'Mix and Match' Documentation for Higher Reimbursement

Recent changes in how CMS permits you to select evaluation and management (E/M) service levels are a benefit to providers who manage patients with multiple chronic conditions.

E/M services may be provided at various levels of intensity, with more intensive services garnering higher reimbursement. E/M service levels (and the codes that describe them) are assigned according the elements of patient history, exam, and medical decision-making (MDM) documented in the provider’s encounter notes.

CMS allows you to choose between two sets of guidelines when translating provider documentation into E/M codes: The 1995 Documentation Guidelines for Evaluation and Management Services and the 1997 Documentation Guidelines for Evaluation and Management Services. The guidelines differ in how they define the history and exam portions of an E/M service (the guidelines are identical regarding MDM).

The ‘95 guidelines define the exam component such that specialist providers found it difficult to report higher-level E/M codes, even when services warranted doing so. The ‘97 guidelines addressed this issue by providing bullet points for single organ system examinations, thereby allowing specialists to report higher level services for intensive, problem-specific exams. The ‘97 exam requirements tend not to work as well for general practitioners, however.

The ‘97 guidelines also differ in the history component, and allow “the status of three or more chronic conditions” to qualify as an “extended” history of present illness (HPI). Under the ‘95 guidelines, providers must document four or more HPI “elements” (location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms) to attain an extended HPI.

Each set of guidelines has its advantages and disadvantages. For many providers, the ideal guideline would combine the ‘95 exam requirements (which are more subjective, as compared to the ‘97 exam requirements) with the ‘97 history element (which are more flexible than the ‘95 guidelines when defining the history of present illness). For many years, such “mixing and matching” of the guidelines has not been allowed.

Effective since Sept. 10, 2013, CMS has revised its E/M Documentation Guidelines to allow an extended HPI, as defined by the ‘97 guidelines, with the other elements of the ‘95 guidelines. As a result, “the status of three or more chronic conditions” qualifies as an extended HPI for either the ‘97 or ‘95 guidelines. 

CMS announced the change as a “Question and Answer” on its website.

Q. Can a provider use both the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services to document their choice of evaluation and management HCPCS code?
A. For billing Medicare, a provider may choose either version of the documentation guidelines, not a combination of the two, to document a patient encounter. However, beginning for services performed on or after September 10, 2013 physicians may use the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 guidelines to document an evaluation and management service.

CMS has also updated its Evaluation and Management Services Guide to reflect the new policy.

Ask your coding staff if they are aware of this change, and if they are measuring E/M services against the revised guidelines. Those physicians who manage patients with multiple chronic conditions, especially, may find that the new rules allow their coding and billing to better reflect the documented level of service provided, thereby legitimately boosting E/M levels and reimbursement levels. If providers are already documenting their services well, they won’t have to change their process to realize an advantage from these revised E/M guidelines.