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The more you learn about them now, the better prepared you'll be when they hit.

Fam Pract Manag. 1999;06(8):43-47

Medicare's “Documentation Guidelines for Evaluation and Management Services” are back in the news again. It appears that the long and winding road to their reconstruction is nearing its end and that you may soon have a new set of guidelines to master.

In June, the AMA forwarded to HCFA its recommended revisions to the guidelines. The revisions were developed by the AMA's CPT Editorial Panel and reflect significant input from many individual physicians and specialty societies, says family physician Douglas E. Henley, MD, vice chair of the CPT Editorial Panel. Although at press time HCFA has yet to complete its review, Henley is optimistic about HCFA approving the recommendations.

“The new framework of the guidelines that we submitted to HCFA is by far easier to understand and easier to use than previous versions,” says Henley. “HCFA has been very involved in developing the new framework. I assume they'll go ahead and pilot test it and make changes later, if pilot testing proves that's necessary.”

Although HCFA won't announce a new implementation date until it completes its review, HCFA's repeated assurances of pilot testing and a grace period that allows time for substantial training and education suggests that implementation of new guidelines could be as much as one year in the future. With that in mind, we want to give you a glimpse of what's in store by highlighting the most significant of the proposed changes. If this preview doesn't satisfy your curiosity, you can see a version of the guidelines that incorporates all of the AMA's recommendations online at

Key Points:

  • The “new framework” for the documentation guidelines is still undergoing review by HCFA, and it may change.

  • The draft guidelines are simpler than the 1997 version in almost every respect, although they still require counting of exam items.

  • By starting now to get used to the existing guidelines, you will help yourself make the transition to the new ones.

A brief history of the documentation guidelines

Once complete, the revised guidelines will replace a 1997 version that has been widely criticized by physicians and medical specialty societies as unreasonably difficult to use. Criticism of the 1997 guidelines grew so intense that HCFA postponed its initial Jan. 1, 1998, implementation date to July 1, 1998, and later postponed implementation indefinitely to allow time for further study and revision. (See the timeline below.) HCFA directed physicians to use either the 1997 version or the original 1994 version in the meantime to ensure that they won't be stung by Medicare carriers' continuing, random prepayment review of E/M claims.

The AMA, whose CPT Editorial Panel had collaborated with HCFA in the development of the guidelines, has found itself in a bind throughout the revision process. When the AMA House of Delegates passed a measure calling for a substantial revision of the guidelines, the CPT Editorial Panel responded by developing a “new framework” aimed at addressing the many concerns expressed about the 1997 guidelines. This version was generally well received when it was introduced at an April 1998 fly-in meeting organized by the AMA and attended by specialty society representatives from across the country. However, progress was halted when the House of Delegates voted in June 1998 to oppose any guidelines that require counting. That action forced the AMA to suspend its collaboration with HCFA, which had insisted that the guidelines must include some counting of elements to be effective. HCFA, it appeared, would move forward with its own revision, using the new framework as a starting point and intending to minimize but not eliminate counting requirements.

A guidelines timeline

November 1994HCFA introduces first version of the “Documentation Guidelines for Evaluation and Management (E/M) Services,” developed in collaboration with the AMA's CPT Editorial Panel. Grace period begins. Implementation deadline set for Aug. 1, 1995.

August 1995HCFA instructs Medicare carriers to incorporate the documentation guidelines into their routine medical review system.

October 1997HCFA introduces revised version of “Documentation Guidelines for Evaluation and Management Services,” developed in collaboration with the CPT Editorial Panel. The revised guidelines include substantial changes in the Exam section. Grace period begins. Implementation deadline set for Jan. 1, 1998. HCFA instructs Medicare carriers to begin random prepayment review of E/M claims.

December 1997Responding to widespread criticism of the revised guidelines, HCFA postpones implementation deadline to July 1, 1998.

April 1998HCFA postpones implementation of the revised guidelines “indefinitely” to allow time for further review and revision. “New Framework” developed by the CPT Editorial Panel is introduced at an AMA fly-in meeting.

June 1998AMA House of Delegates votes to oppose any version of the documentation guidelines that requires counting. CPT Editorial Panel halts further development of new framework and ceases collaboration with HCFA. HCFA continues to work on the guidelines.

September 1998HCFA agrees to minimize, but not eliminate, counting requirements in the guidelines. The AMA Board of Trustees directs the CPT Editorial Panel to provide “technical advice” to HCFA on the guidelines.

June 1999CPT Editorial Panel submits recommendations to HCFA; the proposed revisions require some counting.

Then one year ago, in September 1998, the AMA Board of Trustees directed the CPT Editorial Panel to resume work on the revised guidelines. AMA Executive Vice President E. Ratcliffe Anderson Jr., MD, explained, “If we cannot continue our substantive work with HCFA, we risk the future viability of physicians' involvement in development and maintenance of the codes used to describe their services,” a role the AMA has played for years. Months of revision followed, concluding when the AMA submitted its recommendations to HCFA in June.

The biggest changes

The revisions proposed to HCFA by the AMA include numerous changes, the most significant of which are summarized here. (Remember: all of the following is subject to change in the HCFA review process. Still, this should convey the flavor of the guidelines you will eventually have to live with.)

History. The number of levels of Review of Systems has been reduced from three to two. Each element of history — HPI, ROS and PFSH — now has two levels, and the guidelines describe these levels as brief and extended. In most cases, the level of history is still determined by the highest level that all three elements attain.

Exam. The exam levels and their definitions have not changed, and, as with the 1997 guidelines, determining the level of exam requires counting. However, the revision does away with separate requirements for single-organ-system exams and the dreaded shaded and unshaded boxes. Instead of “bulleted elements” that must be documented to confirm that particular body areas or organ systems were examined, the revision includes “exam items” accompanied by “examples.” In addition to being presented as examples rather than bulleted elements, the clinical content has been expanded significantly and reflects greater input from specialty societies. (See an excerpt from the exam section of the proposed documentation guidelines on the next page.)

Exam items are organized by body areas and organ systems. For example, in the respiratory section, “Auscultation of lungs” is an exam item, and the accompanying examples include “breath sounds, adventitious sounds, rubs, rales, rhonchi.” The examples are strictly examples. To get credit for having performed a particular exam item, it isn't necessary to document every example given, nor are physicians restricted to choosing from among the examples listed.

The revision also introduces “simplified” documentation of a single body area or organ system. For example, a simplified exam of the musculoskeletal systems with the notation of “MUSC normal” would count as one exam item. This would save physicians the effort of having to document a particular exam item for a body area or organ system that doesn't prove central to the exam.

As before, specific abnormal and clinically relevant negative findings must be documented. A notation of “abnormal” without elaboration is insufficient.

Medical decision making. The revision eases the process of selecting the level of decision making considerably, for the first time providing examples to help physicians sort out the differences in physician work associated with common courses of diagnosis, review and treatment decisions.

An excerpt from the proposed decision making guidelines

Medical Decision Making — Moderate

Scope of presenting problem, number of diagnoses considered and/or risk of complications, morbidity or mortalityDiagnostic procedures/tests ordered and/or amount of data to be obtained or reviewedManagement options considered
Three or more or self-limited problemsPhysiological tests under stress (e.g., exercise, pharmacologic stress)Referrals requiring detailed discussion or detailed care plan
One or more chronic mild and/or self-limit-ed problem(s) with ongoing activity (active problem) mild to moderate exacerbation, progression, or side effects of treatmentEndoscopy for average risk patient (e.g., stable vital signs, noncritical illness)Management of medications with moderate risk requiring detailed discussion, detailed assessment for side effects, or limited laboratory monitoring (e.g., digoxin, warfarin, IV heparin, IV antiarrhythmics beyond first day)
Two or three stable chronic illnesses or problems requiring evaluationDeep needle/incisional biopsySurgery or procedure with ASA 1 risk status
Undiagnosed new illness, injury, or problem with uncertain prognosisInterventional cardiovascular or radiologic procedure for average-risk patient (e.g., stable condition, low-risk procedure)Discussion for psychotherapy and/or counseling
Risk of complications, morbidity or mortality is moderate. There may be an uncertain prognosis or the possibility of prolonged functional impairment with or without treatment.Percutaneous removal of body-cavity fluidArranging hospitalization for noncritical illness/injury
Data to be obtained/reviewed requiring at least 10 minutes of physician timeInitiation of total parenteral nutrition
IV contrast imagingReferral for comprehensive pain-management rehabilitation
Therapeutic or diagnostic spinal/nerve injections

An excerpt from the proposed exam guidelines


Examination itemExamples
Inspection of chestShape, symmetry, expansion, intercostal retractions, use of accessory muscles, assessment of respiratory effort
Percussion of chestDullness, flatness, hyperresonance, diaphragmatic movement
Palpation of chestTenderness, masses, tactile fremitus, crepitus
Auscultation of lungsBreath sounds, adventitious sounds, rubs, rales, rhonchi
Other examination (specify)

Low complexity has been defined to encompass straightforward complexity, thus reducing the levels of decision making from four to three (low, moderate and high). For each of the three levels, the proposed guidelines include a table that presents several examples for each decision making component. (See an excerpt from the medical decision making section of the proposed guidelines, left.) The highest level of any of the three components of decision making determines the level of overall complexity.

The revised guidelines also stipulate that the physician needn't document the level of decision making, since it can “usually be inferred from a properly documented medical record.”

What you can do now

Because these guidelines have yet to be approved by HCFA, you can't start using them yet. You can, however, begin to familiarize yourself with them; as we've said, the version implemented by HCFA may be similar to this one. And if for some reason you haven't started using the documentation guidelines, you should. The 1997 version of the guidelines appears to be somewhat similar to the version likely to be implemented next, so you may as well start there (see “FPM resources on the documentation guidelines”).

FPM resources on the documentation guidelines

Until revised documentation guidelines have been successfully pilot tested and approved by HCFA, physicians must comply with either the 1994 or 1997 version of the guidelines. We've published articles on both the 1994 and 1997 guidelines and related tools in past issues of FPM. The reading list below provides more information.

Once revised documentation guidelines have been approved, FPM will publish a new series of articles designed to help you understand the guidelines and put them to use in a way that will minimize your hassles.

Selected FPM articles

  • “Don't Read This Article!” February 1995:47–53.

  • “Exam Documentation: Charting Within the Guidelines,” March 1995:53–59.

  • “Thinking on Paper: Guidelines for Documenting Medical Decision Making,” April 1995:48–60.

  • “A Documentation Toolbox,” May 1995:35–43.

  • “Important Changes in the Documentation Guidelines,” February 1996:50–57.

  • “Exam Documentation Just Got Harder,” October 1997:75–85.

  • “More Help With Exam Documentation,” November/December 1997:63–75

  • Three Documentation Tools That Work,” January 1998:29–41.

  • Coding and Documentation Made Easier,” April 1998:19–24.

Other resources

The Pocket Guide to the Documentation Guidelines may be obtained through the AAFP online catalog.

The Documentation Guidelines are available in two formats: the 1995 version and the 1997 version.

You should also keep an eye on the pages of FPM. We're following the development of the guidelines closely. As soon as revised guidelines are approved by HCFA, we'll publish a series of articles and tools that will make understanding and implementing the guidelines as easy as possible.

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Copyright © 1999 by the American Academy of Family Physicians.

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