Ob-Gyn Coding Alert

Late last year, implementation of the new E/M Documentation Guidelines was delayed until July 1, 1998. Now, in a surprise move, the Health Care Financing Administration (HCFA) has delayed their implementation indefinitely. The announcement came at an April 27th meeting set up by the American Medical Association (AMA) to discuss the guidelines. The session included officials from the AMA, HCFA, state medical organizations and representatives of specialty societies -- including ob/gyn. Richard Berendson, MD, director of HCFAs Center for Health Plan and Providers, read an official letter from Nancy-Ann Min DeParle, HCFAs head administrator overseeing the implementation of the new guidelines.

In the letter Min DeParle wrote: In December 1997, HCFA agreed to (the AMAs) request that carriers use both the 1995 and 1997 versions of the Documentation Guidelines to evaluate claims until July 1, 1998. When we set the July 1 date, neither the AMA nor HCFA fully understood the magnitude of the problems with the 1997 guidelines. I think it is unrealistic to expect that the revisions can be complete by that date, and it is clear that an additional period is needed... The letter stated that HCFA intends to direct carriers to indefinitely delay implementation of the examination portion of the E/M Guidelines set to go into effect July 1, 1998.

So what does this mean for ob/gyns and their practice managers and coders who are all concerned about documenting properly and make sure they are adequately protected should they face an audit? Here are the facts, and some suggestions that should help.

1) Either Version of the Guidelines Will Be Used in Audits. This new statement does not mean that the 1997 guidelines are null and void. It does mean that Medicare will use either the 1995 or the 1997 guidelines as a basis for auditing. Auditors have been advised to use whichever guidelines are more advantageous to the physician.

2) The 1995 Guidelines. Remember, the history and medical decision-making criteria outlined in the 1995 guidelines are the same as the 1997 guidelines. The big difference in the two sets of guidelines is in the criteria for the examination portion. The 1995 criteria required less to be documented for the exam. However, the exam criteria are vague (e.g. comprehensive exam = single-system specialty exam or 8-12 affected body areas or organ systems) and generally leave much to the opinion of the auditor, easily opening the door for differing opinions between the auditor and physician being audited. When opinions differ, the physician may have to appeal. Though the doctor may eventually win, the appeal process brings the extra hassle of more paperwork and lost time.

3) The 1997 Guidelines. The examination criteria of 1997 version are detailed and require more documentation. But the advantage is that the 1997 criteria leaves little room for auditor interpretation. It may be easier for auditors to verify that higher levels of service were correctly coded. While the 1997 criteria requires some education to learn, they are easily mapped using a template and, once learned, many physicians prefer them to the old way of doing things.

4) For Now, Make a Choice. Physicians must comply with only set of documentation guidelines when submitting E&M services to Medicare. You will need to choose which one (1995 or 1997) you want to use. It may be advisable for your practice to use the guidelines with which you are most familiar and comfortable.

Note: Currently the AMA and medical specialty societies are working very hard on revising the 1997 guidelines, although HCFA has set no deadline for new implementation. The results of the above mentioned April meeting were sent to the CPT Editorial Panel for its May meeting, and those efforts are being sent out for feedback, which will be used by the AMA in cooperation with HCFA to produce a new product that can be pilot tested. Only after a successful pilot testing will a new product be introduced to physicians and carriers.