October 2001 Bulletin

HHS steps back from 3rd set of E&M guidelines

The road to developing new Evaluation and Management (E&M) documentation guidelines is lined with that all-too familiar signpost, "Construction Ahead. Expect Delays."

The latest detour could add another year or more to the development of the guidelines—no one is really sure.

Tommy Thompson, Secretary of the Department of Health and Human Services signaled the delay in July when he told a House Committee on Ways and Means that he has halted work on the third version of the guidelines.

"Physicians found the first two sets of guidelines developed in 1995 and 1997 cumbersome," Thompson said. "We agree, and have been working with a contractor, Aspen Systems, to improve them, but physicians have continued to express concern that these guidelines are hindering, not helping, the delivery of appropriate patient care."

Thompson said HHS will "reassess and re-tune our effort. Additionally, I am turning to the physician community to help design constructive solutions. After six years of confusion, I think it makes sense to try to step back and assess what we are trying to achieve.

"For the system to work, the codes for billing these visits need to be simple and unambiguous."

The AMA CPT Editorial Panel has developed a proposal to work with the Centers for Medicare and Medicaid Services (CMS) to develop the new guidelines. The panel proposed to form a work group to review the descriptors and code criteria and the five levels of service, said Jack Emery, assistant director for federal affairs, AMA. The work group would include representatives of the CPT Editorial Panel, specialty societies, CMS and program integrity, AMA Board of Trustees Task Force, AMA-Specialty Society RVS Update Committee (RUC) and the Practicing Physicians Advisory Council, Emery said.

In hearings before Congress and elsewhere, Thompson has been espousing a new responsiveness to the concerns of physicians. His announcement of the reassessment of work on the E&M guidelines follows receipt of a letter signed by the American Medical Association and 39 medical specialties, including the AAOS.

The organizations urged the Centers for Medicare and Medicaid (CMS) to "take the next year to re-examine the imposition of burdensome evaluation and managed documentation guidelines, as well as its commitment to the development of ‘clinical examples.’"

The organizations said, "the development of clinical examples by CMS and its contractor, Aspen Systems, is the most recent example of good intentions gone awry. ...the proposed clinical examples are seriously flawed and need to be scrapped." The problems cited included:


History of E&M documentation guidelines

1983. The federal government and the American Medical Association (AMA) enter into a formal agreement whereby CPT was adopted by the Health Care Financing Administration (HCFA) for reporting services under Medicare.

1992. Medicare transitions to the resource-based relative value scale (RBRVS)-based physician payment system.

1992. AMA introduces Evaluation and Management (E&M) codes.

1994. Office of Management and Budget mandates HCFA adopt documentation guidelines to be used for carrier review of new E&M codes.

1995. AMA and HCFA develop initial set of E&M documentation guidelines, which are criticized as unfair to specialists because of requirements for a single system examination.

1997. E&M documentation guidelines revised, but physicians object to the burden of guidelines and problems with specific areas, including components of single system examinations.

1998. AMA, national specialty societies seek changes in documentation guidelines.

1999. HCFA requests AMA and specialty societies to modify 1997 guidelines to make them more inclusive and less burdensome.

2000. HCFA rejects the 2000 guideline changes and unveils a new draft version of E&M documentation guidelines. HCFA seeks to simplify documentation by using examples of actual physician documentation of examination and medical decision-making, leading to the Aspen Systems contract.

2001. Department of Health and Human Services halts work on guidelines to reassess its effort. The AMA proposed a mechanism to evaluate different methods of documentation including representatives of the AMA CPT Editorial Panel, MedPAC, Centers for Medicare and Medicaid Services, specialty groups, medical directors and payers. The workgroup would add and delete members as the project evolved. Meanwhile, the 1995 and 1997 documentation rules remain in effect.

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