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President's MessageHCFA Revisions Of Evaluation
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| Experience has taught doctors to be extremely wary of all
things from the Health Care Financing Administration (HCFA). Understandably, physician
leaders in organized medicine were justifiably cautious during a recent "town hall
meeting" in Washington where HCFA unveiled the new (June 2000) HCFA revisions of the
evaluation and management (E&M) guidelines. In addition, HCFA announced detailed plans
for a critical study of the proposed guidelines (utilizing both internal and external
sources of review) prior to planned implementation in January 2002. The AMA along with
numerous specialty societies stated that more time was needed to further analyze the new
HCFA proposals as well as to await the outcome of the proposed studies. Interestingly, HCFA seems to be moving "back to the future". As detailed in recent reports in the AMA News, and confirmed by Paul Rudolf, M.D., senior technical advisor for HCFA's Center for Health Plans and Providers, until the new E&M guidelines are implemented, the agency will instruct contractors to review medical records according to 1995 or 1997 documentation guidelines, whichever is best for the doctor. HCFA chose that route after technical assessments of different versions suggested that the 1995 guidelines resulted in more consistent, reliable medical review than the 1997 version or a 1999 model that the CPT Editorial Panel proposed to HCFA last year. "I feel like a dog chasing his tail," said Troy M. Tippett II, M.D., a Pensacola neurosurgeon and member of the AMA's Ad Hoc Task Force on the E&M Documentation System. "It seems like we've made a full circle back to where we started." HCFA plans to test the documentation guidelines in a nationwide pilot project, which it hopes to launch late this year. The agency plans to incorporate peer review of records into the pilot, possibly by having physicians examine claims that a nonphysician reviewer has denied or assigned a lower level of service. HCFA also plans to conduct a second study that will test weighting the medical decision-making component of an E&M service heavier than other components (history and physical exam). A new addition to the 2000 guidelines will be the addition of clinical vignettes aimed at helping physicians document properly. According to Dr. Rudolf, "We will supplement [the guidelines] with specialty-specific vignettes for physical exams and medical decision-making. This is a critical component of what we feel we need to do to unconfuse everybody, to differentiate between the levels of service". Another new wrinkle suggested by HCFA is to study the possibility of reducing from five to three levels of E&M service, and to provide information it gathers to the CPT Editorial Panel. One question that effort will raise for doctors is whether a reduction in the number of levels of E&M coding would result in doctor payment cuts. E&M services represent about $18 billion in Medicare spending and account for about 40% of the program's spending on physician services. "Everybody will be watching that carefully," said Robert Berenson, M.D., director of HCFA's Center for Health Plans and Providers, when asked about the payment implications. He noted that no decisions had been made yet on whether there should be fewer levels of services. He added that precedent exists for maintaining budget neutrality in such circumstances, meaning that overall physician payment would not be reduced. Physicians should be aware that the AMA will monitor all of the actions of HCFA closely. As stated succinctly by the AMA Immediate Past President Thomas J. Reardon, M.D. (and heard in person by the few DCMS members who attended the recent reception/dinner for the AMA President), "As the process moves forward, we will be watching this very carefully." Once again, organized medicine stands tall in its protection of the individual physician in all aspects of the practice of medicine. When you receive your next dues statement, and consider the option of joining the AMA; you might also consider for a moment what might be the outcome of HCFA's modifications of the E&M guidelines if there were no AMA to look out for your interests. July, 2000/ Jacksonville MedicineWhat's New
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