ED Coding and Reimbursement Alert

As though managing the issues associated with ambulatory payment classifications (APC) werent enough to keep us busy, the Health Care Financing Administration (HCFA) released a draft of its retooled documentation guidelines (DGs) in June. HCFA promises significant work to come as these newest attempts at nationally standardized guidelines maneuver through a validation process for a target release by 2002.

Although HCFA and the American Medical Association (AMA) are expected to continue expanding the supporting information for these guidelines, the elements published in this draft will help coders and physicians begin to develop coding and documentation policies to ensure compliance once the draft guidelines are released.

HCFA has applied significant resources to bringing this new draft to providers for consideration due, in no small part, to shared concerns voiced by practicing physicians that the 1997 and proposed 1999 guidelines were inappropriate. In addition, HCFA was concerned that the draft guidelines encouraged physicians to perform unnecessary services or document irrelevant information to bill a higher level of service.

Following significant internal review and technical assessments, HCFA identified significant variations in interpretations of the guideline components among physician and nonphysician reviewers to the extent that nonphysician reviewers assigned a lower level of service when using the 1997 DGs, and physician reviewers assigned a higher level of service when using the proposed 1999 DGs. The variations in the assigned service levels increased when physician reviewers used the proposed 1999 DGs because of the differences in reviewers evaluation of the medical decision-making component.

HCFAs data on physician outlier claims, determined through its review and comparison of the 1995 and 1997 documentation guidelines, indicates that more than 95 percent of outlier claims were either denied or assigned a lower level of service no matter which version was used to score the evaluation and management (E/M) level. About 40 percent were denied altogether, and approximately 57 percent were assigned a lower level of service.

Interestingly, in the outlier review, more claims were assigned two levels of service lower with the 1997 E/M guidelines. Through its technical evaluation, HCFA determined that the 1995 documentation guidelines result in more consistent, reliable medical review.

To limit the confusion, HCFA concluded that it would need to carefully evaluate any documentation guidelines to improve the interpretation of medical decision-making. The 1997 draft guidelines and proposed 1999 guidelines provided unacceptable incentives to perform unnecessary services and generated confusion through the table of medical decision-making. That table was deemed too rigid and the list of examples too irrelevant or incorrect to apply to most E/M services.

In essence, the score sheets that required counting and review of multiple tables created the wrong incentives and deviated from the established CPT definitions, a serious issue with the AMA [...]