The Maze – Part 2
Medical Coding: E&M Guidelines

mazeGood–you’re back. Grab some coffee and head for your seats–the captain has turned on the seat belt sign, since there’s some rough flying ahead.

Before the break, we were discussing medical coding, billing, and reimbursement, in particular how procedures (surgical and otherwise) were handled. Now for the real fun: how do you decide the proper code for so-called cognitive services: the collection of medical history and data, physical examination, test and diagnostics, and medical decision-making? In coding parlance, these are called evaluation and management services, or E&Ms.

An encounter with a physician–in or out of the hospital–involves two broad tasks: information gathering and decision-making. On the information side, physicians use medical history (information about your present symptoms and illnesses, past illnesses, habits, and genetic risk factors); observational information, primarily from the physical exam; and diagnostic studies such as lab or x-ray. On the decision-making side, there are deductions about what problem or illness you have; judgments about the need for additional diagnostic studies or consultation by other physicians; and decisions about treatment such as medication or surgery.

As you can imagine, there are countless variations on this process, both in terms of the extensiveness of the evaluation, the investigative methods, and the complexity of the decision-making process. And so you can assume that quantifying this process objectively, in order to establish proper payment for services is a daunting task indeed. So the Feds, in conjunction with the AMA, came up with “guidelines” for establishing the level of E&M services–actually, 2 sets of guidelines, one in 1995, and a second in 1997. The 1995 guidelines were widely criticized as being too vague and difficult to interpret–a problem which was solved in 1997 by massively increasing their complexity. (Never, ever, suggest to the government that its regulations aren’t clear enough–the resulting deforesting required to supply paper is a principle cause of global warming).

Of course, the guidelines are “voluntary”–much like filing your tax return. If the words “federal” and “guidelines” in the same sentence make you uneasy, you’re on to something: you have to follow the guidelines strictly, but insurers and Medicare are free to interpret them quite loosely–and if their interpretation and yours don’t match, the assumption is that you are committing fraud.

So let’s walk through a typical office visit and see how the guidelines are used to determine level of service, and therefore reimbursement.

When you first see the doctor for a health problem, he performs a medical history, which generally covers several areas: you current symptoms or problems which brought you to the doctor (called a history of present illness, or HPI); other diseases you may have, medications you are taking, surgeries you have undergone (called a past history); habits such as smoking, diet, and alcohol use (called social history); genetic risks and family diseases (called a family history); and a detailed list of symptoms which you may be experiencing in different body areas (called a review of symptoms or ROS).

Got that? Good.

Then you’ve got your physical exam, which may be anything from quick look in your throat to a stem-to-stern (I was tempted to say “soup to nuts”, but it just didn’t sound right) extravaganza.

Finally, there’s the decision-making process: do you need more information, more tests, more studies? How many problems are you trying to sort out, and how complex are they? Is treatment indicated, such as medication or surgery? And how risky are the additional tests or the recommended treatment?

So this is the process which the guidelines attempt to tackle, in order to pay appropriately according to the level of service.

Warning: you are now entering the dreaded “matrix” — the multi-level, 9-dimensional cascade of confusion used by government and insurance companies to determine how much your medical visit is worth in dollars and cents.

Proceed at your own risk: the author assumes no responsibility for seizures, uncontrollable laughter, crying, headaches, whiplash from dozing, or other mental or physical impairments sustained by further reading.

First, there’s your history of present illness, or HPI: is it brief or extended? Depends on how many checkmarks you can check–not on how long it takes. If you have 4 or more of 7 components described (location, quality, severity, duration, timing, context, modifying factors), it’s extended; come up one short, you’re S.O.L.: brief only. Spend an hour getting three checkmarks from an loquacious or demented patient? Too bad, brief history. Have a medical problem that is a square peg unsuited for these round holes? Sorry, it’s a legal brief.

Now, on to your past, family and social history (PFSH): make mention of all three? Good–complete PFSH. You say family history is not terribly relevant in a 90 year-old lady, so you skipped it? Sorry, pertinent PFSH. Didn’t ask that 9-year old kid how much she drinks and smokes? Busted–no complete PFSH for you, pond scum.

Next, you do your review of systems (ROS)–asking about symptoms affecting many body systems: Ask about one or more symptoms mentioned in one system (e.g. chest pain for the cardiac system, shortness of breath for pulmonary, etc.)? Problem pertinent ROS. Got lucky, and nailed two systems? extended ROS. Ten or more (there are 14 systems under the guidelines)? Bingo, complete ROS. Cash in your chips at the caged window, just past the bathrooms on the right.

So we’re done with the history levels, no? Whew! That was tough!

Not so fast, roadrunner–now we have to determine the overall level of medical history:

  • If you have a brief or extended HPI, but no ROS and PFSH, you have a problem focused history.
  • If you have a brief or extended HPI, problem pertinent ROS, and no PFSH, you have an expanded problem focused history.
  • If you have an extended HPI, extended ROS, and pertinent PFSH, you have a detailed history.
  • If you have an extended HPI, complete ROS, and complete PFSH, you have a comprehensive history.

Now, I’m not a cruel man, so I won’t drag you through all the details of quantifying the physical exam. In brief, there are several physical exam categories, for different specialties (e.g. an exam for cardiology, or genitourinary, or pulmonary), each of which detail individual exam items grouped by systems, using bulleted elements (for components–such as listening to the heart, checking the pulse, etc–of each area or system examined) and shaded areas for mandatory system areas. Yes, sadly it’s true: you can’t do a cardiac physical exam without checking the heart–many physicians don’t realize this, of course, and need to be reminded.

So here’s a taste of how to determine the physical exam level:

  • Problem Focused: One to five elements identified by a bullet.
  • Expanded Problem Focused: At least six elements identified by a bullet.
  • Detailed: At least two elements identified by a bullet from each of six areas or systems, or at least twelve elements identified by a bullet in two or more areas or systems.
  • Comprehensive: Perform all elements identified by a bullet in at least nine organ systems or body areas and document at least two elements identified by a bullet from each of nine areas or systems.

There’s no mention of the bullet you might wish to fire into your own brain, for some reason.

Now, if we have survived this, we next tackle the complexity of medical decision making.

Allow me to quote from the guidelines:

The levels of E&M services recognize four types of medical decision making (straight-forward, low complexity, moderate complexity and high complexity). Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:

  • the number of possible diagnoses and/or the number of management options that must be considered;
  • the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed; and
  • the risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patient’s presenting problem(s), the diagnostic procedure(s) and/or the possible management options.

Once again, the masters of mass confusion create yet another grid:

MDM grid
(Medical Decision Making Level Determination)

Once you have determined the level of history, the level of physical exam, and the level of medical decision making, you enter one final matrix, to determine the actual level of code you should bill for the office visit.

E&M grid
(Click to see enlarged version)

There, that was easy, wasn’t it?

No, this is not a belated April Fool’s joke: I am dead serious. Ask any doctor about coding E&M services using the federal guidelines, and watch the reaction. But be sure to stand a few feet away–and cover your ears if profanity offends you.

I kid you not: this is the process you must go through to determine the proper billing code for medical evaluation and management services. This is the matrix which must be traversed each and every time your doctor sees you in the office, the hospital, or the ER. This is the gargoyle which the federal government, and their co-conspirators in the health insurance industry, have created and imposed on our health care system in order to standardize payment for services.

And I’ve spared you much of the worst of it: the guidelines are 60 pages long, and jam-packed with ambiguities, critical undefined terms (such as the meaning of “minimal,” “moderate,” or “extensive”), and nearly worthless “examples” of how to implement them. Their fuzziness is such that precise determination of a level of service is virtually impossible with any precision — and therefore subject to a huge amount of interpretation. As you can imagine, such misinterpretation always works to the benefit of the federal government or insurance company — and makes it child’s play to paint an honest physician as guilty of fraud and abuse when the code levels they submit for payment are “interpreted” as being too high, or to deny payment for legitimate services based on “insufficient documentation.”

“But surely,” you say, “the government and the insurance companies must understand the complexity of these rules, and give the physician the benefit of the doubt, given his professional training, presumed integrity, and expertise?”

Clearly your caffeine levels are becoming toxic, or the ischemia in your gluteus maximus is beginning to to ferment flesh-eating bacteria. Time for a break, stretch those legs (don’t want any pulmonary emboli, you know), and we’ll return shortly with our next episode of Dante’s Internist.

9 thoughts on “The Maze – Part 2
Medical Coding: E&M Guidelines

  1. I’m surprised more drs. don’t go into homicidal rages.

    Jack Kennedy once said that Washington DC had Southern efficiency and Northern charm.

    This system combines socialist efficiency and capitalist generosity.

  2. Dr. Bob, I found your blog recently via Moof, who thinks very highly of you. After having read 3 of your posts – Parts 1 & 2 of the Maze and the filler in between, I know I’ll be a regular visitor here :) Maze-1 was good. Maze-2 is mind blowing.
    Some of my friends ask me why I haven’t tried to get a job in the UK or the US. Apart from all my usual reasons I’ll now refer them to your Maze ‘classes’ and Dr. Crippen‘s blog.
    I can’t believe the amount of time and paperwork involved in billing a single visit! In India, the cost of private (non-governmental) health care is borne by patients in most instances. Hospitals and doctors bill their patients on what corresponds to your ‘UCR’ system. Medical insurance is in its infancy in India. Is this what is in store for us in future?! As a radiologist I may not feel it much, but I pity my colleagues in other specialities. I’m sure there must be more doctors who think like you in the US. Is there some way that you can try and put all this right? Or am I being very naive.

  3. Whew! I can’t believe you did that post! You must be exhausted…

    I’m the physician “Compliance Leader” for my department, so I know well of wthat which you speak. And even though I know the regs like the back of my hand, I still have to call someone at least twice a week to ask how to code a particular visit or procedure I’ve done.

    What I find most interesting is that our docs tend to undercode more than overcode once they learn the rules, because they are so afraid they will be jalied, and becuase they truly underestimate the medical complexity of the decision making they do every day. As I tell them – it only seems simple becuae you do it all the time.

  4. I’ll be talking a bit more about some of the unintended (and intended) consequences of this kind of complexity in a subsequent post. Undercoding is endemic among physicians in order to avoid the federal regulatory Rottweilers–which of course benefits the government and insurers, although they deny that this is their intent.

    And I’ll be talking about some alternatives to this system down the road as well.

    And Grumps–don’t be surprised if some day “going medical” means the same thing as “going postal”…

  5. I’m hoping that by the time I finish PA school, it’ll still be true that I can find a job where I:

    1. complete the provider documentation (thoroughly and accurately, of course)
    2. submit it to the office’s billing coder person, and then
    3. never have to think about it again, if it’s not my $&#!-ing practice

    Sometimes, the idea of being merely an “employee” of a practice, working set hours for set salary, and not having my earnings tied to specifically what I bill for, strikes me as a little… cold. Maybe it feels removed from the core values of medicine, where reward should be commensurate with skill and effort; or maybe I’m just cheap. But then, a discussion like this one smacks me upside the head, and I get a spring in my step thinking about getting paid predictably.

    Bless you for taking on all this extra hoo-haw; doctor money is well-earned. I’m cool with less, if it means I don’t have to navigate this nightmare in quite the same way.

  6. Having just seen my doctor today for an upper respiratory infection (I know–URI, which I suppose, if I had to choose, I would prefer over a UTI, any day), this is especially interesting. Since my husband was in there a week ago with the same general complaint, plus a massive sinus headache of more than a week’s duration, we all assumed I had the same thing. I just don’t wait 10 days to go in; call me a sissy, but my throat hurt way too bad to wait.

    The good doctor, and he is, checked my ears, lungs, nose and glands; gave me his blurb about the difficulty of determining rhinosinus infection from allergies, this time of year; and gave me a prescription for Zithromax. Knowing that I don’t like to take meds unnecessarily, he left it to me whether to get it filled and begin the treatment today, or wait another couple of days (longevity: this is day #4). He started to get up, sat back down and posed, “Why didn’t I swab your throat, you ask?” (I didn’t). He then gave me the guidelines currently in use for doing a throat swab, and I didn’t really fit the profile (excuse my language…). We batted it back and forth. “Do you want one?” “You’re the doctor; what do you think? [Pause] My throat really hurts!” So he did one. Congratulations! You’re positive! Thus he affirmed his belief in listening to the patient, which is one of the reasons we love him so much.

    But I notice that, while he marked the Rapid Strep test, his diagnosis was merely URI. So–did he undercode?

  7. Vicki,

    Hard to say–coding lab tests such as Rapid Strep is a different animal–lots of ICD edits, and for multipanel blood work (the ones with 10 or 20 lab tests in one report) each component test has to have an ICD code.

    Undercoding generally refers more to medical services, especially E&Ms, where there is so much judgement involved in interpreting the rules.

  8. Dr. Bob,
    I am a coder for Wound Care physicians. I was researching an E&M question that I had when I came across your website.
    I just wanted you to know you put a smile on my face and made me laugh today as I was reading your article. I appreciated your humor when describing E&M coding. It can be very tricky at times and makes me feel as a coder like I am banging my head against a wall sometimes and getting nowhere.
    Thanks to you I just gave the doctor a 99214!

    Anita Murphy

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