New E&M guideline design moves forward

HCFA pushes ahead with plans to develop physician guidance "vignettes" for its proposed 2000 evaluation and management documentation guidelines; physicians remain concerned.

By Jane Cys, amednews staff. Nov. 20, 2000.

Washington -- The Health Care Financing Administration in late October laid out a process and tentative timetable to develop vignettes -- a key component of the agency's proposed 2000 Medicare evaluation and management documentation guidelines.

The physician community generally appreciated the HCFA update and welcomed the chance to participate in the vignette development process. But reservations still persist that the vignettes won't meet expectations. Also, HCFA generated new concerns with the process it outlined.

"Family physicians have a lot at stake," said Jake Culp, senior government relations representative for the American Academy of Family Physicians. "We'll just have to wait and see."

HCFA proposed the latest version of the E&M documentation guidelines in June 2000. The idea behind vignettes is to create real-life examples that physicians can follow when documenting the services they provide to Medicare patients.

E&M services account for about $18 billion in Medicare spending annually, or about 40% of spending for physician services. Previous versions of the documentation guidelines attracted the physician community's ire for their reliance on "counting" or "bullet points."

HCFA hired Aspen Systems Corp., an information management company based in Rockville, Md., for about $602,000 to develop 600 vignettes for 20 specialties, said Paul Rudolf, MD, senior technical adviser at the agency's Center for Health Plans and Providers.

Those specialties named are cardiology, emergency medicine, endocrinology, family practice, gastroenterology, general surgery, internal medicine, neurology, neurosurgery, obstetrics-gynecology, ophthalmology, orthopedics, osteopathy, otolaryngology, pediatrics, podiatry, psychiatry, pulmonary medicine, rheumatology and thoracic surgery.

Examples will be developed for two of the three components of an E&M code: medical decision-making and physical examination. HCFA has decided not to develop vignettes for the third component -- patient history -- because it hasn't generated the same controversy as the other two areas, Dr. Rudolf said.

Aspen will rely on current medical records to create the specialty-specific examples. "That's a big positive, because it means that the examples are going to reflect actual clinical practice," Dr. Rudolf said.

Once the development task is complete, medical specialty societies will have an opportunity to review and comment on the examples. The contractor and HCFA will evaluate those comments, make changes and then submit the revised examples to the societies for a second round of reaction and possible revisions.

Carriers and medical specialty societies will also work to develop standard protocol for medical review using the proposed E&M guidelines, Dr. Rudolf said.

The agency hopes to finish the examples by May or June of 2001. Pilot testing of those examples and the medical review protocol will take place after their completion, Dr. Rudolf said.

A starting point

Some medical societies expressed concerns that HCFA planned to develop examples for only three levels of medical decision-making and physical exams even though CPT describes four levels of service for each component.

"We understand the potential confusion, and we are in the process of trying to address that concern," Dr. Rudolf said.

Others raised concerns that HCFA had decided against creating examples that represent their specialty. Daniel Siegel, MD, the American Academy of Dermatology's representative to the AMA's practice expense advisory committee, said dermatologists would receive little direction on how to document their E&M services since HCFA decided to exclude them from this process.

"It should really be all [specialties] or none if they're going to do it correctly," Dr. Siegel said.

Dr. Rudolf said the plans laid out so far are a starting point for the vignette development process. The agency plans to eventually include more specialties, he said.

The Practicing Physicians Advisory Council will take up the proposed 2000 E&M documentation guidelines at its December meeting.