New Guidelines for Physician Documentation of Office Visits to Support Evaluation and Management Claims

Strategic Insights -

Physicians across the US have struggled with accurately documenting office visits to support claims made using Evaluation and Management (E/M) CPT codes introduced in 1992. The lack of clear documentation standards has led to denied or reduced payments from payers, prompting many physicians to code conservatively to avoid trouble. The American Medical Association (AMA) and Health Care Financing Administration (HCFA) have now developed the Documentation Guidelines for Evaluation and Management Services to address this issue. The guidelines cover three key components: medical history, examination, and medical decision-making, and will provide a clear framework for physicians to follow.

Key Takeaways:

  • The AMA and HCFA developed the Documentation Guidelines for Evaluation and Management Services to improve documentation of office visits and support E/M claims.
  • The guidelines cover three key components: medical history, examination, and medical decision-making.
  • Physicians have 6-9 months to implement the guidelines, with HCFA providing additional training and problem-solving in the following three months.
  • Medicare carriers will introduce the guidelines this month, but they will not go into effect immediately.
  • The guidelines are intended to be used in conjunction with the CPT manual and are not a requirement for physicians; they only provide a clear framework for claims reviewers.
  • Private payers may adopt the guidelines as they have done with other Medicare policies.
  • The AMA and HCFA welcome comments and revisions to the guidelines.
  • Physicians code conservatively to avoid trouble with payers due to lack of clear documentation standards.
  • Nationally, Medicare pays $27 to $98 for an office visit with a new patient, depending on the level of work involved.
  • The guidelines will give third-party payers something tangible to apply when reviewing claims and let physicians know what the rules are.
  • 9-month phase-in for Medicare carriers to introduce the guidelines.

Statistics:

- Nationally, Medicare pays $27 to $98 for an office visit with a new patient, depending on the level of work involved (Medirisk, a medical database firm in Atlanta).

- Physicians have 6-9 months to implement the guidelines.

Sources:

- American Medical Association (AMA)

- Health Care Financing Administration (HCFA)

- Medirisk, a medical database firm in Atlanta