Internal Medicine Coding Alert

The big news for internal medicine in the 1999 edition of CPT has more to do with what has not been changed than what has. The 1997 version of the Evaluation and Management (E/M) guidelines, expected to be revised by the Health Care Financing Administration (HCFA) for the 1999 CPT, have been scrapped altogether. The Administration and the American Medical Association (AMA) are now hard at work developing new E/M guidelines, which are not expected to be released until late 1999 at the earliest.

Basically, the Administration has agreed to base the new guidelines on a framework developed by the AMA earlier this year, with one notable sticking pointthe use of counting formulas, says Glenn D. Littenberg, MD, a member of the physician reimbursement and coding committee for the American College of Physicians-American Society of Internal Medicine (ACP-ASIM) and a member of the AMAs CPT editorial panel.

The 1997 guidelines contain templates that require physicians to document a certain number of body systems that have been examined, as well as a certain number of evaluation services or procedures performed.

Its designed so that an auditor can look at the documentation and basically count this and count that, and determine whether or not the physician met a certain level of service. Basically, the medical societies have said that this approach to providing health care is unacceptable, Littenberg explains. But, HCFA has said they consider some form of numerical format necessary to ensure consistency.

The Administration has agreed, however, to develop a less burdensome form of E/M guidelines and to allow the AMA to provide technical advice and coordinate input from state and national medical societies.

After the new guidelines have been developed, and the medical societies have been allowed to comment, the Administration will also do significant pilot testing of the new requirements in certain areas of the country, adds Littenberg.

The ACP-ASIM Working Group on Evaluation and Management Guidelines has drafted a position statement recommending that the new version be implemented in an educational manner, which means that they would be used to review only the records of physicians whose utilization patterns showed them to be outliers, says Littenberg.

If documentation did not meet the new requirements, the physician would be advised of the errors and offered educational assistance on how to document correctly, but no claims would be denied based on this initial review.

If the revised documentation requirements are used in this manner, claims would be denied only in cases where a physician engaged in a pattern of coding that was identified as being a statistical outlier; the physicians documentation was subsequently reviewed by the carrier and found to be inadequate; and the physician subsequently failed to take corrective actions and continued to engage in a pattern of billing that was not supported by the documentation, states a portion of the position statement.

The AMA and ACP-ASIM are continuing to push for this approach to documentation compliance.

The ACP-ASIM coding and reimbursement committee will get an opportunity to go over the most current draft of the guidelines at its next meeting and forward comments to the AMA. For now, practices should still adhere to either the 1995 or the 1997 E/M guidelines.

Lab Test Medical Necessity Stressed

Although there were no new changes to CPT codes that would affect internists in particular, Littenberg advises practices to carefully go over the codes for lab panels. Documentation of the medical necessity of diagnostic tests will be one of the next big areas under compliance scrutiny.

There may be some changes in the lab panels, but nothing really big, Littenberg says.

A comparison of the 1998 and 1999 editions found no new lab panel codes (codes listed as deleted, referring coders to other codes were the same in 1998 and 99 books).

However, coders should read over the language pertaining to the specific codes often used in their practices.

The Office of the Inspector General has indicated in its 1999 Plan of Work that medically justified diagnostic testing will be one of the areas it will be focusing on in compliance audits.

Practices need to ensure that they document the medical necessity for each diagnostic test ordered, including laboratory panels.