Evaluation and Management Codes – Managing the Process Mastering the Rules

Although neurosurgeons often assume that most of their work is performed in the operating room, more than 25 percent of a typical neurosurgical practice collects income from evaluation and management (E&M) services. Moreover, a significant portion of the physician work component of global surgical services in the resource-based relative value system (RBRVS) involves E&M services provided by the surgeon, including hospital and office visits. Finally, the perceived and occasionally real threat of practice audits to examine the appropriate usage of E&M codes has prompted a great deal of interest in mastering this often complicated set of rules. The following review of E&M coding includes the evolution of the rules governing E&M over the past decade, followed by a glimpse into the possible future format that E&M guidelines may take.

E&M Codes Debut in 1992
The current codes for E&M services were introduced into Current Procedural Terminology (CPT) in 1992 along with the adoption of the relative value system for assessing physician work. The American Medical Association’s CPT Editorial Panel began to develop this revision three years earlier to improve coding uniformity. At the same time, the Centers for Medicare and Medicaid Services (CMS-at the time known as the Health Care Financing Administration, or HCFA, an agency of the Department of Health and Human Services) was charged with developing a uniform system as part of standardizing Medicare policy. Multiple factors were considered including levels of service, site of service, differentiating patient type, and the importance of time. A pilot study conducted in 1991 used clinical descriptions of typical patient visits, which were subsequently field-tested in the second phase to determine reliability in actual practice. After revising the guidelines based on these studies, the CPT Editorial Panel implemented the E&M revisions in 1992, and these were accepted by CMS. The previous levels of service were replaced with a “more precise” method of assigning codes based upon the now familiar triad of history, physical examination, and medical-decision making. Although time was included as a contributory component to help guide practitioners, CMS emphasized time as an ancillary factor to facilitate choosing the appropriate level of service.

The work relative value units (RVUs)-the value of each CPT code in the Medicare Fee Schedule- were revised in 1993 by CMS after deciding that the work per unit time should be uniform among these services and the RVU should increase linearly as the level of service increases. The assigned RVUs were reevaluated by CMS in 1998 as part of the five-year review. Concurring with the Relative-value Update Committee’s recommendations, CMS increased the RVUs for E&M services based on the argument that these were undervalued compared with other physician services.

RVU Guidelines Implemented in 1995
Guidelines for proper use of RVU codes were implemented in 1995. At that time, a general physical examination was the template for the E&M service. Since specialists did not perform a general physical examination, but instead performed a comprehensive specialty-specific examination, revised 1997 guidelines included organ-system specific examinations in lieu of general physical examinations. However, the “accounting” method of describing varied physician activities in a bulleted format prompted frustration and discontent among various physician groups. The AMA responded by developing an alternative recommendation for revising the documentation guidelines to CMS.

In June 2000 CMS issued a draft guideline that was revised the following December. CMS contracted with Aspen Systems Corporation to develop clinical examples that would serve as guides for promoting accurate coding of E&M services. Clinical examples derived from actual medical records were used and presented to the AMA in May 2001. Many specialty societies voiced concernsss about the methodology and implications, prompting the AMA to write a letter to Thomas Scully, CMS administrator, describing the identified problems and requesting the opportunity for specialties to develop clinical examples. In July 2001 the Department of Health and Human Services and its agency, the CMS, agreed to work with the AMA, and the CMS brought the Aspen project to a halt. The AMA formed an E&M workgroup to evaluate current problems and make recommendations to the CPT Editorial Panel for consideration. Neurosurgery is indebted to the efforts of Troy Tippett, MD, who served on the E&M workgroup and helped guide the process to fruition.

E&M Workgroup’s Findings
In August 2002, the workgroup presented its findings to the CPT Editorial Panel. Many options were discussed by the workgroup, ranging from developing a single code to maintaining the current guidelines. Given that various clinical scenarios require different amounts of emphasis on the various key components, the workgroup felt that medical decision-making with the required clinically appropriate history and examination will drive the time and physician work required to provide a given service. The workgroup recommended moderate changes to the existing guidelines, including the elimination of some confusing service types and the establishment of new code descriptors and criteria that appropriately reflect the intensity of total physician work, particularly the importance of medical decision-making in the choice of a given level of E&M service.

While either the 1995 or 1997 documentation guidelines are being utilized currently, a newer system is likely to be implemented in the future that reflects the cognitive efforts of the physician in providing patients with appropriate medical care rather than “counting” the number of activities performed.

Gregory J. Przybylski, MD, is associate professor of neurological surgery at Northwestern Memorial Faculty Foundation of Northwestern University in Chicago and a faculty member for AANS-sponsored coding and reimbursement courses.