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HCFA promises to deliver simplified E/M guidelines

Still at issue: whether numerical formulas are necessary to verify physician compliance

From the November 1998 ACP-ASIM Observer, copyright © 1998 by the American College of Physicians-American Society of Internal Medicine.

HCFA has promised to deliver a new, simplified set of evaluation and management (E/M) documentation guidelines to replace the 1995 and 1997 versions that physicians now use.

Physicians and medical organizations like ACP-ASIM have complained that existing E/M guidelines are too burdensome. This past June, the AMA urged HCFA to consider a new, simpler approach for documentation guidelines that does not use numerical formulas to verify that physicians meet record-keeping requirements. (The 1997 E/M guidelines require that physicians review a certain number of systems to receive credit for their work.)

HCFA has insisted that the use of some numerical formulas, or counting, is necessary to "assure consistent interpretation of guidelines by Medicare carriers," but details are not yet available on how this would be implemented. The AMA's CPT editorial panel will work with HCFA to create the new guidelines.

HCFA has said that physicians will test the new guidelines before they are implemented to make sure the new rules are not overly burdensome. HCFA is not setting an implementation date for the new E/M guidelines, in part because it wants to leave adequate time to educate physicians and Medicare carriers before releasing the guidelines. For now, HCFA is instructing Medicare carriers to continue using the 1995 or 1997 E/M guidelines when reviewing claims and to defer to whichever set of guidelines favor physicians on a case-by-case basis. AMA officials have said they don't expect any new guidelines to be released before the end of 1999.

Earlier this year, a joint ACP-ASIM working group had proposed many of the changes that HCFA is promising to make to its E/M guidelines. For more information on this issue and the College's position, go to the "Where We Stand" section of ACP-ASIM Online ( and look for "Statement of the ACP-ASIM Working Group on E/M Documentation Guidelines."

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