May 2003 Table of Contents

GETTING PAID

An Update on the E/M Codes and Documentation Guidelines

There’s a movement afoot to radically alter the way you choose the level of service of E/M codes.

Fam Pract Manag. 2003 May;10(5):14.

Rumors abound regarding the status of the evaluation and management (E/M) codes and the documentation guidelines for E/M services. This update should help to set the record straight.

An important distinction

First, keep in mind the distinction between the E/M codes and the documentation guidelines for E/M services. The E/M codes, like the rest of CPT, are copyrighted and maintained by the AMA. The CPT Editorial Panel decides the content of CPT. The Centers for Medicare & Medicaid Services (CMS) has a seat on the CPT Editorial Panel, but CMS does not control the CPT codes.

CMS does control the documentation guidelines for E/M services, which they developed to help facilitate medical review, but they are not technically part of CPT.

The E/M codes

With that distinction in mind, let’s talk about the status of the E/M codes. These codes essentially have not changed since CPT implemented them in 1992, and most E/M codes are still described in terms of history, exam and medical decision making.

That said, the CPT Editorial Panel, based on recommendations from its own E/M workgroup, is attempting to overhaul the E/M codes. In 2002, the CPT Editorial Panel accepted in concept a set of recommendations that would maintain, for the most part, the current CPT code numbers and families. For example, 99211 through 99215 would still designate established patient office visits.

However, the recommendations would radically alter the way physicians choose the level of service of E/M codes. The proposed changes would define E/M services in terms of total physician work and base code selection on clinical examples for key reference services. The idea is to make code selection more intuitive by providing clinical examples and allowing physicians to compare them with the service rendered and choose a code based on the comparison.

This proposed framework is more intuitive, which is thought to make it easier to use, but it may be less defensible in an audit, since what is intuitively obvious to the physician may not be so intuitively obvious to a reviewer.

The documentation guidelines

This brings us to the documentation guidelines. A hope in revising the E/M codes is that documentation guidelines would no longer be necessary, but there is no guarantee of that. In 2002, the Secretary of the Health and Human Services’ Advisory Committee on Regulatory Reform recommended eliminating the documentation guidelines. However, the Secretary has yet to act on that recommendation. Thus, despite this recommendation and the CPT activity noted above, two sets of documentation guidelines remain in use: 1995 and 1997. Physicians may use either set.

The future

As the next step in this ongoing saga, the CPT Editorial Panel has appointed a task force to establish the process by which clinical examples will be developed and vetted. This will be a laborious and critical process. At the earliest, any changes in the E/M codes will go into effect in 2005. However, it is still uncertain whether the CPT E/M workgroup’s recommendations will be implemented, especially if the development of specialty-specific clinical examples does not progress. So, in the meantime, you should continue to use the E/M codes as you always have, and you should continue to use whichever set of documentation guidelines, 1995 or 1997, best meets your needs. When or if either the codes or the documentation guidelines change, FPM will do its best to educate you.

Kent Moore is the AAFP’s manager for health care financing and delivery systems and is a contributing editor to FPM.

Conflicts of interest: none reported.

Send comments to fpmedit@aafp.org.

Copyright © 2003 by the American Academy of Family Physicians.
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