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Complaints from individual physicians and organized medicine have convinced the federal government to delay the fast-approaching implementation date for Medicare's new documentation guidelines for evaluation and management (E&M) services.
Psychiatrists and other physicians who treat Medicare beneficiaries have been anxious to learn about the revised documentation system by the start-up date of July 1. Flooded with a angry complaints about lack of time for education about the complex guidelines, the American Medical Association (AMA) and the Health Care Financing Administration (HCFA)-the federal agency that administers Medicare-announced after an April 27 meeting in Chicago that HCFA would delay implementation of the new guidelines and develop a revised version of them that will take effect in early or mid 1999.
To make sure HCFA and the AMA heard psychiatrists' concerns about the E&M guidelines, Chester Schmidt, M.D., chair of the APA Work Group on Codes and Reimbursements, and Shelley Stewart, deputy director for federal regulations in the APA's Division of Government Relations, also attended the meeting.
In a letter sent to AMA President Percy Wootton, M.D., several weeks prior to the Chicago meeting, Schmidt described APA's concerns about several aspects of the latest version of the documentation guidelines. Among these was the relationship of the guidelines to the new CPT psychotherapy codes-those numbered from 90804 to 90829-especially those that include an E&M component. The guidelines were not clear about how much documentation psychiatrists would need to provide to satisfy Medicare carriers that psychiatrists fulfilled the criteria for different levels of visits. APA also wanted additional time, Schmidt indicated, to get more extensive feedback from members on whether it should recommend that HCFA reorder the elements of the psychiatric single organ system evaluation, which was to be introduced with the 1997 documentation guidelines.
After the meeting HCFA officials announced that the government agreed to "an indefinite grace period" during which physicians can choose to use either the 1995 E&M coding guidelines for their Medicare patients or the unpopular 1997 version that is about to be replaced-"whichever is more advantageous to the physician, until the revisions have been completed."
The grace period, the agency said, will allow adequate time to test the new version of the guidelines and to educate physicians and regional Medicare insurance carriers about the changes.
HCFA also said that because of the delay and confusion, it was about to inform the Medicare carriers that they were not to punish physicians "for honest mistakes" in using the E&M codes. HCFA Administrator Nancy-Ann Min DeParle assured Wootton that the agency has instructed Medicare carriers not to refer Medicare providers to the Office of the Inspector General for investigation of their submitted bills unless the carrier "determines the situation was not caused by error, and there is evidence of improper billing practices. We have to believe that there is some level of fraudulent intent before we make any referrals [to the inspector general]," she said.
Its major goal in developing a new set of guidelines, HCFA pointed out, is to ensure that they are easier to understand than the ones that were scheduled to take effect in July and that "they are realistically related to the care provided." This was the agency's acknowledgment that the documentation guidelines were overly complex and promised to be onerously time consuming for physicians to use. Reducing Medicare fraud, an emphasis Congress ordered HCFA to intensify, will also remain a crucial goal in deciding what type of documentation will be required of physicians who use E&M codes, DeParle noted.
Wootton emphasized that his organization would not endorse Medicare documentation guidelines "that have no solid basis in what happens in the treatment room each day."
The AMA is spearheading the E&M guideline revision and is including input from medical specialty societies and individual practitioners in the decision-making process.
In the fall, Robert Berenson, M.D., an internist who heads HCFA's Center for Health Plans and Providers, is scheduled to report on the reaction of Medicare providers to the revised guidelines, Stewart said. At that time the AMA will begin an intensive education effort to ensure that physicians understand the changes and the new coding criteria.
Based on that schedule, Stewart expects the new version of the guidelines to become effective in early or mid 1999.
Schmidt left the Chicago meeting "pleasantly surprised at the outcome," he told Psychiatric News. "HCFA reached a very important decision in agreeing to delay implementation of the 1997 [E&M] guidelines, especially in light of the distress conveyed by physicians from all specialties and all parts of the country."
For psychiatrists the next version of the E&M guidelines will likely require fewer elements for taking a history, though the number of examination elements may stay the same. It is in the area of medical decision making that the simplification will probably be most evident, Schmidt said. Tables will be easier to use, and HCFA plans to provide physicians with a generic sample table guiding physicians on how to arrive at the appropriate E&M coding decision. The agency also plans to include specialty-specific vignettes along with the generic table, he indicated.
The meeting also put in place, Schmidt added, "a crucial process for streamlining the documentation guidelines and making them more user-friendly and less burdensome." HCFA and the AMA promised the medical specialty groups that they would distribute draft version of the revised guidelines to them and would evaluate their follow-up input. He said he was also pleased that HCFA is talking about field testing the revision of the documentation guidelines, a step that was not taken with previous versions.
The AMA's Wootton characterized the Chicago meeting by noting that it "has gathered the right leaders, at the right time, in the right place, to do the right thing to improve the intimate relationship between practicing physicians and their patients, and the practical relationship between practicing physicians and Medicare." -K.H.