E&M guidelines, emergency care rules under HHS review

Physicians say they welcome the government's vow to work with them to address these thorny issues.

By Geri Aston, amednews staff. Aug. 6, 2001.

Washington -- The government will reassess its effort to develop new Medicare evaluation and management coding guidelines and the federal rules governing treatment of uninsured emergency patients, Health and Human Services Secretary Tommy Thompson announced in late July.

The decision is evidence of a new HHS "culture of responsiveness" to the concerns of physicians and other Medicare participants, Thompson said. Indeed, physicians have pointed to major problems in recent years with both the E&M guidelines and the Emergency Medical Treatment and Active Labor Act.

Reaching out

To work to find solutions to problems in those two areas and others, the Centers for Medicare & Medicaid Services announced the creation of seven "Open Door Policy Committees." One of the panels is devoted to physician issues. Each committee will include senior level agency staff and will meet monthly with relevant interest groups in an effort to build relationships with those organizations and to generate ideas for program reform.

"The goal is to force the institution to be more outward looking," said Tom Scully, CMS administrator.

The AMA said it welcomed the government's effort to reach out. "We are encouraged by this, especially the focus on the documentation guidelines," said Timothy T. Flaherty, MD, AMA chair. "It's been a real concern for all of organized medicine."

Thompson announced his plans to reassess the E&M guidelines at a House Ways and Means Committee hearing. In his testimony, he acknowledged that physicians had found the 1995 and 1997 versions of the documentation guidelines "cumbersome," and he said the agency agreed. He also noted that the government's proposed 2000 version was also causing concern in the physician community.

"We had hoped that this current effort would be a way to reduce burdens on physicians, but it appears it needs another look," Thompson said. As a result, the agency has halted development of "clinical examples," a component of the draft 2000 guidelines, he said. The examples, being created by Aspen Systems, a Rockville, Md., information management company, were intended to serve as true-to-life cases that physicians could follow when documenting E&M services.

But physicians had many problems with the clinical examples. The AMA and 38 medical specialty groups sent a letter June 29 to Scully outlining 14 faults with Aspen's draft product. Among the complaints were that the examples use inappropriate clinical terminology, are not relevant to typical physician-patient encounters, exclude major patient groups and would require more documentation.

"The proposed clinical examples are seriously flawed and need to be scrapped," the groups wrote.

New solutions needed

Thompson vowed to work with the physician community to design "constructive solutions" to documentation guideline problems. He also proposed looking beyond the documentation guidelines.

"We need to go back and re-examine the actual codes for billing doctor visits," he said. "For the system to work, the codes for billing these visits need to be simple and unambiguous. I look forward to working with the AMA and other physician groups to simplify the codes and make them as understandable as possible."

But the AMA is urging the government to focus on the guidelines, not the codes, Dr. Flaherty said. "The real problem for physicians is the excessive documentation harassment of the guidelines," he said. "You need accountability, but you don't need to make it like an IRS audit."

Ruben King-Shaw, CMS deputy administrator and chief operating officer, said the agency's Open Door Policy Committee geared toward physicians would focus on the guidelines and not the E&M codes.

But some physicians say the codes themselves should be addressed.

"The AMA and CMS should start from scratch and think out-of-the-box about this and find a way to make it easy to code and to document codes," said Joseph Heyman, MD, a member of the Practicing Physicians Advisory Council.

One way to simplify the codes would be to cut the number of service levels from five to three, he said, as long as the reworked levels were fair and the top tiers weren't simply eliminated in order to pay physicians less.

Eye on EMTALA

At the hearing, Thompson also pledged to revisit the EMTALA regulations. "While the law in this area is well-intentioned, we understand that providers view the current regulations as burdensome," he said.

"I have directed CMS to go back and revise these regulations and make any necessary changes to ensure they protect patients without creating unnecessary burdens on hospitals or physicians," he said.

Scully said EMTALA's scope had "become overbroad." He also said one thing the relevant CMS Open Door Policy Committee might look at was whether the interpretation of the types of facilities covered by the law should be narrowed. For example, should hospital outpatient departments be subject to EMTALA?

The American College of Emergency Physicians is pleased that CMS is turning its attention to EMTALA burdens, said Charlotte Yeh, MD, chair of the college's task force for health care and the uninsured.

One of the first tasks for the committee should be to "develop clarity about what EMTALA is and isn't," Dr. Yeh said. Variation in enforcement of the law across the nation and differences in interpretation of the statute by the administrative branch and the courts have left emergency physicians confused about what is required of them, she said.

"EMTALA creep" -- the expansion of the law over the years -- has had a chilling effect, Dr. Flaherty said. Hospitals are afraid to offer some services, and physicians are less willing to serve in an on-call capacity because of EMTALA threats, he said.

ADDITIONAL INFORMATION:

Reaching out

The Centers for Medicare & Medicaid Services announced three initiatives aimed at getting input from physicians and others and reducing administrative burdens. They are:

Open Door Policy Committees. These panels will give interest groups an opportunity to share ideas with the government on how to address pressing issues. The seven committees are geared toward: physicians; hospitals and rural health; nursing homes; health plans; nurses and allied health professionals; home health and hospice; and end-stage renal disease and dialysis.
Listening forums. CMS plans to launch a series of regional forums in September to give physicians and others opportunities to voice their concerns and ideas for improvement.
In-house expert teams. Panels across CMS will develop ways to reduce administrative burdens and simplify regulations.