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Fam Pract Manag. 1998;5(6):8-10

Nothing since the health care reform debate has created such ire or angst in the physician community as the proposed Documentation Guidelines for Evaluation and Management (E/M) Services. These guidelines were developed by HCFA and the AMA in concert with representatives of organized medicine; they were brought about because of HCFA's desire to determine whether providers billed appropriately for E/M services. It is not useful to re-analyze the development of these guidelines or to try to assign blame or responsibility.

The guidelines were originally intended to be a relatively noninvasive way for HCFA to ensure that the medical record would document the services being delivered and support physicians' reimbursement claims. Unfortunately, the guidelines have become more intrusive with every step in their evolution. The medical record simply isn't intended to support claims, and implementing the 1997 guidelines would require radical modification of the documentation systems employed by many physicians. Almost everyone who has studied the guidelines agrees that they would require a significant increase in physician time, would clutter the record with extraneous material, would actually impede patient care and would not even be effective in preventing fraud. The 1997 guidelines are fatally flawed.

Despite their flaws, the guidelines might not have caused so much controversy if they had not been coupled with the federal effort to ferret out fraud and abuse. Federal officials and others have repeatedly claimed that they could fix the financial problems of Medicare if they could stop fraud and abuse in the system. The Office of Inspector General recently announced the results of its annual audit of HCFA, which found that HCFA improperly paid $20.3 billion in claims in 1997. The audit attributed approximately 29 percent of that figure to physicians' services, most of it due to claims with improper documentation or none at all. The AMA has called into question the Inspector General's methodology. Regardless whether the audit figures are accurate, the specter of HCFA using unworkable guidelines as a tool to squeeze so much money out of claims alarmed physicians across the country.

There was an overwhelming outcry from practicing physicians and their organizations that these guidelines would interfere with care and decrease access for Medicare beneficiaries. The AAFP took the position that the guidelines are so flawed that they need to be completely redone and that any future guidelines should be pilot tested to demonstrate that they are workable. In response to the increasing clamor, the AMA held a meeting on April 27 in Chicago to look at what needed to be done to come up with acceptable guidelines. All medical specialty and state societies were invited.

This meeting started with the reading of a letter dated April 24 from Nancy-Ann Min DeParle, the administrator of HCFA, to Percy Wootton, MD, president of the AMA. In this letter HCFA states that final implementation of the 1997 guidelines will be delayed and that no further guidelines will be implemented until they have been revised and pilot tested and until physicians and carriers can be educated on their use. In the meantime, physicians should continue to use either the 1994 or the 1997 guidelines, whichever they find more advantageous.

In addition, the letter states explicitly 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.” Furthermore, it contains the reassurance that “sanctions are intended for physicians who act in ‘deliberate ignorance’ or with ‘reckless disregard’ of the truth or falsity of information.”

Also at the meeting, the AMA CPT Editorial Panel announced proposed changes in the 1997 guidelines. The changes are substantial and appear to constitute the basis for new and much improved guidelines. (See “Changes Proposed for the E/M Documentation Guidelines” for a summary.) They appear to require medical documentation that is much more closely related to what physicians would consider an adequate medical record, especially in the case of the multisystem exam. All medical specialty societies have been asked to comment on the proposed modifications and to suggest further refinements and improvements. The AAFP will participate actively in this process, continue to represent the interests of our members and work to assure that new guidelines will not interfere with patient care.

The fraud and abuse issues are still significant. We are reassured by Ms. DeParle's statement but would like further assurances that the Department of Justice and other investigating bodies will not go after physicians for unintentional mistakes. We have heard many stories about physicians who have been inappropriately sanctioned or threatened. It is critical that we document these and bring these into the open. By doing so we can make an even stronger statement about the necessity for preventing further misapplication of the fraud and abuse regulations.

It would be disingenuous to say that this problem is solved. We have a long road ahead of us. One of the most important steps will be the pilot testing. The results must show that the proposed guidelines will allow us to continue providing high-quality, cost-effective patient care and will not increase the already heavy workload of physicians. We are cautiously optimistic that we are on the right track. Between here and success, however, there are still many ways the effort can be derailed.

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Copyright © 1998 by the American Academy of Family Physicians.

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