The Covert Rationing Blog

E&M Guidelines and Patient Care

November 28th, 2007 by DrRich

The Happy Hospitalist has posted on the mysteries of documenting for Medicare that one deserves reimbursement for delivering medical care to a patient. HH’s description of the documentation hoops through which physicians now must jump is detailed enough that it’s actually difficult to read. Which is the point.

The E&M (”evaluation and management”) guidelines, introduced in 1995 and revised in 1997, apply to the documentation that physicians are now obligated to provide in support of their Medicare billing. For every patient encounter, doctors are required to write a “note” that fully justifies the billing code they are using (of which there are five levels). The E&M guidelines are part of the government’s fraud reduction activities, and ostensibly reduce the opportunity for fraudulent billing. This, on its face, seems fair enough.

But through their utter opacity and complexity, only partially reflected by the 48 pages of dense prose that comprise them, the E&M rules (in government parlance, “guidelines” are always “rules”) in fact greatly magnify the doctor’s opportunity for making inadvertent documentation errors, and thus of producing a “fraudulent” bill. (As nearly as DrRich can tell, all the government’s anti-fraud initiatives actually create new regulatory speed traps for unwary doctors.)

HH’s post nicely demonstrates how writing a progress note according to the the E&M rules requires assembling a complicated set of “elements” from Column A and Column B, as from a Chineese menu, for each of four subject areas of the patient encounter - the history, the physical exam, the assessment, and the plan. Then somehow, one must translate the result (which reads like a computer-generated form letter) into the proper, fully-supported billing code.

Even if this mess led to a straightforward means of determining proper billing codes (which it does not), it results in a medical progress note that is virtually undecipherable. This means that when another doctor (or even the same doctor on a different day) tries to read the progress notes to figure out what’s been going on with the patient (which used to be the point of medical progress notes, before they became primarily a vehicle for auditors), they cannot.

When the E&M guidelines were first introduced, they were recognized immediately by doctors as a complete abomination. Indeed, the great hue and cry from angry physicians (and the arrival on the scene of a new Republican administration) caused the Secretary of HHS to appoint a special commission to review the E&M guidelines in 2001. The commission concluded that indeed, the E&M guidelines were entirely counterproductive to patient care, and in June, 2002 voted (20-1) to recommend abandoning them altogether.

But HHS declined to follow the recommendations of its own commission, instead leaving the E&M guidelines in force “temporarily,” and vaguely promising to revise them “soon” in order to make them less dangerous to patient care - knowing full well that the saurian lassitude of the bureaucracy would easily outlast the fleeting indignance of the medical community.

Accordingly, not only has HHS failed to take (or, alternately, succeeded in not taking) steps to revise the E&M guidelines, they also have vigorously pressed forward with audits and prosecutions for the federal crime of healthcare fraud, based on physicians’ inadequate compliance with them. And, as the bureaucrats must have predicted, there has not been any substantial noise from doctors about revising these guidelines for several years now.

What’s more - judging from the current aspect of younger doctors, exemplified, DrRich supposes, by the Happy Hospitalist - there never will be. For the E&M guidelines - while still hated - have been fully absorbed into modern medical practice; they are just another of the multitudinous impediments that various entities have busily created in order to obstruct decent patient care, just one of the countless absurdities one must live with if one wants to practice medicine in the U.S.A. The E&M guidelines, in other words, have become normal.

Accordingly, a multimillion dollar industry has sprung up to help physicians better comply with these coding guidelines (or rather, to teach them strategies for avoiding federal audits, since nobody can truly comply with undecipherable guidelines). Physicians across the country are spending the time and money allotted for their continuing medical education learning to become better accountants, rather than better physicians.

And so, the E&M guidelines have become just one more example of how covert rationing (in this case, promulgated as a means of further controlling physician behavior, even at the cost of explicitly and “officially” harming patient care) invariably leads to increased complexity, opacity and waste.

Posted in Wonkonian Rationing, Primary Care in America

3 Responses to “E&M Guidelines and Patient Care”

1. Dan wrote on 11/28/07 at 5:21 pm :

   You hit the doggone nail on the head again. Anyone reading a progress note dictated by a physician attempting to comply with E & M guidelines and code the encounter as a level 4 in order not to lose money on the visit will be struck by the similarity to a progress note written by a 3rd year medical student. All kinds of irrelevant information will be included for the purpose of avoiding that nasty Medicare audit later on. Of course, with an EMR that has templates allowing the physician to rapidly click on the relevant items to be included, the time factor can be managed. This doesn’t improve patient care, except indirectly by permitting the physician to stay in business instead of takiing a secong job as a Wal-Mart greeter.

2. The Covert Rationing Blog » Blog Archive » Another Way to Run Afoul of E&M Coding wrote on 12/4/07 at 10:23 pm :

   […] Last week, DrRich ranted on the E&M coding guidelines, and attempted to demonstrate how this oppressive and uninterpretable set of rules has harmed patient care, and has exposed many if not most doctors to the constant threat of an unpleasant visit from the Office of the Inspector General. […]

3. The Covert Rationing Blog » Blog Archive » Covert Rationing Even Wrecks Socialism wrote on 12/11/07 at 2:00 pm :

   […] contracts that any sane person would find unconscionable; forcing doctors to practice under a set of coding “guidelines” that prevent good patient care and serve as traps for “fraud;” and in general, making […]

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