October 1998 AAOS Report

HCFA plans new E/M guidelines with formulas

The Health Care Financing Administration (HCFA) announced that it will develop a new set of documentation guidelines for Evaluation and Management Services to replace the 1995 and 1997 versions now being used by carriers to review claims. HCFA acknowledged the strong opposition of the American Medical Association (AMA) to the use of counting or numerical formulas, but said it has decided that some counting is necessary to assure consistent interpretation of the guidelines by Medicare carriers. A new framework developed earlier this year in conjunction with the medical profession will serve as the starting point for the new set of guidelines. No date has been set for implementation. HCFA said it will take the time to develop guidelines, test the response and burdens and educate physicians and Medicare carriers on revised requirements. In the meantime, Medicare carriers will continue to use either the 1995 or 1997 guidelines when reviewing claims, depending on which is most advantageous for the physician. The AMA said it "strongly regrets HCFA's insistence on retaining some quantitative formulas," but noted HCFA's willingness to minimize the use of the formulas and to take the time to develop and test the guidelines. The AMA said it does not expect any new guidelines to be implemented before late 1999.

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