To the Editor:

I have a fundamental difference of opinion with the Health Care Financing Administration (HCFA) regarding coding and office/progress notes. [See “Sneak Preview of the (Revised) Revised E/M Documentation Guidelines,” September 1999.]

Office notes are maintained as evidence of what we have done in a patient encounter, and they serve two general purposes: to remind us of the patient's clinical problems and treatment plans, and to help us communicate with colleagues about the care we have rendered.

The progress note is by no means the entire record of the visit. It is simply a snapshot of what transpired. For lack of time, many routine and normal findings are not recorded. In addition, because our job is to find the problem, not what is normal, we chart largely by exception. When we perform a physical on an established patient, it is a waste of time and chart space to record the family history for the fifth time or to go through the entire review of systems.

HCFA's bullet-counting system has twisted what should be a clinical document into an economic document, which physicians try to “fluff up” to achieve higher visit levels. The clinical effects of this are a loss of esteem for the writer of those notes and incredibly poor communication — but great documentation for the bean counters.

Response:

I agree that the 1997 “Documentation Guidelines for Evaluation and Management Services” are unnecessarily onerous for patient visits. That's why the CPT Editorial Panel has submitted a “new framework” to HCFA that would greatly simplify these guidelines. Like it or not, such guidelines are required to justify reimbursement for each visit.

I disagree, however, with the assertion that the medical record is not a reflection of the complete patient visit. In addition to being a clinical document, the medical record is also a legal document, and thus all pertinent positive and negative findings of the history and exam should be clearly documented. Remember: If it is not documented, it did not occur.

It's also important to remember that the documentation guidelines do not require the re-documentation of history and exam elements that have not changed; a reference to the previous recording of this information is adequate. And if you use the proper CPT code for preventive medicine visits, the documentation guidelines don't even apply!

While the current guidelines do need to be revised for easier clinical application, I believe that carefully applied guidelines can empower family physicians to code appropriately at higher levels of service for work we always do but usually do not record.