August 1998 Bulletin

AMA urges E/M guidelines based on peer review

Evaluation and Management documentation guidelines should be based on what a peer physician reviewer would need to assess the level of service provided, based on the medical record and other pertinent information, as well as the pertinent CPT guidelines and definitions, the American Medical Association told chief executive officers of medical societies and associations in July.

E. Ratcliffe Anderson Jr., MD, AMA executive vice president, updated the officials in a letter, following actions by the House of Delegates in June which essentially scuttled the E&M guidelines that were being developed.

In April, AMA leaders looked like heroes when Health Care Financing Administration (HCFA) announced at an AMA "fly-in" that it would back-off its E&M documentation guidelines and wait for the AMA to develop guidelines that were more acceptable to physicians. It was the culmination of a firestorm of protest from physicians that the guidelines were too complex and time consuming. The AMA had negotiated a plan to produce guidelines that were more acceptable to physicians and that would be pilot-tested before being implemented.

The AMA CPT Editorial Panel offered a new version at the "fly-in" and made changes in May, based on comments from the audience.

In June, the House of Delegates threw the process up for grabs when members voted to oppose a fundamental feature of the guidelines. The delegates opposed "any documentation system that requires quantitative formulas or assigns numeric values to elements in the medical record to qualify as clinically appropriate medical record keeping." There was concern about the use of medical records as a bookkeeping device and about the confidentiality of medical records.

AMA leadership warned that HCFA could respond by developing its own "black box" which wouldn't be as favorable for the physicians.

The CPT panel is scheduled to meet August 21 to consider the next course of action. AMA's dilemma is how to keep physicians in the process of formulating the guidelines. HCFA's dilemma is how to formulate guidelines that would show Congress quantitatively, that public funds-Medicare reimbursements-are being used appropriately.

In the July letter, Dr. Ratcliffe said, "physicians' medical record documentation should be sufficient for a peer physician to assess the level of service reported and medical necessity. Compliance with documentation guidelines should provide a safe harbor for review E&M services.

Dr. Ratcliffe also urged HCFA to cease prepayment reviews of E&M services and to shift to focused medical review of outlier cases, using an independent peer review process by physicians.

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