Increase Pay-up and Provide Audit Defense with '97 E/M Guidelines
Published on Thu Oct 01, 1998
You may have breathed a sigh of relief this July when the Health Care Financing Administration (HCFA) indefinitely delayed the new 1997 Evaluation and Management (E/M) Guidelines. But this postponement doesnt get you off the auditor hook, experts warn.
Cardiologists and their practice managers who perceive this delay as a reprieve -- and therefore think they dont have to worry about their documentation are making a huge mistake, says Steve Arter, executive vice president in the compliance and education division, QuadraMed Corporation a healthcare services company in Point Richmond, CA.
Although HCFA allows physicians to use whichever version of the guidelines (either the 95 or 97) which is more advantageous to their practices, they must comply with one of them, points out Percy Wootton, MD, immediate past president of the American Medical Association, and a clinical cardiologist in Richmond, VA.
If you relax your documentation efforts, youre just setting yourself up for the auditors, Arter warns.
For example, HCFA will continue to randomly audit between 1% and 3% of Medicare charts every year, specifically looking for adequate documentation of E/M coding.
If your record keeping doesnt come up to par, your cardiology practice may be forced to refund overpayments and pay penalties. HCFA will also be performing chart audits on claims submitted by practices that seem to be operating differently from the norm, he adds. For example, offices that are billing more Level 5 office visits that other similar practices in the same geographic area may be targeted for an audit.
Thats why the erroneous belief that the 97 E/M guidelines no longer apply can be the kiss of death for practices that get audited, Arter believes.
Which Version Should Cardiologists Use?
The experts we spoke to advise cardiology practices to switch to the 97 version, even though the move will entail more paperwork. They cited these reasons:
1. The 97 guidelines decrease interpretation on the part of the auditor. Although many physicians dont like the fact that the physical examination and history portions on the 97 guidelines require more details than those of the 95 version, that very specificity can be to your advantage, says M. Tray Dunaway, MD, author of the Pocket Guide to Clinical Coding and a physician with Sentinel Health Partners in Camden SC.
Editors note: The Pocket Guide to Clinical Coding is self-published by Dr. Dunaways company, Rebel Records. The cost per single copy is $10.75, including shipping and handling. For more information, see www.rebrecords.com or e-mail at coding@rebrecords.com. The mailing address is 1413 Mill St. Camden, SC 29020-2934.
Rather than go by vague guidelines, I prefer using the specific 1997 version because I know I can document these points adequately. That way its not left up to the auditor to determine what [...]
