My name is Mark J. Segal, PhD. I am a Vice President at the American Medical Association (AMA) with responsibility for our CPT activities. It is my pleasure to appear this afternoon before the National Committee on Vital and Health Statistics (NCVHS) to discuss documentation guidelines for evaluation and management (E&M) services.
The AMA is pleased to have the opportunity to update you on our efforts on this important issue. I am pleased to follow Dr. Bart McCann from the Health Care Financing Administration (HCFA), one of our nation’s experts on procedural coding and a valued colleague.
I recognize that members of the Committee have a number of questions about the guidelines and I will make only brief formal opening remarks so that we may have time for a useful discussion.
Dr. McCann has outlined where these guidelines came from, as well as their relationship to the E&M codes that came on-line in 1992. He has also explained the context in which HCFA approached the need for and development of documentation guidelines for E&M services.
I would like to take a few moments to outline the rationale for and nature of the AMA’s involvement to-date, as well as how we are dealing with the widespread physician concerns that have emerged.
Our work with HCFA on this project reflects our commitment to several principles:
As you may know, these revised guidelines were issued last July and education began shortly thereafter. They have been on the HCFA web page and were featured in the AMA’s quarterly publication CPT Assistant. At the same time, it is clear that informing and educating physicians on these guidelines has been insufficient and must be improved.
Although the post-July period brought forward suggested changes from a few specialties, some of which were reflected in revisions to the Skin and Multi-System examinations, the initial dissemination did not involve enough focused information and assessment.
As we recognized that a problem was emerging late last Fall, we asked for and HCFA quickly granted a 6-month extension of the grace period for the new guidelines.
In December, at our House of Delegates meeting, it became clear that more and better education was not enough. Our members had significant concerns with the burden imposed by the guidelines, and problems with specific aspects, notably components of the single system examinations.
I should underscore that the guiding principle of the CPT Editorial Panel was to allow the relevant specialty societies to determine the content of their own single system examinations. Thus, we worked extensively with and deferred to the over 90 specialty societies that are members of the CPT Advisory Committee. This process took place over a three-year period and we had agreement from the pertinent specialties on the single system examinations included in the 1997 guidelines. As I mentioned, we and HCFA also have acted quickly on requests for further refinements that emerged after July.
Still, it is clear the guidelines in their present form are untenable, especially given physicians’ substantial concerns that, with a heightened fraud and abuse enforcement climate, they will be unfairly penalized for inadvertent coding or documentation errors or omissions. In this climate many physicians see these guidelines as rigid rules that must be followed to the letter in every instance if severe fraud and abuse penalties are to be averted.
This view was never our intention. The guidelines are intended to be is a template for reviewers who must evaluate medical records to assess coding accuracy and a documentation-oriented guide for physicians and their staffs on how one should code and document E&M services.
Physicians are, overwhelmingly, highly ethical professionals who do a difficult job under extreme time pressures. There has never been any serious suggestion, let alone evidence, that physicians were or are a significant source of health care fraud or abuse.
Nor is there is any evidence that, since the E&M codes were put in place in 1992, physicians have been unable to code reliably or are upcoding. Indeed, our members tell us that they are downcoding to be safe.
Moreover, we know that there is no single standard for documentation in the medical record, nor should there be. If one reads the text of the guidelines, it is clear that multiple approaches to documentation can be accommodated.
If the next version of these guidelines is to work, documentation should be first and foremost a function and byproduct of clinical care. Physicians and their staffs should code, and be able to code, based on this documentation. The sequence should be: (1) document for clinical reasons; (2) code from documentation; and (3) be able to verify code selection from the documentation and guidelines based in CPT definitions.
What is the AMA doing now to deal with this problem? We are working closely with all elements of organized medicine, is implementing a three pronged action plan to respond to immediate concerns and longer term needs. The plan begins with advocacy, followed by necessary corrections to the guidelines. Finally, there is education, teaching physicians how to apply the guidelines in daily practice.
On advocacy, we will take every necesarry step to prevent physicians from being subject to unwarranted fraud and abuse penalties and sanctions for inadvertent errors or omissions in all types of coding documentation. We will demand that physicians be treated as ethical professionals.
Moreover, claims reviewers must be required to exercise judgment as they review complex clinical documentation and evaluate related coding – and they must have the training to do so. The current version of the guidelines recognizes that some elements of code documentation are, of necessity, subjective, especially the complexity of care provided. In the inevitable gray areas, physicians should have the benefit of the doubt, certainly for payment and most emphatically for any question of fraud and abuse.
Finally, we will seek changes in the guidelines that will minimize the threat of unwarranted fraud and abuse prosecution. We are also calling for a pilot study before the next version of the guidelines is fully implemented .
Our second priority is to change the guidelines themselves. We are well aware that many physicians do not think that the current guidelines have a solid enough basis in what really happens in the treatment room each day.
Our first step in this process was securing agreement from Dr. McCann and his colleagues at HCFA that needed changes to the guidelines need to be identified systematically and then implemented. We have been very pleased at HCFA’s rapid acceptance of this principle.
Our next step was to ask the specialty societies, state medical associations, organizations representing non-MD health care professionals, and other interested parties to submit to the AMA, by March 15, their specific comments and suggestions for improving the guidelines.
We will collate and evaluate these data and using them as the foundation for a special “fly-in” meeting to be held with specialty societies, state medical associations, and larger county medically societies on April 27 in Chicago. We are pleased to invite one or two representatives of the Committee or your staff to attend, should you be interested.
At this meeting, members of the AMA Board, the CPT Editorial Panel, and AMA and HCFA staff will be available to hear specific problems and to assist in developing workable solutions. We also, by that time, hope to have available for discussion, different formats that may ease considerably their usage in a variety of clinical situations.
In developing revisions, as Dr. McCann outlined, we must recognize that HCFA will use these guidelines and definitions within the context of the RBRVS. If HCFA believes that the resulting modifications have lessened the value of the examinations, there may be reductions made in the relative value units of those exams. This is particularly important in considering modifications to single organ system examinations, where considerable effort has already been made to ensure that the “physician work” encompassed by those examinations is comparable to the “physician work” represented by a general multi-system examination.
We must also take a holistic approach to the revision process. Not only must we address specific comments and revisions on discreet components of the guidelines, we must also that the resulting guidelines are efficient, accurate, and non-burdensome. Although specific comments are more immediately helpful than a comment that “this is too complicated,” the latter comment is equally important and must be fully addressed.
The CPT Editorial Panel has and will be devoting a major portion of its February, May and, August meetings to refining the documentation guidelines based on the input received in March and April.
The third part of our plan is Education. We have begun to work with our state and specialty partners to develop teaching materials and tools to increase the accuracy and reduce the burden of coding and documentation. Once the guidelines are revised, we will work with states and specialties to ensure that these materials reach the hands of grass roots physicians.
We also want to ensure that physicians have enough time for education before new guidelines are mandatory. As a result, we have already begun discussions with HCFA about an extension of the current grace period and are optimistic that we will come to a good result. From the comments we receive later this month, we will have a better idea of the time needed to make needed revisions and the earliest that revisions could be completed.
In conclusion, please be assured that we recognize that clinical documentation is essential to good patient care. We hope new guidelines will ultimately encourage and assist physicians and other health care professionals in providing proper documentation.
We are also mindful that the time required for documentation, beyond what is clinically necessary, can only come out of patient care. Patient-doctor relationships already feel the crush of time. Moreover, through accurate information and needed changes in enforcement approaches, physicians must be able to provide high quality, well documented patient care without laboring under the fear of unwarranted fraud and abuse penalties and prosecution. We welcome your support for these propositions.
Thank you for the opportunity to present the views of the AMA this afternoon. I would be pleased to respond to any questions.