E&M Guidelines: Taking a Close Look

Original story posted on: April 12, 2021

Chronic or acute: questions persist in the new guidelines.

You know, we have been using the new evaluation and management (E&M) guidelines for 96 days now, and if they had the ease and efficiency, we were told they had, I don’t think we would still be stumbling over the questions that we get on a daily or weekly basis like we do.

I think if we were able to process the changes with the good intent in which the American Medical Association (AMA) made them, then of course, yes, we could, but I don’t think that same good intent is the one in which they will be processed at the level of the carrier. Is that due to malfeasance? Is that due to literal interpretation of the rules? Is it due to the old standby thinking of the carrier versus the physician?

The first column of the new medical decision-making (MDM) table, which is really the table of risk, is emblematic of the complexity of the presenting problem. There are multiple drivers in this column, but I think we would all agree that the main driver is whether the problem is chronic or acute. In the grading of the complexity of the chronicity and acuity, it becomes “easier” to reach higher levels of complexity for chronic conditions than acute conditions. AMA has now included a definition within the new guidelines indicating that a chronic condition is one the patient will have for at least one year, or until death.

So, now I ask you, my auditor friends, out there: is it incumbent upon the provider to prove this within the documentation? And let me add that I am not talking about when the provider says the patient has chronic back pain. In those instances – when the provider has diagnosed and documented the word “chronic” – we are good. It is when the word “chronic” is not documented, but rather inferred, that there’s an issue.

Let’s talk examples.

Say glaucoma or diabetes: the average person realizes that these are chronic conditions – that once a person has them, they have them. And while they may become controlled, they are lifelong conditions. Therefore, when the provider states that a patient has these conditions, I feel pretty confident that the carrier will count them as chronic conditions. However, how can I, from a compliance perspective, raise my “pretty confident” to “confident?” The history and present illness (HPI). While we don’t score history, it can complement the MDM, and having duration included would help define the chronicity of the problem.

What about a patient with hearing loss or lower back pain? These are problems that could be chronic or acute in nature. I will say one problem I have found in the these first 96 days with this new definition involves working with a physician with such an example. I tell them that for a patient they are managing for lower back pain, I will have to downcode, because they did not document that it is a chronic problem; the documentation of duration is less than one year, so therefore I have to categorize it as acute (there are not systemic or complicating factors to relate to the moderate category). However, it could be categorized (had the duration met the chronic factor) as a chronic, exacerbated problem that is being managed by increasing medication and sending the patient to physical therapy.

Herein lies the frustration. The AMA’s changes are well-intentioned, purposeful, and patient care-driven. But the interpretation that will be made from the verbiage listed will not be used in that same well-intentioned, purposeful way.

The moral of the story: be purposeful and well-intentioned in your documentation and tell the patient story, focusing on the SOAP (subjective, objective, assessment, and plan) note.

Shannon DeConda CPC, CPC-I, CEMC, CMSCS, CPMA®

Shannon DeConda is the founder and president of the National Alliance of Medical Auditing Specialists (NAMAS) as well as the president of coding and billing services and a partner at DoctorsManagement, LLC. Ms. DeConda has more than 16 years of experience as a multi-specialty auditor and coder. She has helped coders, medical chart auditors, and medical practices optimize business processes and maximize reimbursement by identifying lost revenue. Since founding NAMAS in 2007, Ms. DeConda has developed the NAMAS CPMA® Certification Training, written the NAMAS CPMA® Study Guide, and launched a wide variety of educational products and web-based educational tools to help coders, auditors, and medical providers improve their efficiencies. Shannon is a member of the RACmonitor editorial board and is a popular guest on Monitor Mondays.

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