The AAFP has fought long and hard for a change in CMS' evaluation and management (E/M) documentation guidelines. The latest effort came in the form of a letter to CMS Administrator Seema Verma that details the Academy's feedback to questions CMS introduced during a March 21 national listening session.
Physicians and nonphysician clinicians were invited to participate in that session and make suggestions for improving the E/M documentation process; an audio recording and transcript from that event are available online.(www.cms.gov)
In its April 23 letter(4 page PDF) signed by AAFP Board Chair John Meigs, M.D., of Centreville, Ala., the Academy boldly stated that the E/M documentation guidelines don't support patient care or improve health care quality.
"They are most commonly used to justify billing levels rather than help physicians diagnose, manage and treat patients," said the AAFP. Furthermore, adhering to the documentation guidelines consumes an inordinate amount of physicians' time that would be better spent caring for patients.
CMS posed specific questions during the March session. Those queries, along with the AAFP's recent written responses, are summarized here.
Q. How can CMS lessen the level of burden associated with the documentation of E/M visits necessary for billing?
A. CMS must work quickly to revise the outdated guidelines that were established in 1995 and 1997. Any staff member involved in the patient's care -- or the patient, if appropriate -- should be allowed to record information in the medical record, after which the physician could confirm or supplement that information by simple notation.
Q. How do private insurers and other payers approach payment and documentation for E/M services?
A. Most payers outside of Medicare use an approach similar to that of CMS for documentation and payment of E/M services. One private insurer has taken a position that medical decision-making should align with the complexity of the patient.
Q. What changes would you make to current guidelines that require documentation in three domains -- history, physical exam and medical decision-making?
A. Generally speaking, the guidelines place an enormous burden on physicians without offering any benefit to clinical care. CMS could lessen the load on physicians by addressing redundancies in documentation requirements.
Guidelines should align with clinical expectations and outcomes. Currently they do not, because the guidelines were written in an era of paper-based medical records before widespread implementation of electronic health records or the emphasis on team-based care.
Current required elements that include past, family and social history "have the potential to degrade the patient-physician encounter to a 'fill-in-the-blank' session rather than a medical treatment session."
Lastly, CMS tends to place value on the quantity of tests or procedures performed and/or reviewed. Test and procedures are easy to count, "but evaluating the complexity of diagnoses, tests and procedures demands a better mechanism for uniform and meaningful documentation."
Q. Do you have suggestions for updating documentation rules by changing the underlying E/M code set?
A. The underlying E/M code set is itself a major part of the problem. Revision of the E/M code set should be a collaborative effort among all stakeholders and should happen as soon as possible; however, "CMS should not let reform of the underlying E/M code set delay reform of the documentation guidelines."
Q. Should CMS make specialty-specific changes to the documentation guidelines?
A. The AAFP has called for the elimination of documentation guidelines for CPT codes 99211-99215 and 99201-99205 for primary care physicians in the three domains of history, physical exam and medical decision-making.
"If CMS eliminates the documentation requirements for the history and physical exam domains only, then guidelines to support medical decision-making driven E/M documentation need to be in place first and broadly agreed to by the medical profession."