Part B Insider (Multispecialty) Coding Alert

Published on Mon Jun 28, 2004 PDF

But "average payment" idea dead on arrival, AMA says

Happy with the status quo on E/M coding? You'd better be.

There's little chance of any changes to evaluation and management coding rules in the near future, according to the AMA and other sources. After three years of buildup, the much-ballyhooed "clinical examples" for E/M coding failed even to warrant official discussion at the AMA's recent delegates'meeting.

The issue didn't come up, the AMA says. There was no discussion of the issue on the house floor, according to the AMA, and no resolution or report brought up the issue. This stony silence reflected a recognition that the clinical examples project had come to a halt.

Clinical examples were an attempt to replace the current numbers-driven 1995 and 1997 guidelines with something more nuanced and intuitive. Physicians would pick the correct level of E/M services by matching their narrative description of the patient's problem and what they did to a template that signified a level of service.

The AMA tested this idea by asking 11 specialty societies to come up with narrative examples for each E/M level for their specialty. These were posted on a Web site where members of those specialty could attempt to use them to choose an E/M code. The surveyors compared the physicians' responses with the target E/M levels for each example.

Unfortunately, the tests showed that clinical examples didn't improve correct coding for E/M visits, according to the AMA. While it's not necessarily true that clinical examples are dead, their current form is unlikely to return. The CPT editorial panel will have to approach this issue from a new angle.

One official at the Centers for Medicare & Medicaid Services suggested a new idea for using a new mechanism involving "average payments" to set levels of E/M coding. This isn't an official view at CMS, according to the AMA, but simply the views of one CMS official. If CMS did suggest an "average payments" methodology, it would be "dead on arrival" at the AMA.

The AMA and CMS have committed to spending a year rolling out whatever new methodology for E/M coding they come up with, notes consultant Cheryl Gregg Fahrenholz, president of Preferred Healthcare Solutions in Bellbrook, OH. That includes education of specialty societies and outreach from the CMS technical work group. So even after CMS and the AMA come up with a new methodology, don't expect to see it take effect right away.