MD pressure will likely mean further E/M changes
MD pressure will likely mean further E/M changes
Final implementation unlikely this year
Under pressure from various medical groups, it is very likely that HCFA will again extend the deadline for formally switching to the newly issued Medicare evaluation and management codes from June 30 to Oct. 1- or even next January, Physician's Payment Update has learned.
Until a final implementation deadline is set, providers are free to use either the old or the newly issued E/M codes at their discretion.
Meanwhile, the American Medical Association's CPT code educational panel is expected to consider recommendations to further simplify the E/M codes at its May meeting. Noting that the proposed codes have come under intense criticism from physicians as too complicated and confusing, AMA officials have indicated they are open to "any and all suggestions to revise the documentation guidelines."
"HCFA officials have told us they would 'most likely' accept any suggested changes made by the CPT educational panel," notes a lobbyist for one provider specialty association that has been very active in the E/M coding debate.
HCFA officials also indicate they do not expect the AMA to publish the evaluation and management documentation guidelines in CPT 1999, and future guideline updates will be done annually through the AMA CPT Editorial Panel process. As such, if there are any additional concerns about the latest revisions in the E/M after this next round of changes, they will probably be addressed through the CPT process.
"These guidelines put an undue excessive documentation burden on physicians for the sole purpose of billing, not for quality medical care," notes Robert Dougherty, the American Society of Internal Medicine's vice president for government relations.
"They are so complex, many physicians now question whether the process that must go into making billing decisions is becoming more complicated than making actual medical decisions."
According to one ASIM study, there are 42 choices providers must consider just to select the proper level of E/M service. Omit the values for the overall history, overall physical, and overall medical decision making and you still have 6,144 different possible ways an office visit for a new patient could be classified by the proposed E/M system, says ASIM.
"We feel reporting the proper E/M code is so complicated under the new guidelines that physicians are always at risk of making inadvertent coding errors, which can trigger a whole new set of problems in this age of intense scrutiny of claims for fraud and abuse," notes Dougherty.
ASIM also is lobbying the AMA and HCFA to take a less aggressive and more educational enforcement stance when it finally comes time to implement the completed E/M guidelines.
"HCFA can best encourage physicians to document and code correctly - helping to ensure that Medicare pays for each E/M service appropriately - by implementing the soon-to-be revised guidelines in an educational manner," according to an ASIM position paper.
"The guidelines should be used to review only physicians whose utilization (patterns of care) indicates that they are outliers. If a physician's documentation does not comply with the guidelines, the physician should be advised of this and be offered educational assistance on how to document better, but no claims would be denied based on an initial review," states ASIM.
If the revised documentation requirements were used as suggested, claims would only be denied in one of three cases:
· if a physician engaged in a pattern of coding that was identified as being a statistical outlier;
· if the physicians' documentation was subsequently reviewed by the carrier and found to be inadequate;
· if the physician subsequently failed to take corrective actions and continued to engage in a pattern of billing that was not supported by the documentation.
"Given all of the emphasis that Congress and the administration are placing on reducing waste, fraud, and abuse in the Medicare program, it is unlikely that HCFA will limit carriers' authority to recoup overpayments that are discovered during an initial post-payment utilization review," notes Dougherty. "In such instances, physicians may be required to reimburse Medicare for the overpayments, plus interest, which can run into tens of thousand of dollars."
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