HCFA To Test Revised Documentation Guidelines

New Documentation Guidelines Now on Web

Documentation Guidelines Streamlined

View an online PowerPoint presentation at HCFA's website by following this link:

http://www.hcfa.gov/medicare/062200em.ppt

New Documentation Guidelines Now on Web

The Health Care Financing Administration has posted a draft of the new evaluation and management documentation guidelines on its web site so physicians can review them and send comments to HCFA.

In a June status report on the development of the new guidelines HCFA said that it agrees with physicians that "we need simpler, clearer documentation guidelines."

HCFA has said it will conduct two studies of the new guidelines. The first will weight each key component of the guidelines equally, and the second will assign significantly greater weight to the medical decision-making component.

After initial studies are completed by the spring of 2001, HCFA expects to implement the new guidelines by January 2002.

The new guidelines can be accessed at http://www.hcfa.gov/medicare/2000emd.doc.

Documentation Guidelines Streamlined

HCFA will pilot-test the revised guidelines during the coming year. The target for adoption of new guidelines is 2002.

The HCFA press release announcing the new guidelines did not specify which guidelines auditors will use while the revised guidelines are pilot tested.

The revised guidelines are shorter, down from 50 pages to 12 pages. Compared with the 1997 version, the new guidelines require more documentation in some areas and less in others. The revisors based their revisions on the 1995 guidelines, according to a HCFA press release. The 1995, 1997 and 2000 versions are available for downloading at http://www.hcfa.gov.

Payers may require documentation to validate 1) the site of service, 2) the medical necessity and appropriateness of services provided and 3) that services have been accurately reported, the guidelines state.

The general principles of documentation, as stated in the revised guidelines, are:

• The medical record should be complete and legible.
• The documentation of each patient encounter should include: the chief complaint and/or reason for the encounter and relevant history, physical examination findings and prior diagnostic test results; assessment, clinical impression or diagnosis; plan for care; and date and a verifiable legible identity of the health care professional who provided the service.
• If not specifically documented, the rationale for ordering diagnostic and other ancillary services should be able to be easily inferred.
• To the greatest extent possible, past and present diagnoses and conditions, including those in the prenatal and intrapartum period that affect the newborn, should be accessible to the treating and/or consulting physician.
• Appropriate health risk factors should be identified.
• The patient's progress, response to and changes in treatment, planned follow-up care and instructions, and diagnosis should be documented.
• The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.
• An addendum to a medical record should be dated the day the information is added to the medical record and not dated for the date the service was provided.
• A service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.
• The confidentiality of the medical record should be fully maintained consistent with the requirements of medical ethics and of law.

Requirements for history and examination

Level 1 visit
There are no specified requirements for documentation of a level 1 visit. (No change from 1997 guidelines.)

Level 2 visit
The clinician must document a minimum of 1 element of history of present illness and 1 element of examination. (No change from 1997 guidelines.)

Level 3 visit
The clinician must document a minimum of 1 element of history of present illness, 1 element from review of systems (ROS), 1 element from past, family and social history (PSFH) and 1 element of examination. (Compared with 1997 guidelines, the revised guidelines require 1 additional historical element (PSFH) but 5 fewer elements of exam.)

Level 4 visit
The clinician must document a minimum of 4 elements of history of present illness, 3 elements from ROS, 2 items from PSFH and 3 elements of examination. (Compared with 1997 guidelines, the revised guidelines require 1 additional element of ROS and 1 additional element from PSFH, but 9 fewer elements of examination.)

Level 5 visit
The clinician must document a minimum of 4 elements of history of present illness, 9 elements from ROS, 2 items from 2 of the three PSFH areas and findings from 9 body areas or organ systems. (Compared with the 1997 guidelines, the revised guidelines require 1 fewer ROS and greatly reduce and simplify the requirements for examination.)

Note re PSFH:
At least one specific item from 2 of the 3 history areas must be documented for a complete PFSH for the following categories of E/M services: office or other outpatient services, established patient; emergency department; subsequent nursing facility care; domiciliary care, established patient; and home care, established patient.

At least one specific item from each of the 3 history areas must be documented for a complete PFSH for the following categories of E/M services: office or other outpatient services, new patient; hospital observation services; hospital inpatient services, initial care; consultations; comprehensive nursing facility assessments; domiciliary care, new patient; and home care, new patient.

New patients
If seeing a new patient, a clinician must meet documentation requirements regarding history, exam and medical decision-making. In contrast, if seeing an established patient, the clinician need meet the requirements of two of the three components of medical work; for example, history and exam, or history and medical decision-making.

Medical decision-making

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