Group Calls for Radical Reform of E/M Documentation Guidelines

Ken Terry

February 01, 2019

The American Medical Informatics Association (AMIA) on January 28 called for the US Department of Health and Human Services (HHS) to adopt a long-term electronic health record (EHR) strategy of "decoupling clinical documentation from billing, regulatory, and administrative compliance requirements."

Commenting on HHS' new roadmap to reduce the regulatory and administrative burden of EHRs and health information technology (IT), Douglas B. Fridsma, MD, president and CEO of AMIA, said his organization supports the goals outlined in the clinical documentation section of the strategy paper.

"However, we recommend that CMS [the Centers for Medicare & Medicaid Services] chart a course toward more dramatic E/M [evaluation and management ] documentation guidelines reform — or abandon the methodology altogether," he wrote in a letter to officials of CMS and the Office of the National Coordinator of Health IT (ONC), which developed the strategy.

CMS's E/M documentation system, which is used by private payers as well, "does a poor job of capturing the complexity of the patient's clinical status, the relevant clinical decision making, and the sizeable administrative demands related to patient care," Fridsma said.

To comply with the E/M coding requirements, he noted, much "superfluous and duplicative information is recorded," which is not only a waste of time but also makes it difficult for clinicians to find important information in patient charts.

Instead of continuing following the current E/M guidelines, AMIA recommends that CMS convene specialty societies and health IT professionals to develop new E/M coding criteria and revamp EHRs to accommodate them.

This would be a giant step beyond where CMS has already gone with the E/M guidelines. In November, the agency announced, as part of its 2019 update of the physician fee schedule, that it will phase in a plan to simplify the requirements for billing office visits. Starting in 2021, CMS said, it will collapse the level 2, 3, and 4 E/M billing codes into one. That will leave three E/M codes, including level 1, which doesn't involve a doctor's services, and level 5, designed for patients with complex conditions that take more time and work.

In addition, under the new regulation, doctors will be able to use the complexity of medical decision making or the time spent on a visit, instead of the current E/M guidelines, to justify their E/M coding. Physicians who continue using the E/M guidelines won't have to re-record the list of required elements at every visit if the doctor attests to reviewing previous data.

Changing EHR Design

The biggest obstacle to ONC's roadmap, Fridsma said, is the structure of current EHRs. "Most EHRs are designed to support transaction-based, fee-for-service (FFS) billing requirements and business processes for regulatory/administrative compliance, rather than reflect clinical observation and treatment."

EHRs got this way partly because they were initially sold to physicians in the belief that better clinical documentation would justify higher E/M codes and thus higher payments. But the AMIA chief said the current design of EHRs can be traced partly to Medicare regulations, such as conditions of participation, the CMS claims processing manual, and the annual "work plan" of the HHS Office of Inspector General (OIG). CMS's Merit-Based Incentive Payment System (MIPS) and Promoting Interoperability Program have also made EHRs more complex.

For example, Fridsma said, the Medicare conditions of participation include a discharge planning regulation that specifies a multistep process for hospital discharge planning, all of which must be reflected in the EHR. The OIG work plan focuses on adverse events in hospitals, including clinician review processes that must be integrated into the EHR. And the data that must be reported to MIPS don't necessarily reflect the patient's clinical story, but they do require complex documentation at the point of care, he said.

Decoupling documentation for clinical care purposes from such administrative and regulatory requirements, Fridsma said, "can markedly reduce clinical burden." Changing or dropping the E/M guidelines is key to this decoupling, he stated. "Greater reform [of E/M coding] or development of a new approach should be the central workstream towards decoupling clinical documentation from billing requirements."

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