Part B Insider (Multispecialty) Coding Alert

Published on Fri May 12, 2006 PDF

But keep an eye open for more carrier-level meddling

The American Medical Association shows no sign of moving ahead with new national guidelines for your evaluation & management documentatio--but that doesn't mean you can relax.

The national guidelines may not change any time soon, but local carriers such as Trailblazer will continue to push forward with regional guidelines, observers predict. Carrier reps will use those guidelines to audit your claims until you follow the new rules.

The Centers for Medicare & Medicaid Services has no policy to encourage the carriers to make their own E/M rules, officials say. The carriers have "discretion" to interpret national policy when "rules are unclear or when there is an absence of rules," says one official.

But there's no "national directive" pushing carriers to come up with their own E/M guidelines . Comments by one CMS official during a physician Open Door Forum may have given the wrong impression, the source adds.

Of course, if the AMA and CMS agreed on new national E/M guidelines, there wouldn't be any need for the carriers to come up with their own local rules. But CMS isn't even talking to the AMA about coming up with new national guidelines, officials say.

The idea that carrier-level guidelines might be intended to prod the AMA into action is "mere speculation," says Michael Beebe, director of CPT editorial and information services at the AMA. "If CMS wants something, they call us up and tell us what they want," he says.

Trouble ahead? You can no longer compare a Texas physician's E/M documentation to that of a New York physician's, because the rules will be different, says Quinten Buechner, a consultant with ProActive 
in Cumberland, WI. Regional differences will make it harder to have any kind of meaningful pay-for-performance scheme, which would be based on comparing doctors all over the nation, he warns.

It may take up to a year for Trailblazer auditors to start using the new guidelines, and other carriers may be waiting to see how Trailblazer fares before following suit, Buechner notes.