractor Directors. Their purpose was to provide all health care physicians and claims reviewers with information to prepare or review documentation for evaluation and management services. The guidelines place special emphasis on assuring that diagnostic procedures and records are:

"consistent with the clinical descriptors and definitions contained in CPT";

"would be widely accepted by clinicians and minimize any changes in record-keeping practices"; and

"would be interpreted and applied uniformly by users across the country."

The Documentation Guidelines for Evaluation and Management Services contain a great deal of information that needs to be reviewed and incorporated by all physicians. It reinforces information that we have shared in previous risk management articles. Those practitioners who have followed our advice on proper record keeping should already be in compliance with these guidelines. A few of the terms used are different in that:

"chief complaint (CC)" is what we refer to as "present symptoms and complaints";

"review of systems (ROS)" is what we refer to as "examination findings"; and

"past, family and/or social history (PFSH)" is what we refer to as "past medical history."

All physicians are required to follow these guidelines. It is not difficult to follow them, especially if you use comprehensive standardized reporting forms and/or standardized computer documents that collect and print out or electronically transmit the information to Medicare or other third-party payers.

Few practitioners enjoy government regulations, but what these guidelines offer is not bad, cumbersome or difficult, especially if the practitioner has a positive attitude and chooses to be in sync with what is needed to practice successfully in the 21st century. This does not guarantee that your bills for services will be paid or that your patient will be reimbursed for services you've rendered, but like it or not you have to conform to said guidelines regarding Medicare or face some very serious consequences.

Record Keepers Are Record Breakers

If you simply take and record a good patient history, keep it up-to-date, follow usual and customary examination procedures, develop and state the treatment plan and follow the usual and customary SOAP note format, you will not only go a long way to be in accord with what Medicare requires, but also the requirements of other regulatory agencies, insurance companies, peer review, etc.

History of Present Illness (HPI)

The HPI should include: location; quality; severity; duration; timing; context of the patient's pain or health problem; any modifying factors; and any associated signs and symptoms. Your description of this information can be brief or extended relative to giving an adequate description of it and depending on the cause or nature of the problem. If you use standardized paper or computer documents that keep you asking the right questions of the patient, you will make it easy to determine, record and provide said information.

ROS (Review of Systems) Results of Examinations

The ROS is a system to inventory one or more of the following body systems:

Constitutional symptoms (e.g., fever, weight loss)
Eyes
Ears, Nose, Mouth, Throat
Cardiovascular
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary
Neurological
Psychiatric
Endocrine
Hematological/Lymphatic
Allergic/Immunological

Information should be obtained by direct questioning of the patient or by having the patient complete a "new patient entrance questionnaire." All areas in which the patient has a positive response must be pursued and documented.

Past, Family and/or Social History (PFSH)

The "new patient entrance case history questionnaire" should ask questions pertaining to past, family and/or social history and indicate the primary avenues of future questioning and examination. The extent of the history can then be problem focused, expanded problem focused, detailed or comprehensive. Those are options, but it behooves every practitioner to be as thorough as possible in obtaining data with regards to present complaints, past, family and social history.

Persons who are hired to review claims are going to look closer at records that are sparse, illegible and poor or minimal. Physicians who are unaware or refuse to comply with these guidelines invite close scrutiny and problems with regulatory agencies. Using forms that do not document the information required is a sure invitation to investigation by governmental agencies. Records that are minimal and/or illegible are going to be more highly scrutinized, so save yourself future hassles by doing the right job up front.

Chief Complaint (CC) Present Symptoms and Complaints

The patient must be afforded the opportunity to write the chief complaints or be interviewed for their chief complaint. Chief complaints must include a description of all symptoms, problems, conditions, past/present diagnosis, past or present care or treatments/medications. Our experience has proven that it is best to take a brief history when the patient telephones for an appointment, which allows the practitioner to become familiar with the major problem(s) the patient is suffering from and make some initial decisions regarding time that may be needed for the first visit, possible diagnostic tests, etc. No appointment/walk in practices create a great deal of unnecessary work for themselves and very often fail to be in accord with the guidelines. There are no short cuts to success. Attempting to cut corners always causes the individual to be cut short.

Documentation of Examinations

The accepted levels of evaluation and management (E/M) services involve four types, including:

Problem Focused -- an examination limited to the involved body area, organ or system.

Expanded Problem Focused -- a limited examination of the involved body area or organ system and the symptomatic or related body area(s) or organ system(s).

Detailed -- entails an extended examination of or to the afflicted area(s) or organ systems or related organs or systems.

Comprehensive -- entails a multi-system or comprehensive examination or full examination of one or more systems or organs directly or indirectly related to the patient's symptoms.

Essentially the more comprehensive a practitioner's examination, the better the opportunity to evaluate the patient and come to a clearer diagnosis and treatment plan. Practitioners who keep their examination skills highly tuned can perform competent examinations quickly and efficiently. We should do the best for our patients regardless of what insurance does or does not pay for. We should never do more to make more, but rather do what we know we should do for the betterment of the patient.

Our next article will discuss the required elements of musculoskeletal examinations and essentials of proper reporting.