Feds, physicians near settlement on E/M regs
American Medical Association to issue final recommendations to HCFA by the end of the month
Months of haggling between HCFA and a host of physician groups over the touchy subject of evaluation and management guidelines may finally be coming to an end. Although the final shape of the new guidelines remains unknown, many physicians remain only guardedly optimistic, especially considering what many perceived as the government's overzealous use of the old guidelines in its controversial PATH initiative.
If you thought only physicians at teaching hospitals were likely to be affected, think again: In its 1999 workplan, the Office of the Inspector General announced that this year it will take a hard look at "whether physicians are correctly coding evaluation and management services in locations other than teaching hospitals."
That means that the government could apply the aggressive tactics it developed in the PATH initiative to your group practice by the end of the year. (See related story, page 3.)
According to Robert Dantuono, assistant vice president for health care affairs at the Washington, DC-based American Association of Medical Colleges, the new timeline for the development and implementation of HCFA's final evaluation and management guidelines looks like this:
- This month, the Chicago-based American Medical Association's (AMA) CPT editorial panel will meet to give final consideration to the recommendations of the various physician specialty societies. Following this, the panel will send its own final recommendations to HCFA.
- In March, HCFA will "edit" the recommendations and formulate a process for pilot testing a draft of the final guidelines. The process should last through June.
- HCFA will probably publish the final guidelines before the end of August, but they won't take effect until the end of the year. The intervening months will be used as an "educational period" for practices to get up to speed on the new regulations.
The biggest point of contention is with regard to the use of quantitative numerical formulas in E/M documentation procedures. "We don't yet know whether or not they'll scale back the numeric counting requirements in a way that we're recommending," Dantuono says. "I don't have a sense of where they're going to go."
Neither does the AMA, which remains concerned by what it characterizes as "HCFA's insistence on retaining some quantitative formulas" - even though in its last official statement on the matter, HCFA did hint that it might consider minimizing the use of such formulas this time around. One thing is clear: The final guidelines are likely to be accompanied by a detailed clarification on standards for sanctions or prosecution for suspected fraud and abuse. The clarification is expected to stress that physicians won't be held accountable for honest mistakes.
"We've made it very clear," says a HCFA spokeswoman. "We want to continue to work with the physician community to develop E/M guidelines that meet all of the interested parties' needs. We need for there to be accountability in the program, and physicians need to help us meet that need. Meanwhile, physicians want guidelines that aren't disruptive to patient care, and we recognize that. We've said that we're committed to taking the time necessary to get this important work done correctly."
While the government and physician groups try to hammer out a workable compromise, physicians are left with the option of adhering to either the 1995 or 1997 version of HCFA's E/M guidelines. Experts warn, however, that physicians who opt to use the simpler 1995 guidelines run the risk of being left behind on the learning curve when it comes time to adopt the update, says Catherine Fischer, reimbursement policy advisor for the Marshfield (WI) Clinic. That's important because, this fall, you may only have four months to educate yourself on the new guidelines before they take effect.
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