E&M Guidelines to Bite the Dust?

For 10 years, the government has been attempting to impose a new set of documentation guidelines on doctors aimed at assuring "compliance" with Medicare billing codes.  After several iterations of these "Evaluation and Management" (E&M) codes, all of which generated loud protests on the part of physicians, the Health and Human Services Secretary, Tommy Thompson, last year commissioned a special advisory committee to reassess the E&M efforts.

In May, the advisory committee, by a count of 20 to 1, recommended that the E&M guidelines should be eliminated in their current form, and did not propose an alternative plan.

DrRich comments:

The E&M guidelines have always been a travesty. These guidelines are meant, of course, to “help” physicians document the proper billing code for the health care services they provide.  Essentially, under the E&M rules, every progress note written in the patient’s medical record must comply with a government-imposed format. If the prescribed notes are not followed, it may be determined that the billing code used is insufficiently documented, and the physician may be charged with health care fraud.

Of course, all versions of the new E&M rules are extremely complex (they cover 48 pages), difficult to follow, vague, and self-contradictory.  I and many physicians who have tried to use them find them very time-consuming, confusing, and difficult to correlate with the five levels of billing. 

Writing a progress note in a patient's chart used to be an art.  These notes should be brief but thorough, so that a physician caring for the patient at a later time would be able to skim through the medical records and immediately focus on key events.  The notes should thus not be cluttered with extraneous or irrelevant data. 

The new E&M rules require these notes to be packed with irrelevant information related to the history, physical exam, assessment and plan.  For instance, the physical exam portion of the note must be written in accordance with one of four levels of complexity (problem focused, expanded problem focused, detailed or comprehensive).  Documentation of each of the four levels of complexity must comply with requirements that read like a Chinese menu.  For example, for a “detailed” physical examination, the note must document “at least two bulleted elements from each of six areas/systems OR at least twelve bulleted elements in two or more areas/systems.”  The “areas/systems” are a list of body systems such as “cardiovascular” or “respiratory,” and the “bulleted elements” are lists of pieces of the physical examination that must be written down, such as “femoral arteries (e.g. pulse amplitude, bruits).”

For each patient encounter, one must assemble a progress note based on several pages of such instructions. Aside from being insulting, these documentation requirements are not at all straightforward, since they do not correlate with what is clinically relevant. 

Further, they are time-consuming.  It takes at least five to ten minutes per patient nowadays to write a note that is (as nearly as I can tell) in compliance with the law.  If we see 20 patients a day (a conservative number for most doctors), that’s perhaps 150 extra minutes a day.  Since the number of patients we see each day doesn’t change, a good bit of that extra time must come out of the time that we might otherwise be spend actually talking to patients.

In addition, correlating your carefully constructed note to the proper billing code is, at best, a challenge. A proper correlation depends on the “level” of the history taken, the “level” of the physical exam, and the “level” of complexity of the medical problem – and all those “levels” depend on which elements you’ve selected from which Chinese menu.  To say the least, this all tends to be somewhat confusing – which is too bad, because an error can land you in jail.

What you are finally left with is a progress note that is filled with all sorts of extraneous, federally-required information that makes it inherently difficult to read.  Another doctor trying to sort out what you really think about the patient, from amidst the morass of three bulleted elements from Menu A and twelve bulleted elements from Menu B, will have trouble doing so.  But a bureaucrat auditing billing patterns will have everything laid out for him just as he wants it – and that’s what’s the feds have considered most important, at least until now.

Thanks to the vote of the HHS Advisory committee, there is at least an even chance that the feds, after 10 years of trying , will for now lay the effort aside of attempting to impose draconian documentation rules.

June, 2002

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