Internal Medicine Coding Alert

In June, the CPT Editorial Panel of the American Medical Association (AMA) completed its proposed revisions to the draft Evaluation and Management (E/M) Documentation Guidelines proposed by the Health Care Financing Administration (HCFA) in June of 1998.

When finalized, the new documentation guidelines will replace the 1995 and 1997 guidelines now in use by physician practices across the country.

According to a letter from Editorial Panel Interim Chair Tracy R. Gordy, MD, to HCFA Administrator Nancy Ann Min DeParle and published on the AMAs website, the recommended changes to the HCFA draft document include:

indicating the current CPT examination
definitions as the initial criteria for selection of an examination level, with numerical criteria used to assist physicians and reviews in implementing decisions.

recommending no increase in the amount of
numerical thresholds of examination items
required to count the examination of a body area or system.

recommending that qualitative definitions of
each examination level be given more weight than quantitative evaluation of elements, and that quantitative evaluation requirements should indicate a range of the number of items typically expected for a certain level of examination.

adding new language to be included in
Selecting the Level of Service instructions.

The panel also proposed to add language to the initial introduction to the guidelines Documentation: The Basics, which clarifies that the medical record should be first and foremost a tool of clinical care and communication and that the confidentiality of the medical record should be fully maintained. No information in the record should be divulged to another party without the patients written, informed consent. HCFA is now culling over the panels recommendations before deciding which ones will be incorporated and in what form, says Brett Baker, third-party relations specialist with the American College of Physicians-American Society of Internal Medicine (ACP-ASIM) in Washington, DC. ACP-ASIM has also referred a copy of the draft, along with the proposed revisions, to an internal committee for review and comment, says Baker. The organization expects to release an opinion statement after HCFA releases the final version of the draft guidelines.

Internists should not expect any concrete change in the guidelines soon, notes Baker. Even after the administration finalizes the draft guidelines, they must still set up a plan for pilot testing the new document before implementation.