Jun 1998 Table of Contents

REIMBURSEMENT STRATEGIES

MEDICARE UPDATE

Changes Proposed for the E/M Documentation Guidelines



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Fam Pract Manag. 1998 Jun;5(6):14-15.

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It's official. Implementation of the revised E/M documentation guidelines has been delayed to allow time for further changes. The announcement was made at a special fly-in meeting convened by the AMA on April 27. In a letter to AMA President Percy Wootton, MD, that was made public at the meeting, HCFA Administrator Nancy-Ann Min DeParle agreed to postpone implementation until “revisions have been completed and there has been an adequate period of time for testing and education.”

In the meantime, carriers will continue evaluating claims using the 1994 and 1997 versions of the documentation guidelines, “whichever is most advantageous to the physician,” the letter states. A new implementation date will be announced in the fall, and DeParle pledged that HCFA will work with physicians to make the guidelines easier to understand. (See the related editorial in this issue.)

A new framework

The focus of the AMA meeting was a “new framework” for the guidelines developed by the CPT Editorial Panel and presented by family physician Douglas E. Henley, MD. The proposals, which will be subject to further review and revision in the coming months, include significant changes in the history, exam and medical decision- making guidelines. The proposed changes are the product of comments the AMA received from approximately 100 individual physicians, 10 state associations and 35 specialty societies, including the AAFP.

Here is a summary of the proposed changes:

  • Redefine the HPI so that its level depends on the number of historical items documented, not the number of HPI elements;

  • Redefine the extended HPI to include assessment of the status of at least three acute conditions;

  • Make the overall level of history dependent on documenting two of three elements rather than three of three elements;

  • Clarify that when a history cannot be obtained because of specific patient conditions, the history may be deemed comprehensive;

  • Eliminate the distinction between general multisystem and single-organ-system exams by incorporating exam elements for each into one long list, adding elements for other types of exams (pediatric, maternity, etc.) as needed;

  • Eliminate the requirement to count systems and body areas documented, and make the level of exam dependent only on the number of exam elements documented;

  • Reduce the number of elements that must be documented for each level of exam;

  • Eliminate the “presumption rule” for comprehensive exams, which said that a comprehensive exam could be justified only if all elements of the exam were performed, even though documentation was not required for some;

  • Reduce the levels of medical decision making from four to three (straightforward, moderate complexity and high complexity);

  • Allow the most complex component of medical decision making to determine the overall level.

Next steps

During the meeting's afternoon session, representatives of the AMA, the CPT Editorial Panel and HCFA gathered additional suggestions from participants in discussion sessions devoted to history; examination; medical decision making; training and education; pilot testing, evaluation, maintenance and monitoring; and communications and advocacy. Henley said the CPT Editorial Panel would make these suggestions the focus of its May meeting and release a new draft of the guidelines for comment in time for the AMA annual meeting in June (the new draft was unavailable at press time). At its August meeting, the CPT Editorial Panel plans to make additional revisions resulting from the June-July comment period and finalize the guidelines for pilot tests tentatively scheduled to begin in the fall.

Enforcement concerns

A number of physicians expressed anxiety about being targeted for fraud and abuse investigations despite their best efforts to follow the documentation guidelines. In her letter, DeParle addressed the growing concern: “Many physicians fear they will be unjustifiably targeted for fraud and abuse investigations as a result of simple coding errors. I want to do what I can to allay those fears.” She added, “I want to assure you that physicians will not be punished for honest mistakes and we will not make referrals to the Office of the Inspector General for occasional errors.” DeParle also wrote that HCFA will remind carriers that physicians are not to be punished for honest errors.

FPM will continue to update you on the Editorial Panel's activities and announcements from HCFA, and we plan to publish articles and educational tools as soon as new documentation guidelines are finalized.

Copyright © 1998 by the American Academy of Family Physicians.
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