Important Changes in the Documentation Guidelines

Even before HCFA formally announced its new evaluation and management (E/M) documentation guidelines over a year ago, physicians involved in developing them were complaining that they weren't weathertight. Various terms were undefined or so loosely defined that a well-intentioned physician and a well-intentioned auditor could disagree flatly on how to code certain visits. Given that the purpose of the guidelines was to provide a commonly accepted mechanism for coding E/M visits, these flaws promised big trouble. Now HCFA has repaired two major ones.

The first change concerns the history of present illness (HPI). As originally framed, the guidelines for documentation of the HPI did not adequately address the patient with controlled chronic problems. The guidelines specified seven elements of the HPI (location, quality, severity, duration, timing, context, modifying factors and associated signs and symptoms), all of which pertain largely to acute problems. They defined an extended HPI as having four or more of these elements and a brief HPI as having one to three of them.

This definition tended to undervalue the HPI for follow-up visits with patients who have multiple chronic problems. If the problems are well-controlled enough to be asymptomatic, even the most careful and thorough HPI might not be able to turn up four or more of the specified elements. (How do you give the duration of a symptom that isn't there?) As a result, the HPI tended to put a ceiling on the level of the visit: A brief HPI limits the level of history to problem focused or expanded problem focused, and that would limit the level of a follow-up visit to 99213 unless both the exam and the medical decision making were involved enough to justify a higher level without reference to the history.

To address this concern, HCFA is redefining the extended and, by implication, the brief HPI. An extended HPI is now defined as four or more elements of the HPI or the status of three or more chronic conditions. Presumably, then, a brief HPI would consist of one to three elements or the status of one or two chronic conditions, although HCFA does not state this explicitly.

This means, for example, that when a patient presents periodically for monitoring of well-controlled diabetes, hypertension and chronic obstructive pulmonary disease, you no longer have to struggle with identifying such things as the location, quality and duration of the present illness. Instead, you simply have to note the status of the multiple chronic conditions. The number of conditions, in turn, will determine whether the HPI is brief or extended.

To see this in practice, let's see how the old and new definitions differ in the way they apply to a sample history. Consider the following portion of a visit note:


S: Mr. Doe returns today for a routine four-month F/U for evaluation and management of his NIDDM, hypertension and OA. No new complaints. He denies headache, visual changes, chest pain, SOB or extremity numbness. No increased joint pain. Dietary compliance good, and his BP and home glucose monitoring records indicate acceptable control of both. Reviewed medication list; compliance appeared acceptable.


While this clearly represents a conscientious and thorough questioning about exacerbations of Mr. Doe's problems, the only way we could justify calling this an extended HPI under the old definition is by metaphysics: Does not having headache say something about location, for instance? Does not having increased joint pain say anything about severity? With the revised definition, however, finding the level of the HPI is straightforward: It gives the status of three chronic conditions, so it's an extended HPI. Period.

The other change HCFA has made is meant to better distinguish an expanded problem-focused exam from a detailed exam. In the original guidelines, the two types of exam are defined as follows:

Expanded problem focused: a limited examination of the affected body area or organ system and other symptomatic or related organ system(s).

Detailed: an extended examination of the affected body area or organ system and other symptomatic or related organ system(s).

Since the only difference between the two definitions was the difference between limited and extended -- and since the guidelines made no effort to define these terms -- the whole distinction was a matter of interpretation. Physicians wondered, reasonably, what would happen if their interpretation and the auditor's differed.

To better distinguish these two exams, HCFA has added a guideline saying that the medical record for a detailed exam involving multiple organ systems should include findings about five to seven organ systems/body areas. Consequently, by implication, the medical record for an expanded problem-focused exam would include findings about two to four organ systems/body areas, although, again, HCFA has not said so explicitly.

This means, for example, that if your documentation of the exam reflects findings about the constitutional (i.e., vital signs), cardiovascular, respiratory and neurologic systems, you have documented an expanded problem-focused exam. However, if your documentation of the exam reflects findings about the gastrointestinal system in addition to the systems mentioned above, you have documented a detailed exam. Thus, in essence, HCFA is defining limited and extended in terms of organ systems.

While the phrase "organ systems/ body areas" might suggest that the body areas defined in the original guidelines may be freely counted together with organ systems, our understanding is that the approach of the original guidelines still applies in that the difference between an expanded problem-focused exam and a detailed exam is measured principally in terms of systems examined, not body areas. A more useful restatement of the new guideline might borrow from the original definitions:

An expanded problem-focused examination is an examination of the affected body area or organ system and one to three other organ systems.

A detailed examination is an examination of the affected body area(s) or organ system(s) and four to six other organ systems.

To see how the new guideline works in practice, let's look at the objective portion of a note from a follow-up visit with a 55-year-old man with hypertension:

The note documents examination of six body areas (head, neck and four extremities) and four systems (constitutional, eyes, ENT, respiratory). By the original guidelines, then, the exam is either expanded problem-focused or detailed depending on whether you believe this to be an "extended" exam. With the clarification, however, it clearly qualifies as a detailed exam. Consider yourself lucky. You've just seen life get a little simpler.

The exam guidelines still contain one crack through which the weather can get in: the definition of a "complete single-system exam." Since that involves a separate definition for each of the 12 organ systems Medicare recognizes for the exam, it's proving to be a relatively tough problem. According to a HCFA spokesperson, however, definitions are essentially complete for most systems. The remaining challenge is to make the language of the definitions more consistent with the language used for multisystem exams.

In addition, there is apparently some doubt that a complete single-system exam for some of the systems (the skin and the musculoskeletal system, in particular) should in fact be considered equivalent to a complete multisystem exam. Since multisystem exams are much more common than single-system exams in family practice, however, the repairs HCFA has already made to the guidelines should make a material difference to your comfort in an E/M audit -- and your confidence in coding for reimbursement at the level you deserve.

Kent Moore is the AAFP's manager for reimbursement issues and a contributing editor to Family Practice Management. Robert Edsall is editor-in-chief of Family Practice Management.

This is a corrected version of the article that appeared in print.