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The long-awaited documentation guidelines from the Baltimore-based Health Care Financing Administration (HCFA) still have not been finalized, but recommendations recently published by an advisory panel are likely to be close to the final version, say experts interviewed by ED Management.
Currently, you can choose between HCFA’s 1995 or 1997 documentation guidelines.
"HCFA has stated that if an audit occurs, which ever guideline is most advantageous to the provider will be used in any assessment," explains Peter Sawchuk, MD, JD, MBA. He is chair of the Dallas-based American College of Emer gency Physicians (ACEP) panel on coding and nomenclature committee and is ACEP’s representative on the American Medical Association (AMA) advisory committee in Washington, DC, that developed the recommendations sent to HCFA. "In most cases, that will be the 1995 guidelines, since the 1997 guidelines are not very useful for most emergency medicine practices," Sawchuk says.
Emergency medicine made its mark
ACEP gave significant input on the recommendations for the new guidelines, says Mason Smith, MD, FACEP, president and CEO of Lynx Medical Systems, a Bellevue-WA-based consulting firm specializing in coding and reimbursement for emergency medicine.
The structure of the medical decision making components was largely driven by emergency medicine, Smith says. "We actually created the approach adopted for the physical exam," he notes. "So we had a substantial impact in how the physical exam should be approached and how medical decision making should be measured."
In June, the AMA advisory panel submitted its recommendations to change HCFA’s original guidelines, with input from ACEP. HCFA is reviewing those suggestions, Sawchuk says. "They could decide to adopt them as is, modify them, or not adopt them at all," he says. "Everybody’s waiting to hear HCFA’s response."
However, in a controversial move, the AMA published its recommendations on its Web site (www.ama-assn.org) before getting HCFA’s response. The decision to publish revisions before getting approval from HCFA is unprecedented, says Smith.
"So this creates a very interesting quandary for ED physicians," he explains. "The issue is, if the AMA has published these guidelines as their official interpretation of the code, is that in fact the official interpretation?"
Guidelines may be official by early 2000
HCFA has stated that the 1995 or 1997 guidelines are still the only ones it recognizes for audit purposes. "But the reality is, there are substantial changes proposed by the AMA editorial panel, which are likely to be adopted by HCFA," Smith says.
Although HCFA has not responded to the panel’s recommendations officially, they likely will be adopted in full, he predicts. "It is significant that one member of the panel is a HCFA representative."
The earliest projected implementation date is January 2000, so it could occur with the next CPT publication, Smith says. HCFA is likely to decide on the final regulations before it implements ambulatory patient classifications (APCs, the basis of the outpatient prospective payment system which is slated to be implemented in July 2000), he says. "So we should have final guidelines sometime between January and March of 2000."
(See story on HCFA’s switch to APCs for outpatient reimbursement in the August 1999 issue of ED Management, p. 1.)
The new documentation guidelines also will affect hospital pay under the new APC guidelines. "So when this goes forward there will be double the effect," Smith says.
One key controversial area remains: Should counting specific elements of the exam be part of the final guidelines or not?
The 1997 guidelines required explicit, detailed counting of elements in the physical exam and history before a certain level of coding could be submitted. "The new guidelines have made it much more flexible," says Charlotte Yeh, MD, FACEP, medical dir ector for Medicare policy at the National Heritage Insurance Co. in Hingham, MA. "But the question is whether it’s sufficiently flexible to meet the needs of the provider community."
Yeh thinks HCFA is willing to allow for some flexibility. "But some element of counting will probably remain, whereas the AMA approach is no counting whatsoever," she says. "It will take time and effort to find the right middle ground."
This is a very positive changes
The overall impact on emergency medicine will be positive, Smith predicts.
"The new guidelines are more rational overall," he says. "Most emergency physicians perform an exam consistent with HCFA’s expectation, but few document it. This is a very positive change, because they are refocusing on the history of the present illness and physical examination, and that’s what emergency physicians excel at."
It’s important to remember that the HCFA documentation guidelines are still in limbo, Yeh cautions. "HCFA intends to take its time before issuing any final guidelines. They have publicly stated that are interested in doing pilot studies before issuing guidelines."
HCFA is being cautious to ensure the guidelines are feasible, she explains. "They need to take a considered approach, to ensure they are workable and satisfy both the need for HCFA to determine proper documentation and, at the same time, not be overburdensome to providers."
Become familiar with the draft guidelines to prepare for implementation, Yeh recommends. "In the meantime, be sure you are familiar with the current guidelines, so you can decide which version best represents the evaluation of the services performed."
The revised guidelines are moving in the right direction, she says. "There are certainly improvements over the 1997 guidelines. Those made it very hard to fulfill the highest level of coding requirements because they were so detailed and not very reflective of the actual practice of emergency medicine."