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The AMA is undertaking a project to educate physicians about changes in Medicare's evaluation and management (E&M) coding guidelines. In so doing, the AMA is taking advantage of a six-month delay in implementing the new codes, which were scheduled to become effective January 1.
The AMA had convinced the Health Care Financing Administration (HCFA)-the federal agency that oversees the Medicare program-that physicians needed much more time than the January 1 implementation date would have allowed to grasp the sometimes complex modifications in E&M coding. The AMA had told HCFA officials that without such a cushion, many physicians might be unclear about how the coding guidelines were being altered, and HCFA and Medicare insurers would be confronted by a barrage of errors and confusion.
In addition, APA and several other medical specialty societies had identified problems with documentation guideline proposals in their areas. They explained their qualms to the AMA, and this also contributed to the decision to postpone the start date for using the revised codes and documentation guidelines.
HCFA consented to delay implementation until July 1. During the six months from the beginning of the year until that date, Medicare providers can elect without penalty to use either the existing E&M codes and guidelines or switch to the new ones.
In early February, following agreement on the implementation delay, the AMA announced details of "an aggressive campaign" to persuade HCFA to "correct" several elements of the documentation guidelines for coding E&M services and to ensure that physicians are adequately educated about the changes.
The initiative has three focuses. The first is "advocacy to ensure that physicians are protected from unwarranted fraud and abuse penalties" in cases where they inadvertently choose an incorrect code or make documentation errors.
The second is to ensure that HCFA's E&M guideline modifications "are comprehensive and result from a process through which national medical specialty societies, state medical associations, and other health care professional organizations continue to provide the AMA, the CPT Editorial Panel, and HCFA with detailed recommendations" that would improve the final guidelines.
Finally, the AMA promises to enlist APA and other medical specialty groups in "an extensive educational effort" to help physicians understand the coding changes and the audit criteria Medicare carriers will be using in conjunction with E&M guidelines.
With psychiatry's E&M codes undergoing a significant modification for 1998, APA is planning its own education initiative in addition to joining the AMA campaign.
After considerable input from APA, particularly Chester Schmidt, M.D., chair of the APA Work Group on Codes and Reimbursements, HCFA redefined psychiatric E&M codes to allow coding for a "single organ system examination," which renders E&M codes more useful and appropriate for the services psychiatrists often provide in addition to psychotherapy. Psychotherapy services have their own set of codes.
Many of the insurance companies contracted to process and approve Medicare claims made it extremely difficult for psychiatrists using the previous guidelines to document to the insurers' satisfaction that they had met the criteria for billing for E&M services. The problem is rooted in part in the fact that E&M codes were generally designed for internists and family physicians who routinely examine several systems during a patient visit, one of which may involve a psychiatric service. The new standards should make it easier for psychiatrists and other specialists to use E&M codes.
In all, HCFA has developed E&M content and examination requirements applicable to 10 single-organ systems.
Psychiatrists will be able, under the new system, to use a five-level grid that classifies the type of patient visit by comprehensiveness according to the number of elements chosen from a list of mental status and other psychiatric examination components and the complexity of those services. Treating psychiatrists will still have to supply documentation to support the E&M coding level appropriate to the examination.
"That psychiatrists can now access various levels of service under E&M codes-including those for hospital visits, consultations, and nursing home and rehabilitation services-allows us to provide the services we usually do and still fulfill the requirements for a comprehensive exam and then be reimbursed appropriately," Schmidt explained.
APA is continuing to work with HCFA and the AMA to improve the guidelines governing this documentation to ensure that they accurately describe the services psychiatrists provide and are clear to the Medicare carriers, which will be assessing compliance. The agency hopes these revised guidelines will reduce the variability with which these insurance carriers have been interpreting the guidelines and physicians' complaints when their reimbursement requests were challenged by those payers.
The AMA and HCFA have pointed out that in their process for jointly developing the revised E&M guidelines, they tried to adhere to several general principles, including that the guidelines had to be "consistent with the clinical descriptions and definitions contained in the CPT, would be widely accepted by clinicians and minimize any changes in record-keeping practices, and would be interpreted and applied uniformly by users across the country."
Part of the development process is recognizing and incorporating elements of two sometimes competing agendas that are at work in revising the guidelines. The AMA emphasizes that its primary goal is to ensure that the final product improves the care Medicare beneficiaries receive. HCFA, however, is focused on developing coding guidelines that provide it with an efficient audit tool.
"APA needs to take the position that part of its work with the AMA will be to untangle the two conflicting agendas" to ensure that improving the factors related to patient care does not take a back seat to audit efficiency, Schmidt told Psychiatric News.
A workshop planned for APA's 1998 annual meeting in Toronto organized by the Work Group on Codes and Reimbursements and the Work Group on the Harvard Resource-Based Relative Value Study, chaired by Donald Scherl, M.D., will be devoted to educating psychiatrists about Medicare's new E&M coding definitions and documentation guidelines.
-K.H.