Part B Insider (Multispecialty) Coding Alert

Published on Thu Oct 20, 2005 PDF

CMS defends carriers' rights to make up their own E/M rules

If you're concerned about TrailBlazer Health Enterprises' new audit tool for evaluation and management claims, you're not alone.

Many physicians in Texas have been questioning the new TrailBlazer audit tool (See PBI, Vol. 6, No. 36). The Texas Medical Society's socioeconomic committee will be taking up the issue, according to physicians, and so will the Texas College of Emergency Physicians. They'll be seeking more information on how TrailBlazer developed the tool, and what statistical basis, if any, it has. The Emergency Department Practice Management Association also has formed a taskforce on the issue.

There are two components to the TrailBlazer audit tool that worry physicians: It says that it won't give credit in the Review of Systems for cases where a physician discusses some systems and then writes "all other systems negative." Also, TrailBlazer has created a complicated points system for Medical Decision Making.

Emergency physicians, in particular, are very concerned that the audit tool isn't applicable to emergency medicine and will limit their ability to 99284 or 99285 encounters. They point to the fact that they won't gain a point for "direct visualization," and that reviewing and summarizing old records and discussing the case with another provider are each only one point.

So far, no physicians have reported being audited using the new tool, but TrailBlazer has been defending its right to use it. And the Centers for Medicare & Medicaid Services stood up for TrailBlazer at the Nov. 3 physician Open Door Forum. Quinten Buechner with ProActive Consultants in Cumberland, WI asked CMS officials about the TrailBlazer policy, and they responded that carriers have a right to make their own policies.

"I Know It Creates Angst"

Buechner cited a CMS memo stating that Medicare would judge physician E/M claims according to either the 1995 or 1997 E/M guidelines. CMS officials responded that the guidelines were just guidelines, and they're not in any law or regulation.

"I understand the concerns, believe me," said Kit Scally with CMS. "I know it creates angst."

"If you're doing a complete exam and you go through two or three systems and say all remaining are normal or negative," then you should at least have a form or checklist to let the reviewer know which other systems the physician reviewed, Scally claimed. "There are 15 organ systems. If you only qualify two, and you say the remainder are negative, we don't know whether you're talking about four or the remaining 13."

Some providers worry that each carrier will have its own E/M audit policies, which make your life more confusing and mean different policies for different regions. But Scally said that CMS officials are working with the carrier medical directors in an evaluation and management workgroup, to create "greater uniformity."

Advice: You shouldn't let audit tools like TrailBlazer's change the way you code E/M visits, insists Kenny Engel, compliance officer with Martin Gottlieb & Associates in Jacksonville, FL. The TrailBlazer tool includes the 1997 E/M guidelines and not the 1995 guidelines, but you should still feel free to use whichever guidelines are more advantageous to you, Engel advises.

The main purpose of the TrailBlazer audit tool appears to be to supplant the tool created by the Marshfield Clinic and used widely by doctor's offices, Engel adds. But carriers have tried to ignore the Marshfield tool in the past and have come up against the weight of physicians' support for it. Engel cites a 2002 case in which Florida Medicare audited physicians and refused to accept the Marshfield tool. The physicians relied on the Marshfield tool for their defense, and eventually won, says Engel.

So far, Engel has only tried auditing one claim for a 99285 encounter using the TrailBlazer tool, and it still coded as a 99285. Other coders have tried to use the tool to audit their charts but have given up in frustration because the tool is so hard to figure out. "It would be pretty bad if they made the tool available but then provided no education on the use of it," complains one coder.