Defining “self-limited problem”

When 99211 isn't appropriate

Office visit + allergy vaccine injection?

Office visit + treadmill exam?

Epoetin alpha for anemia

Medical decision making score sheets

HCFA releases new Medicare documentation guidelines, plans pilot tests

The Health Care Financing Administration (HCFA) recently unveiled a draft version of the newest Medicare documentation guidelines for evaluation and management (E/M) services. HCFA Administrator Nancy-Ann DeParle says the guidelines have been simplified and, pending the results of pilot testing, could be in place as early as 2002.

HCFA used the original 1995 version of the guidelines as the basis for its latest draft when studies showed it enables more consistent, reliable medical review and greater work equivalency across specialties and deviates less from CPT definitions when compared with the 1997 guidelines and the version proposed in 1999. The revision is designed to minimize counting of elements, and will incorporate specialty-specific vignettes for physical exams and medical decision making.

HCFA plans to begin pilot testing in 2001. One test will place equal emphasis on all elements (i.e., history, exam and medical decision making), and a second test will place greater emphasis on medical decision making.

Until new guidelines are implemented, Medicare contractors will continue basing medical records review on either the 1995 or 1997 versions of the guidelines, whichever is most advantageous to the physician.

Editor's note: While this department represents our best efforts to provide accurate information and useful advice, we cannot guarantee that third-party payers will accept the coding and documentation recommended. For more detailed information, refer to the current CPT manual and the “Documentation Guidelines for Evaluation and Management Services.”