Protecting Yourself Against E&M, CPT, and Other Govt. Afflictions

M. Tray Dunaway, MD


As medicine moves toward the new millennium, the latest aggression of the federal government with medicine has been launched in the ongoing "fraud and abuse" campaign. The practice of medicine has become criminalized, reimbursements have decreased, and with the passage of the Kassebaum-Kennedy law, the risk of audits by both public and private third party payers is the highest it ever has been. At the essence of this controversy is physician documentation.

When I was a medical student, history and physicals were lengthy and tedious. As my proficiency increased, my documentation decreased. The busier I became with patient care, I documented only essentials needed to optimize care. My medical records have taken on new meaning. Third party payers use my documentation as a measure to gauge, and often diminish reimbursement. "If you didn't document it, you didn't do it" became the mantra of medical record gurus. My reimbursement, third party payer audits, demanded refunds, and fines are now all documentation-based. In the hospital medical records department, "CC" no longer means Chief Complaint, but rather Co-Morbid Condition, a documentation device to increase DRG reimbursement to help in their own struggles.

According to Dr. Lee McCormick, president of the Pennsylvania Medical Society, there is more physician anger over the new Evaluation and Management documentation guidelines than any other single issue affecting physician practice in the last 10 to 15 years. It certainly has been divisive. Animosity between third party payers and providers has heightened. With recently announced Orwellian "fraud and abuse" bounty-hunting senior citizen whistle-blowing-detectives, discord and damaged public relations between physicians and patients is assured. Even the AMA, co-author of the new federal AMA/HCFA documentation guidelines (although in an apparent attempt to distance themselves from the guidelines, the AMA now refers to them as the "HCFA documentation guidelines"), has significant internal divisions. The leadership of the AMA has previously supported the guideline revisions, while the AMA House of Delegates continue the fight against these divisive imposed burdens.

So here are the facts as I see them:

° A recent HCFA audit of Medicare claims for E&M services demonstrated a full 40 percent of the claims were denied due to inadequate documentation. Additionally, 20 percent were either downcoded or denied in part because of poor documentation.

° HCFA recently claimed 12.6 billion Medicare dollars were paid out in 1998 from false claims, and previously has stated 10 percent of Medicare payments were "fraudulent."

° Criminal convictions for "fraud and abuse" are up 400 percent from the previous year and $1,000,000,000.00 (that's a billion!) was collected in fines last year.

° There appears to be no end in sight for the current "fraud and abuse" campaign against medicine and by all appearances it's getting worse.

° Hopes for a political settlement are dismal. HCFA has demanded and the AMA has consented to retain a medical record counting or numeric scorecard determination system on reimbursement.

° Public and private third party payers are holding us to 1995 E&M documentation guideline standards. Revisions will be made, but will most likely be minor changes from the 1997 guidelines.

° We had better learn how to apply the existing rules to protect ourselves by filing accurate claims because the audits, fines, and penalties will continue before any final E&M documentation guideline revisions.

So what can physicians do? We need to continue to fight to maintain the right to practice good medicine and for the right to be fairly reimbursed for our efforts. In the meantime, we need a simple and inexpensive way to deal with the imposed guidelines to keep us as economically viable as possible and to avoid audit exposure. The nature of E&M documentation and application to CPT coding has become progressively more complex. The simplification of CPT is desirable, but probably is not going to happen as the AMA controls CPT and HCFA mandates its complex, obtrusive use.

The responses of organized medicine to the new guidelines have been varied. The AMA has publicly asked for suggestions and guidance concerning the guidelines and ways to educate physicians over a year ago, but nothing I am aware of has been developed. Some organized medicine groups have been waiting for finalized guidelines to be revealed. Others seem more interested in profiting from physicians than actually helping them with compliance issues.

I submit an algorithm that departs from our traditional approach to taking a history and physical in a few minor but critical steps. I have used this algorithm in my own practice and it has effectively allowed me to produce the same codes and documentation the "experts" do, but without having to become a coding "expert" in the process.

Physicians do not formalize medical decision making (MDM) the way auditors do. The components of MDM, risk, amount of data, number of diagnoses and management options, are not specified precisely the way an auditor would. If we knew the rules when creating medical records, we could use them. This is technically an open book test. How many open book tests did you take in medical school? There was a reason my school didn't give open book tests, we wouldn't have to study! We typically do include some of the MDM components anyway, why not use the rules to make sure the actual requirements are included?

If physicians know what to include by audit standards, the level of coding will be more precise and reimbursement will become more accurate. By following this algorithm as a blueprint, specific documentation supports the chosen CPT code, and remains flexible enough to create a unique medical record. What follows is a brief overview of this workable system:

1. Risk is formally assessed for a patient encounter using AMA/HCFA guidelines.

2. Counting or numeric audit form generated checklists allow the physician to "score" the record before the auditor does using 1) amount/complexity of data to review/order and 2) number of diagnoses or management options to provide the remaining components for MDM.

3. Precise MDM is formalized by accurate Risk, Amount Complexity of Data, and Management/Diagnosis options determinations.

4. Once the defined level of MDM is known, the correct CPT code to correlate with the MDM level can be determined. This exact CPT starts the medical record for billing ease.

5. Specific history and physical documentation guidelines for each CPT code are determined which can be organized in a dictatable format.

The medical record now sustains correct reimbursement based on a MDM-driven CPT code assignment. Because the documentation supports the CPT code, audit risk is minimized. The accurate CPT code is on the medical record itself. There is no process breakdown between the actual physician work and services billed from the methodically-derived CPT code. The physician is reimbursed fully, but perhaps not always fairly, for his work.

This algorithm does not reduce the amount of paperwork we must submit for more accurate reimbursement. It does afford us some degree of protection and prolonged viability while we fight to stop the hemorrhaging of our profession at the hands of the swarms of officers sent hither to harass us (and our patients) and eat out our substance.

In my hometown of Camden, South Carolina, Charles Lord Cornwallis spent the winter of 1780-1781 terrorizing the downtrodden patriots in South Carolina. He was defeated and his second-in-command, Charles O'Hara, yielded Cornwallis' sword to Major General Benjamin Lincoln, General George Washington's own second-in-command, the following October 19th in a stunning reversal of fortune. We must continue to rail against government and other third party payer aggression for medicine to have its Yorktown yet.

Dr. Dunaway is a general surgeon at Kershaw County Medical Center in Camden, SC. He wrote the Pocket Guide to Clinical Coding and speaks nationally on E&M coding concerns and instruction from a unique clinical perspective. Dr. Dunaway may be reached through Rebel Records, Inc. at (803) 425-8555 or http://www.rebrecords.com.

Originally published in the Medical Sentinel 1999;4(5):179-180. Copyright ©1999 Association of American Physicians and Surgeons (AAPS).