Cardiology Coding Alert

Increase Pay-up and Provide Audit Defense with '97 E/M Guidelines

You may have breathed a sigh of relief this July when the Health Care Financing Administration (HCFA) indefinitely delayed the new 1997 Evaluation and Management (E/M) Guidelines. But this postponement doesnt get you off the auditor hook, experts warn.

Cardiologists and their practice managers who perceive this delay as a reprieve -- and therefore think they dont have to worry about their documentation are making a huge mistake, says Steve Arter, executive vice president in the compliance and education division, QuadraMed Corporation a healthcare services company in Point Richmond, CA.

Although HCFA allows physicians to use whichever version of the guidelines (either the 95 or 97) which is more advantageous to their practices, they must comply with one of them, points out Percy Wootton, MD, immediate past president of the American Medical Association, and a clinical cardiologist in Richmond, VA.

If you relax your documentation efforts, youre just setting yourself up for the auditors, Arter warns.
For example, HCFA will continue to randomly audit between 1% and 3% of Medicare charts every year, specifically looking for adequate documentation of E/M coding.

If your record keeping doesnt come up to par, your cardiology practice may be forced to refund overpayments and pay penalties. HCFA will also be performing chart audits on claims submitted by practices that seem to be operating differently from the norm, he adds. For example, offices that are billing more Level 5 office visits that other similar practices in the same geographic area may be targeted for an audit.

Thats why the erroneous belief that the 97 E/M guidelines no longer apply can be the kiss of death for practices that get audited, Arter believes.

Which Version Should Cardiologists Use?

The experts we spoke to advise cardiology practices to switch to the 97 version, even though the move will entail more paperwork. They cited these reasons:

1. The 97 guidelines decrease interpretation on the part of the auditor. Although many physicians dont like the fact that the physical examination and history portions on the 97 guidelines require more details than those of the 95 version, that very specificity can be to your advantage, says M. Tray Dunaway, MD, author of the Pocket Guide to Clinical Coding and a physician with Sentinel Health Partners in Camden SC.

Editors note: The Pocket Guide to Clinical Coding is self-published by Dr. Dunaways company, Rebel Records. The cost per single copy is $10.75, including shipping and handling. For more information, see or e-mail at The mailing address is 1413 Mill St. Camden, SC 29020-2934.

Rather than go by vague guidelines, I prefer using the specific 1997 version because I know I can document these points adequately. That way its not left up to the auditor to determine what I should have documented, says Dunaway who wrote the guide after becoming frustrated with trying to decipher the puzzle of E/M coding.

Arter agrees. For the first time physicians are being told the rules of the game and the rules are written in black and white, he says.

2. The 97 edition can help you get paid more. Even though the 97 guidelines certainly arent perfect, Arter maintains they are the best thing thats happened to increase reimbursement.

For example, he believes that, if followed, the 97 version
offers physicians an opportunity to ethically code at a higher level and get reimbursed for the services they are already providing.

Physicians tend to do far more than they document, and undercode for what they actually do because of the fear of being audited. Now (with the new guidelines) that physicians know what to document, they can get credit for all of the services provided and optimize reimbursement, Arter says.

Dunaway adds, I realized that I was undercharging and even though I might not like the rules in the new guidelines, it behooves me to learn and follow them in order to be reimbursed at a higher level.

3. The 97 guidelines can help prevent audits. Because the newer version demands that doctors beef up their documentation efforts, that factor in itself can stem the audit tide.

Physicians are commonly falling dismally short of even the 95 documentation requirements, Arter notes.
For example, HCFA is performing a pre-payment audit on 1% of all E/M services based on the 95 guidelines, he says. About 65% of the claims are failing to meet these documentation requirements and, out of that percentage, four out of six claims are failing to even qualify as an E/M service while the other two are being downcoded, he explains.

4. The basics of 97 guidelines are here to stay. Still, some cardiology practices are reluctant to switch to the 97 guidelines while the implementation is on hold.
This June, the AMA House of Delegates passed a resolution asking HCFA to eliminate the stringent criteria for single-organ system examinations, and put more emphasis on the other elements of E/M services such as patient risk and medical decision making.

Yet Arter believes HCFA probably wont go along with the AMAs request, because it is adamant about not reducing
documentation standards.

The agency may revise the guidelines so that physicians can select from one giant list of bullets instead of the current shorter lists from each system, but there still will be specific elements that must be documented, he says.
Dunaway agrees. Understand, there will eventually be new documentation guidelines, revised from the current ones, but in reality, they wont change much -- so wed better get used to it, he says. The key to survival is to learn to apply the rules as they stand now.

Tip: Determine Risk First

The more M. Tray Dunaway, MD, tried to comply with the 97 E/M coding guidelines, the more frustrated he became.

Every time I set out to determine the level of service, I got totally lost. I knew there had to be a better way of formatting the information in a manner that doctors can understand, says the physician with Sentinel Health Partners, a multi-speciality group in Camden SC.

Determine patient risk first. If you start with the history and physical, then you may be doing too much or too little -- you dont know if it will match the requirements [for levels of service] he advises.
Instead, start with the risk assessment because its the key to correct coding, Dunaway says.

The cornerstone of the new guidelines is medical decision making, of which patient risk is the main component, so I built my system around it, Dunaway adds.

By first determining patient risk, he explains, the physician can then move easily through the medical decision making phase, scoring each section accurately, he claims.

My reimbursement has improved and an auditor from a private payer said she was amazed at how nice the records were, Dunaway says.

Editors Note Well keep you updated on changes to the E/M guidelines as they occur. Meanwhile, HCFA says that this fall it will develop and field test nationwide E/M pilot projects. In January 1999, HCFA will make changes to draft guidelines as a result of the field tests. By fall 1999, the refined E/M guidelines are scheduled to be implemented.