Physician's Coding Strategist-MedPAC expected to frame next stage of E/M debate

Practice management mavens are anxiously waiting to see what position the powerful Medicare Payment Advisory Commission (Med PAC) takes on a series of critical coding and reimbursement issues in its annual report to Congress scheduled for delivery in March. At the top of the curiosity list is what will MedPAC say about the Health Care Financing Administration's (HCFA) much-debated evaluation and management (E/M) guidelines.

In a December draft of its recommendations, MedPAC pushed HCFA to get moving on its long-promised but delayed California pilot test of its proposed E/M guidelines and other possible "alternative" approaches. However, sources say there is a strong contingency within MedPAC that favors a more hands-off approach, instead urging HCFA just to make the E/M guidelines as simple as possible.

"If the guidelines are too complex to be applied, then they are no good to anyone," says William A. McBain, an Ithaca, NY, managed care consultant and MedPAC member.

Other MedPAC commissioners, such as Ted Lewers, MD, who also chairs an American Medical Association (AMA) panel on the issue, wants the advisory board to deliver a more forceful message.

Indeed, the AMA has been rattling its political saber since its mid-December meeting in San Diego, where it passed resolutions reaffirming the group's opposition to "counting." Counting is the numeric method of evaluating physician services, a scheme HCFA has backed. The AMA also underscored its desire to get the agency's E/M field tests launched.

Meanwhile, the AMA is pressuring HCFA to suspend prepayment and post-payment audits of E/M claims until it implements final E/M regulations. The AMA also wants Medicare to let physicians use the guidelines it proposed last May, as well as the 1997 and 1995 guidelines, "until such time that there is final agreement with HCFA on a documentation system that is consistent with AMA policy," the organization said in a statement.

Also on the AMA's coding agenda for 2000 are these items:

• have HCFA provide more detailed descriptions and specific examples of services in the next Current Procedural Terminology (CPT) manual;

• support the concept of a "time-based charge" for coding administrative duties, such as phone pre-certification and utilization review activities;

• pass legislation forcing insurers to recognize and pay for all published CPT codes, including modifiers;

• prepare a report for the AMA 2000 annual meeting on the addition of CPT codes that recognize the different work components involved in treating pediatric patients;

• develop a proposal requiring Medicare carriers to reveal detailed reasons for rejecting claims.

E/Ms: The proposal time forgot

Last May, the AMA's CPT editorial panel voted support for a measure asking HCFA to implement its own alternative set of E/M guidelines rather than the agency's 1998 proposal, which has been on hold because of protests from providers that it is unworkable.

Ever since then, the AMA has been waiting for word from HCFA about when it will test its proposal and set a date for ruling on it. In the meantime, HCFA has said practices can use either its 1997 or 1995 E/M guidelines for coding purposes.

Last December, Robert Berenson, MD, director of HCFA's Center for Health Plans and Providers, told HCFA's Practicing Physicians Advisory Council that HCFA had a commitment with the California Medical Association to test its so-called "California Plan" as an alternative to the CPT panel's recommendations. A main difference in the two proposals is that the California Plan uses a peer review system rather than Medicare carrier staff to resolve E/M claim disputes.

Before moving on the test, Berenson also said HCFA wanted to finish a feasibility study of the idea. That would mean the pilot program would begin later this year, and changes and the revised proposal probably would be floated next year. By that time, practitioners will have been waiting for a finalized E/M rule for at least five years.