Medicare Compliance & Reimbursement

Clinical examples are too subjective to please CMS auditors.

Physicians shouldn't throw away their calculators yet. They'll be using the points system for evaluation and management coding for another year.

A recent meeting of the E/M editorial panel reviewed the results of the pilot group that tried to code using clinical examples instead of the 1995 or 1997 guidelines. The panel went over the E/M coding that physicians arrived at from the case scenarios posted online by the American Medical Association. The results were not encouraging, say sources close to the process.

Originally, "clinical examples" were supposed to take effect next year. Now, the best case scenario is that they'll take effect in 2006, says Cheryl Gregg Fahrenholtz, president of Preferred Healthcare Solutions in Bellbrook, OH. It'll take that long to get a usable system in place, she says.

For clinical examples to go forward, there needs to be a mechanism in place to let auditors figure out whether people are coding correctly, Fahrenholtz adds. If a methodology is based solely on case scenarios, "you don't have any counting system for auditing purposes." The Centers for Medicare & Medicaid Services wants there to be some way to quantify whether the physician met certain coding standards.

"Right now, a case scenario is too subjective," adds Fahrenholtz. Because the AMAhad been focusing entirely on subjective clinical examples, CMS'response "kind of threw them for a loop," she says.

"It would have been very difficult to enforce them because they're awfully subjective," agrees Jim Collins, president of Compliant MD in Matthews, NC. It wouldn't be possible to provide examples that covered every single possible encounter in the field, so doctors would have to extrapolate to arrive at E/M levels. It would be hard for doctors to defend themselves during an audit, and also hard for auditors to figure out a fair comparison for a particular procedure with the examples.

The new version will have to be some combination of numerical metrics with narrative case scenarios, says Fahrenholtz.