South Carolina surgeon M. Trayser Dunaway, says he'd be happy if all medical records were kept on 3- by 5-inch note cards.
Today's medical practice and billing, however, requires much more detailed documentation and record keeping. The federal government recently declared the prosecution of healthcare billing fraud one of its top priorities, and a reliance on note cards in this fraud-suspicious environment would likely land Dunaway in jail.
To help himself and other physicians understand and simplify medical record keeping, Dunaway has authored the Pocket Guide to Clinical Coding (Camden, S.C.; Rebel Records; $10.75)).
Since 1992, when HCFA instituted a Medicare physician fee schedule, each patient visit and procedure has been coded according to the Current Procedural Terminology codes. Every service receives a code and an appropriate billing level, from one to five.
To help physicians use the codes and bill correctly, HCFA issued evaluation and management documentation guidelines in 1995. In 1997, because of confusion generated by the original guidelines, HCFA issued new E&M guidelines with more requirements and greater detail. Originally scheduled to go into effect Jan. 1, the implementation of the new guidelines has been indefinitely postponed while HCFA tests their effectiveness and considers revisions. A number of physicians complained the guidelines as proposed were confusing and cumbersome, and that they forced physicians to do unnecessary work to get paid. For example, the guidelines for a comprehensive exam listed more than 40 steps physicians must perform and document.
The American Medical Association is leading the effort to to revise the 1997 guidelines. Physicians from across the country met with HCFA officials last month in Chicago to discuss the new guidelines. Some physicians wanted a delay; others wanted the guidelines completely rewritten.
In a recent letter to members of the Pennsylvania Medical Society, President Lee McCormick, M.D., railed that he is "personally outraged" by the new guidelines. "We appreciate that good documentation is necessary for quality patient care. However, the documentation involved with these guidelines is excessive. Documentation should be a way to enhance care of our patients, not to satisfy HCFA."
The first list of descriptive terms and codes for reporting medical services and procedures, the CPT codes, was created by the American Medical Association in 1966. They were designed to provide a uniform language for reliable, nationwide communication between healthcare providers. Thirty-two years later, they are the standard for processing public and private insurance claims.
Though HCFA's 1995 guidelines were intended to help physicians code and bill appropriately, some physicians claimed they were too narrow. The guidelines focused on what are known as multisystem exams, in which more than one organ or body part is examined. They made no reference to single organ or single system exams, which left many specialists confused -- and often underpaid.
Under the 1995 E&M guidelines, for example, an ophthalmologist who submits a level-four bill for a high-level ophthalmology exam will not meet all of the criteria for a comprehensive high-level exam, because he or she has examined only one "system." HCFA offered no guidance in such situations, so Medicare carriers developed their own, somewhat arbitrary, criteria for specialists' billing. Other carriers limited the billing levels of family physicians, according to the AMA, reasoning family doctors could never code higher than level three because the services they provide are not complex.
The resulting confusion and controversy led HCFA to issue the new guidelines, which added more clinical specifics to the multisystem exam and more guidelines for 10 single-system exams. Despite the role of the AMA and a number of specialty societies in helping HCFA draft the new guidelines, they still have been greeted with considerable resistance by physicians.
Melvyn Sterling, chair of the California Medical Association's Medicare E&M Committee, says the guidelines will add an additional five to seven minutes to each patient visit. Sterling, an internist in solo practice in Orange, Calif., says, "Either that means staying late at night or seeing fewer patients -- probably seeing fewer patients." The guidelines have "changed my focus from being focused on the patient to being focused on the chart in order to protect myself."
In a recent letter to the Wall Street Journal, one Washington internist declared, "Documentation requirements are on the verge of subsuming medical care itself."
"I'm jumping through the hoops, but they're not essential to what I'm doing," author Dunaway says. "I want to know what medical problems my patients have, but if somebody comes in with appendicitis, I fix it and then I never see them again. I don't need all the paperwork."
McCormick says some of his members have complained that the new guidelines would add at least two hours to their day. "It becomes counterproductive to good patient care because you can sometimes get so lost in the minutiae."
McCormick also says the proposed guidelines would make extra work by requiring physicians to document what are known as "negatives." For example, in the past, physicians may have mentally noted there were no problems with a patient's nose, but now the guidelines require that they make note of that fact. "The last time I did a physical exam during which I documented all the negatives was when I was in medical school," he says. "Physicians just don't function that way."
For many doctors, the cost of compliance also is a concern. "It takes me about two minutes to figure out what I need to do, but it takes at least 30 minutes to do the paperwork," Dunaway says. "We're going to employ a physician assistant this summer. I can do my two minute assessment, and then he can go back and fill in the boxes behind me. That will help, but I have to pay him."
Transcription costs are expected to go through the roof at the Mayo Clinic in Rochester, Minn., according to rheumatologist Audrey Nelson. "It becomes an extremely time-consuming, onerous activity, not only to do, but to document and transcribe," she says. "And the cost of transcription is phenomenal."
Some organizations, including the Mayo Clinic Jacksonville (Fla.), are betting electronic patient records systems will speed documentation, but critics point out that the new guidelines will not work with any existing system and that new software will have to be designed to accommodate the new guidelines.
One of the more theoretical, but often-heard physician complaints is that the proposed guidelines reward nuts-and-bolts work over medical decisionmaking.
"The new guidelines asked physicians to record an inordinate amount of material to justify a particular fee," McCormick says. "Physicians don't just gather all the information they can possibly gather and then decide what's useful. What they do is think in algorithms and decision trees. The guidelines are not set up to recognize that of thinking."
Instead, McCormick would like to see guidelines that recognize the "thought processes that go into the diagnosis and management of the patient without having to show I've asked what their father and mother died of," he says. "If a physician recommends brain surgery for a brain tumor and then spends an hour talking to that patient and family, but can't charge a higher fee unless he has documented the family history and social history, that's absurd. We're not asking for physicians to get a free ride, but we are asking that the reimbursement be appropriate to the time and effort spent."
It's not just time-consuming paperwork physicians say they dread. "More important in my mind is the threat of legal action for fraud and abuse," McCormick says. The 1996 Health Insurance Portability and Accountability Act greatly expanded the government's fraud and abuse investigative resources. While HCFA Administrator Nancy-Ann Min DeParle is on record saying occasional coding errors won't be the government's focus, many physicians remain uneasy.
"If I don't have every element of a level three, then, according to the current interpretation of fraud and abuse, I've committed fraud," says Randolph Smoak, a general surgeon in Orangebury, S.C., and an AMA trustee.
Such fears are apparently justified. HCFA recently conducted an ongoing audit of physicians' documentation related to E&M services and found that 40% of audited claims were denied because of insufficient documentation and another 20% were reduced to a lower service level, according to Jean Harris, deputy director of the provider purchasing and administration group.
Harris says, most often, the physicians simply didn't respond to requests for documentation, and the claims were subsequently denied. Other times, she says, the documentation wasn't adequate. The audits did not result in criminal investigations, but may have raised red flags for future auditors. "Auditors are always suspicious," she says. "They wonder if (laziness) is the reason the physician didn't send the record, or if it's because he had something to hide."
HCFA's failure to educate physicians about the new guidelines also has drawn fire. A California Medical Association survey found that nearly 30% of those surveyed were not even aware of the guidelines.
"HCFA budgets zero money for education and implementation," says Bertha Safford, a family physician in Ferndale, Wash. "They leave that entirely to medical specialty societies, and I think that's terribly unfair. We have to finance everything that it takes to educate physicians about this dramatic new way to document charges."
Says the AMA's Smoak: "You can't throw a system at the whole of medicine and say, 'here's a new system you've got to use for your reimbursement,' without going through some serious training."
While HCFA's Harris says the agency is receptive to feedback, some physicians fear the agency will do little more than tweak the current system. "I am sure they're going to do something about the amount of material in that single system exam and particularly the recording of all the negatives," says the Mayo Clinic's Nelson. "But the thing that I am not sure we'll be able to get them to do is to find a way for medical decisionmaking to be the exclusive level determinant for code."
Smoak suggests getting rid of some of the "onerous components," such as requiring certain negatives and repeating history-taking.
"You can't abandon the whole system, because you've got to have a system in place," he says. "But there has to be something that will not take away the amount of time that physicians spend with patients."
Amid all of the complaints about the new guidelines, there is a small cadre of supporters. Catherine Fischer, reimbursement policy adviser for the Marshfield (Wis.) Clinic, reminds critics that physicians spurred the guidelines, which partially arose from their claims of underpayment. "Physicians brought forth the efforts. The physicians wanted everything that they did to be counted. If you want everything you do to be counted, you need an exhaustive list," she says.
Fischer believes that complaints of burdensome and unnecessary documentation are exaggerated and she doubts the guidelines will turn a 15-minute exam into a 45-minute paper jam. Exams for most established patients are a level three, she says, and do not require elaborate documentation.
"The guidelines aren't telling people what to do," says Susan Turney, an internist at the Marshfield Clinic. "The guidelines say, document the services you feel are medically necessary for that patient, for that problem. Then use the guidelines to bill for the service that you provided."