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.