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 [...]