In its 2018 Physician Fee Schedule Proposed Rule, the Centers for Medicare & Medicaid Services (CMS) suggested that it was open to the idea of revising the current (1995 and 1997) E/M Documentation Guidelines, and solicited comments from “a broad array of stakeholders, including patient advocates, on the specific changes we should undertake to reform the guidelines, reduce the associated burden, and better align E/M coding and documentation with the current practice of medicine.”

Well, since they asked, I have a few suggestions…

How to Change History

Let’s start with the history section:

The History of Present Illness (HPI) is the most important part of the history section, and cannot readily be cloned (for a new patient, at least). It’s proof of one-on-one conversation with the patient (although, in my experience, the provider rarely collects this information).

I propose the HPI as a stand-alone component, with simple scoring. One element equals problem focused, two equals expanded problem focused, three detailed, and four comprehensive.

Move the Review of Systems (ROS) out of the history section. I am not saying this information shouldn’t be documented; but, I don’t think it should carry so much importance in the history section. The ROS appears to be of limited use because I have seen it referred to, many times, only to find that the patient actually hadn’t completed that portion of the questionnaire.

The ROS should probably be an integral component of a preventive visit, and it can appear in a more limited fashion elsewhere in the note (we will get to that, later).

Move the Past Medical, Family and Social History (PFSH) into the medical decision-making (MDM) component. I’ll explain this later, also.

Re-examine the Exam

Now, on to the examination.

Many providers rely more upon data than actual prodding and inspection of the human body. So, let’s move the data into the Physical Examination (PE) section.

A head-to-toe PE is the most likely section of the note to be auto-filled or cloned when billing, for example, a Level 4 or 5 patient visit (99204 or 99205). Cloning can be declared in an audit with consistent negative findings of an organ system that has little or nothing to do with the presenting problem.

General surgeons and oncologists (among others) would benefit greatly by data being moved into the physical examination. So, let’s add, “up to four data points to four organ systems” for a comprehensive examination.

Let’s toss out the decision to obtain old records, while we’re at it. How would an auditor know this ever happened? Replace it with endoscopic report review; one examination point. Endoscopy is a valuable diagnostic tool that currently does nothing to elevate an E&M level, unless the provider watched the DVD of the procedure (and even this is debatable).

Clarify an Expanded Problem Focused versus Detailed Examination. I suggest two to four for Expanded Problem Focused, and five to seven for Detailed. You force coders to put on a clinician’s thinking cap with the current 2-7 organ systems, for both expanded problem focused and detailed—and few of us are both clinicians and coders.

Making MDM Easier

The MDM is now simplified:

Data has been moved out of the MDM, now; therefore, figuring out the complexity of the visit has been streamlined.

Clarify prescription drug management. MAC’s differ on their approach to this Table of Risk element. Personally, I believe it should be defined as stop, start, increase, or decrease dosage.

Toss out “further workup” (in my opinion, another ill-defined element) and replace it with, “Comorbidities, conditions, or historical elements affecting treatment.”This represents elements that can be pulled in from the ROS and PFSH. They are assigned one point, no matter how many there are. This element would apply only to new problems, just as “further workup” does, at present. It will be easy for an auditor to see if this entry is valid in relation to the presenting problem.

In the Table of Risk, clarify the difference between “acute uncomplicated illness or injury” and “acute complicated injury.” There is whole lot of grey area in between a simple sprain and being knocked unconscious. We can do better

A New Way, Demonstrated

To complete your thought experiment, let us work with the new template for a new patient with a sore throat:

History: Sore throat X3 days with pain level 7/10 = Detailed history.

Examination: Vitals (let’s just get rid of general appearance of the patient, okay?), ENT examination, auscultation of heart and lungs, and a rapid strep test. Five points = detailed.

MDM: New problem, relevant allergy (penicillin). Strep test positive, prescription drug management = 99203.

MDM: New problem, relevant allergy (penicillin). Strep test negative, uncomplicated viral illness, OTC Tylenol for pain relief = 99202.

Now, onto a new patient consulting an oncologist for treatment options:

History: Throat CA first discovered 6 months ago when visiting his PCP for a difficulty speaking. Pain level 8/10. 4 points = Comprehensive history.

Examination: Vitals, ENT, anterior and posterior cervical lymph nodes, auscultation of the heart and lungs. MRI report review, blood work ordered, tracheoscopy with bronchoscopy report reviewed. 8 points = Comprehensive examination.

MDM: New problem, current smoker = 4 points. Chemo scheduled and Fentanyl patch prescribed for pain = High complexity MDM.

Overall E&M level = 99205.

Note: a controlled substance in the form of an epidermal patch technically meets the Table of Risk requirement of “parenteral.” Parenteral is defined as, “Administered or occurring elsewhere in the body than the mouth and alimentary canal.”

Alternative scenario: If the provider prescribed Oxycodone by mouth for pain and did not characterize the chronic condition of cancer as a severe exacerbation, along with the existing Comprehensive History and Examination elements, the visit would level 99204.

The Advantages

What I like most about this model is the importance it places on the HPI, demonstrating one-on-one interaction with the patient, and provider engagement with the patient’s symptoms. Plus, it stresses the ever-growing importance of diagnostic tools over poking and prodding the patient. Also, this new approach simplifies medical necessity, which is the overreaching criteria for determining an E/M level for an encounter.

Sure, it’s still a little tough to calculate, but not nearly as tough as the 1995 and 1997 guidelines!

Of course, there are a lot of other factors to consider and hundreds of scenarios to run, to tweak this system into a more perfect model. Consider this opinion to be food for thought, discussion, and debate.