Pediatric Coding Alert

You can still use them if you want to...but why would you? The Evaluation and Management (E/M) Documentation Guidelines which were initially implemented in January 1998 and were to have been enforced beginning next month (July 1998) are now canceled indefinitely. Physicians spoke up against the guidelines loud and clear, and the Health Care Financing Administration (HCFA) and the AMA heard the outcry. At an April 27 summit in Chicago sponsored by the AMA, more than 300 participants, including representatives from HCFA and the CPT Editorial Panel, met to air their problems over the new guidelines, which were to have been published in CPT 99.

In addition to the indefinite delay in enforcement, the summit produced more good news for physicians, including pediatricians. The new guidelines, when they are developed, will be created with greater understanding of what a doctor really does in his or her job (besides documenting what he or she does).

In a letter to AMA President Percy Wootton, MD, Nancy-Ann Min DeParle, administrator of HCFA, notes that many physicians fear they will be unjustifiably targeted for fraud and abuse investigations as a result of simple coding errors. Simple coding errors are not going to make you a target, says DeParle -- unless those errors are part of a pattern.

The Word From HCFA

But this doesnt mean HCFA is going to stop reviewing E/M claims aggressively. HCFA must be sure the payments we make on behalf of our beneficiaries are for medically necessary and appropriate services, and that the services have been accurately reported, writes DeParle. An audit released in April indicates that we still have much work to do, particularly in the area of ensuring that documentation for physician claims is adequate, she continues. Inadequate or no documentation is the principal cause of the improper payments identified in the audit.

DeParle says doctors and HCFA must work together to improve the guidelines so they do not impose requirements in excess of those associated with clinically appropriate medical record-keeping practices.

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), civil monetary penalties may be assessed for coding that the person knows, or should know, will result in greater payments than appropriate, says DeParle. However, the statute is very clear that there must be a pattern or practice of such behavior.

Physicians will not be punished for honest mistakes, DeParle stresses. There will be no investigations for error; instead, there must be evidence of intentional improper billing practices. In short, the only physicians who need to worry are those who act in deliberate ignorance or reckless disregard. Criminal penalties will not be levied unless the physicians had knowing and willful intent to defraud the government.

Pediatrician Involvement

Even though DeParle is addressing Medicare providers, remember that managed care is increasingly using the Medicare system, including RBRVS, for all patients. In addition, state Medicaid agencies do the same. So pediatricians are affected by what HCFA does in terms of coding.

And that makes it especially unfair that pediatricians were left out of the guidelines, says Richard A. Molteni, MD, FAAP, the AAP representative on the CPT Editorial Panel. If pediatricians had attempted to comply with those guidelines, wed be arrested for child and sexual abuse, states Molteni, who is chief of pediatrics at Penn State Geisinger Health System in Danville, PA. We would be required to do things to children that would be prosecutable. (The guidelines consist of bulleted items, many of which are not usually appropriate for pediatrics, such as rectal exams.)

Carla McDonald, senior health policy analyst with the AAP Division of Physician Payment Systems, was there at the April 27 meeting. She is pleased with the outcome, because it means that pediatricians will be involved in the next formulation of documentation guidelines. They said they are interested in including pediatrics, she reports. And the next round wont look anything like the current one (reported on in the January and February 1998 issues of PCA). Theyre not sure what theyre going to look like, says McDonald. But theyre going to be different.

Considering the level of bad feeling surrounding the E/M documentation guidelines, the April 27 summit was a very amicable meeting, says McDonald. There were lots of pediatricians there.

Prior to the meeting, the AAP had planned on creating its own documentation guidelines, because the AMAs were so unresponsive to pediatricians needs. Now, however, that wont be necessary, says McDonald. Thats not something were looking to do any more, she tells us. Now, theyre willing to work with us.

Molteni is pleased by this development as well. They have agreed to work with the AAP to develop age-specific criteria, he says. However, there might not even be specific bullets any more -- which would be welcome by all physicians, not only pediatricians.

Its good thing the guidelines are changing, sums up McDonald.

What Happens Next

Unfortunately -- or fortunately, from the viewpoint of physicians -- HCFA and the AMA are probably going to have to go back to the drawing board with these documentation guidelines. This time, there will be a lot more input from practicing physicians, including pediatricians. We need to move quickly to something new, says Robert Berenson, MD, director of HCFAs Center for Health Plans and Providers, who spoke at the summit (and hand-delivered the letter from DeParle to Wootton).

The good news is that the guidelines which were released last fall and due to be in next years CPT are, essentially, no longer in existence (chucked is the word AMA president-elect Nancy W. Dickey, MD uses). The bad news is that there is going to be a lot of work involved in creating new ones. They must be created, and they must be tested. Steven E. Krug, MD, FAAP, a member of the AAP RBRVS PAC and specialty advisor for pediatrics to the AMA RUC, was at the summit, and specifically requested that pediatricians be used in the pilot testing of whatever new guidelines HCFA comes up with. Then, there will be a time period for physician education.

Krug, who is also head of pediatric emergency medicine at Children's Memorial Hospital in Chicago, says that most pediatricians will probably be using the older guidelines, even though HCFA is giving physicians the option of using either. The big exception, says Krug, is pediatricians who are in a university setting where a compliance program generally means all physicians must follow Medicare rules. "They have become facile at it," he tells us.

The plan is for the guidelines to be reworked over the summer. DeParle says she will set an implementation date for the new ones in the early fall, once she knows what the schedule is for testing and education.

Our advice is to continue using the E/M documentation guidelines that came out in 1995 (and are published in CPT 98), unless, as DeParle says, it is more advantageous to you to use the new ones (no chance). The main point is that you have to document what you do, even under the old guidelines. You already know this from dealing with managed care. But you dont have to document according to a preset list of bullets which was created for Medicare patients. [Editor's Note: We will keep you apprised of what pediatricians can expect from the next set of guidelines as they evolve].