Evaluation and management has come full circle

I have been in the highly regulated healthcare industry for all my adult life---27 years to be exact. Part of what I love about being in health care is the ever-changing landscape. The one constant in my 27 years is evaluation and management (E/M) coding based on the 1995 and 1997 E/M guidelines. The MAC carriers have their guidelines, sure, but I always had the 1995 and 1997 E/M guidelines. This structure has been in place for 21 years, so I have them beat by six years. In the back of my mind, I always knew these guidelines would be on the chopping block and revised, but how? I think Lyle Schofield, 3M senior technical manager, data science, says it best:

“I don't know if I need to be quoted on this (I doubt I'm the first one to have this observation), but E/M coding is the largest volume by far of Medicaid dollars spent, the most expensive to dictate, one of the most complicated to code, with vague guidelines, with the most inter-coder disagreement, for the least amount of money.”

In considering the CMS proposal for changes to the E/M guidelines, I can't help but reflect back on my years in the healthcare industry, I often compartmentalize the different stages of my auditing and teaching work. I think of my E/M experience---my timeline with E/M---in three phases:

“Please, please, please write something down” era

I started working the guidelines in a paper chart world.  We were masters of reading and deciphering squiggly lines. We learned each clinician's handwriting. I spent most of my time trying to get providers to write something down---please, anything---and also to write legibly for the auditors. I won’t tell you how many charts had just two words written on them for a date of service. The guidelines were new, but we knew even at that time, two words wouldn’t cut it. I was young and optimistic, but I did feel like the providers were masters of their universe and my sense was that they weren’t “unhappy.” I had this false sense that being a doctor was an awesome job. My grandma was a nurse in the operating room for 50 years. When she wasn’t working, she was house sitting for the surgeons. The houses were mansions and lovely. Looking back at paper charts from my perspective today is extremely eye opening. I recently had a chance to look at my husband’s medical record from the VA. As a child, he had several surgeries and was in and out of the hospital. The chart documentation was only about half a paragraph. Dates with diagnosis and treatment.

“Don’t go to jail” era

I was fortunate enough to work with clinicians that were early adopters of the electronic medical record. I do remember this technological shift in the industry. It was a time when I would have no problem calling insurance companies to explain the computer was down and request they reprocess the claims. Fraud and abuse were at the forefront and insurance companies were hiring their own physicians/clinicians. I still hear reverberations of this time with some physicians and clinicians today. They distinctly remember being threatened with jail time. You could feel a real shift in the atmosphere. Auditors that worked for the clinicians could be heard saying such things as “you won’t look good in orange.” 

I am glad to say that I have never used that tactic when working with clinicians. I have the utmost respect for clinicians and always believed I would not have a job without them. Electronic medical records hit the scene and I felt like the clinicians were on the upswing of documenting. I rarely heard clinicians complain that another provider's medical record had too many HPI elements or history elements---the concern was cleaning up the problem and medication list. Clinicians and physicians were now counting clicks. I did extensive trainings with clinicians about their coding and often found that clinicians were undervaluing their work. I never instructed them to do anything for coding but rather, if it makes sense and you performed the work, to please document.

I never thought I would see the day that clinicians would use NLP voice recognition and medical record software, as well as participate in software super user groups. I even saw clinicians choose their place of employment based on an organization's use of medical record software. My personal clinician was in private practice and I spent many years in her care. One day, I came to the office and saw a bunch of new equipment and I knew she had finally merged with a system. I assume it must have been impossible for her to stay in private practice and keep up with all the costs and technology.

Once I started teaching about the impact of Hierarchical Condition Categories (HCCs) on physician practices and the importance of documenting based on the severity of a patient’s illness, I began to feel the physicians were ready to revolt.  No one said it, but I sensed that they viewed this as another burden. I always had to discuss the financial impact to get buy-in, and even then, it felt like it was ONE MORE THING. I heard that the number of students going into internal medicine residency was dropping.  Potential students were going to be investment bankers instead. I will never forget one clinician in my training session who told me that medicine is an art, and that documentation is a piece of that art. In my heart I want the physicians and clinicians’ voices to be heard for the sake of their job satisfaction. I was naive when I was 19 years old, but I felt like the clinicians I worked with then were happier.

…..And now the "paradigm shift” era

Full disclosure: I am writing this blog based on my general feelings and I know that I haven’t been the greatest historian with exact timelines. I remember the events based on the experience of the healthcare community as a whole. When I listened to CMS' new E/M proposal, my first thought was, I wonder how the clinicians are feeling about this? I do agree these guidelines are very old and I have seen the confusion among clinicians when I try to explain what gets credit and what doesn’t (bowel sounds anyone? Yup, no credit under 1997 guidelines). I have heard clinicians tell me about crazy algorithms that they use to calculate an E/M CPT code. I have also seen clinicians throw their hands up and decide that a level three is safe. In other words, rather than try to figure it out, let’s just go middle of the road. I do have the sense that the clinicians will be asked to do more with less. Will documenting a level two history and exam really ease their burden? I read some of the 15,000 entries that came in during the comment period. I did not read all of the comments, but I read enough to recognize a consensus. Almost all clinicians who submitted a comment were not in favor of the proposed changes to E/M.  In my brief review, I did see one comment that was in favor of the proposal, and interestingly enough, it was from a software vendor. Here are some of the highlights:

“Your current proposition is another government suggestion by bureaucrats who know nothing about what your average physician has to deal with on a daily basis. So now you are asking us to accept the same fee for an uncomplicated visit versus the most complicated visit. I guess the next time I see my automobile mechanic I will ask him why his fee for changing my transmission is so much higher than an oil change. Or more accurately I should ask him if I can pay the lower fee for both.”

“As if the logic of your first proposal isn't bad enough I would like to know how this will ease my documentation burden? A complicated visit will still require more complicated documentation than a simple visit. In closing I vote no.”

“If we are only allowed to address one problem at a time or go bankrupt, fewer and fewer internist will be able to stay in practice.”

“We do not believe the streamlined payments would be equitable across primary and specialty care. Most importantly, we are very concerned about the impacts this set of proposals will have on clinical practice and patient access to care nationwide. Specifically, we are concerned that the proposed payment methodology will cause providers to shift focus away from Medicare beneficiaries and away from clinically-complex patients.”

The overall theme is that the CMS proposal will hurt patient care and cause significant negative financial impact.

If I were to compile sound bites from the last 20 years of the messages clinicians heard regarding their E/M coding, it would be maddening and downright confusing from their point of view:

“If it not documented, it wasn’t done”
“You could be put in jail”
“Let the auditor feel your pain”
“Document, document, document”
“Canned notes are a no-no!”
“Do not copy and paste”

And now that we have come full circle, we get to go back to the physicians and clinicians that we have trained all these years to document and now say…good news, you only have to document 2-3 bullets for HPI, maybe two reviews of systems, one pertinent history, a limited exam, a definitive diagnosis and plan and you are done! Forget everything that I have been telling you for years, I hope this is easier…also, go back and change all your templates. Most of the trainings that I have performed revolved around the medical decision making component which I feel will still be one of the key drivers to ensuring the visit meets medical necessity. The focus will shift, but the overarching criteria of medical necessity is still at play.

I am fortunate to work for a manager that I look up to. She has several pieces of wisdom that she shares frequently, one of which could be applied to what we are facing in the E/M realm. She strongly believes that people will support what they create. I know the E/M guidelines are due for an overhaul. but the right people should be in the room. The AMA has formed an E/M workgroup with physicians and health professionals with the goal of analyzing the issues and providing concrete solutions by 2020. The comments for the proposal strongly encouraged CMS to work with the AMA workgroup whose sole purpose is to come up with recommendations. I believe the guidelines need to be overhauled and we need to seriously consider the burden facing our physicians and clinicians. I agree with the stepped approach and with the patients over paperwork initiative. It is an exciting time in health care, and I never thought I would see E/M come full circle: “Please write something down” to “Level two documentation will now suffice.” 

Jean Jones is a coding analyst at 3M Health Information Systems.