I can only guess that someone was trying to convince CMS that medical care was becoming about outpatient chronic and multimorbid care, that even the maximal level outpatient payment would not suffice.
Before 1995 we had three levels of billing outpatient visits which all payed less than the 14 and 15. The manual used examples from multiple specialties to help you decide which visit your visit compared to. They were rather good examples clearly coming from practicing physicians. You could just decide which of the series of vignettes described an equivalent amount of work. Rule out angina was definitely a 3. At the time I was reading AMA News religiously (free for having joined AMSA when I was a student), and never was it mentioned that CMS had a problem with how we chose our level to bill.
Then came the 1995 E and M guidelines, which should more appropriately be called rules because no longer was our judgment required. Where did they come from? Well without even knowing it was the nonpracticing remnant left in the AMA you could certainly guess it was someone like your internal medicine subspecialist attending who dominated most of your classroom and hospital based education, at least in the eighties. The ROS used to be taught as an exhaustive list, and no one ever said any part of it was optional on admit. You quickly learned it was impracticable and the only way to get your work done was to figure out where to cut corners. Most settled on defining one problem from every system as “complete”, and just writing that, though the lowest on the totem pole had to write each system and a symbol for negative. That way you’d never have to remember the question or the answer or be responsible to follow up on a symptom that was unrelated to the issue at hand. We all knew that whatever way it was documented, the meaning was undefined. Another strategy was putting your HPI pertinent positives and negatives there instead.
Then as now, no studies were done to determine how to work up a problem you discovered only by ROS, obviously not the same population as those who scheduled a visit with a cheif complaint. We all had to figure out on our own how to apply this ivory tower stuff in the real world, and we did a pretty good job. No one ever suggested the ROS should be done at outpatient visits until they had to define a complex outpatient visit that deserved more pay. So the ivory towers figured that since hospitalized patients were the pinnacle of complexity, and probably all they knew, the admit H and P should be the model. The complete physical exam was becoming recognized as obsolete only in the outpatient world, but that got included too as an alternative.
And so it began. And we exhibited the same false bravado we had to in our training, saying to any power, ‘sure I can do that too’ when you can’t, and then of course cut corners. There’d be no reaction to the ivory towers, just as in our schooling. It was before social media and before we got squeezed to death with enforceable demands. There was no noticeable public discussion before or after implementation of the 1995 rules either. AMA News or or FP newsletters and journals saw their role as merely teaching us how to do it.
But still they worried the interpretation of the rules in some parts was too ambiguous for vigorous enforcement, so then came the 1997 guidelines. All of a sudden doctors objected en mass because it was even more cumbersome and silly, and they’d had two years to realize what was going on. The AMA News published apologies to us for nearly a year, constantly expressing shock at the magnitude of the response, and the compromise was that we could choose the 1995 guidelines instead.
What if we were not so full of false bravado and said it sooner?