December ___________________
Nurse Consultant
Division of Data Analysis
Provider Compliance Group
Office of Financial Management
Center for Medicare and Medicaid Services
402 Otterson Drive Suite 120
Chico, California, 95928
Re: CMS letter______________, Dr __________ date ______________ Comparative Billing Report: (CBR)
Dear Ms. _______________;
Thank you for this opportunity to respond to the (CBRs) letter sent to Dr ____________. (Copy attached
for easy reference). I wish to formally offer our concerns and recommendations why this “Comparative
Billing Report (CBRs) does not “educate providers on their billing patterns for selected study topics.”
1. The American Medical Association Evaluation and Management, (E/M) 1995 or 1997 guidelines
are not specialty specific, therefore we don’t believe it is appropriate to compare physicians like
Dr ______________who are boarded in Hematology and Medical Oncology with primary care
physicians.
2.
We are concerned this (CBRs) letter to Dr ______________ does not address the core issue of
appropriate coding. If physicians are not coding correctly across the US for fear of audits, then
sending graphs that may contain error rates may not be an appropriate educational notice.
a.
b.
Dr John Holcomb chair of the Texas Medical Association is quoted recently in the AMA News as
saying “most physicians are not using 99215 , because they don’t want to be audited.”
It is a national tragedy in health care that physicians as a whole are under coding for fear of
audits. This (CBRs) letter does not offer objective information about expected coding patterns
and does not mention the need for education and agreement of what is expected in the clinical
documentation to code appropriately.
We agree with your comments in this CBR letter that “Providers have a front line role in assisting the
Center of Medicare & Medicaid Services (CMS) in effectively managing Medicare resources.”1 We now
offer to you this opportunity to work with us to establish a meaningful process to accomplish the CMS
goal.
I have included in this letter a detailed report that identifies our issues. These alarms are backed up
with several citations from the American Medical Association that advocate that under coding is a major
problem and leads to the conclusion that these E&M guidelines should be “dumped”. “E&M guidelines
still don’t work; panel says dump ‘em” 2
1
Page 5 of the Dr ________________ Comparative Billing report on Evaluation and Management Services Provided by NPI 1215009287 CBR
No. CBR016-1215009287
2
AMA News June 10, 2002 Markian Hawryluk
I have addressed this with our board and Practice name _____________plans to continue conducting
additional audits that will confirm the correct level of coding. In 2013 PRACTICE NAME _____________
plans to be more proactive by working with CMS and other insurance companies to review samples of
PRACTICE NAME _____________ clinical notes to prospectively confirm our coding.
Recommendations and Request for information
1. We would like to create a meaningful education and audit process as outlined by the various
OIG reports.
a. PRACTICE NAME _____________ requests a prospective educational plan to correct the
fear of the audit bell curve that has been presented in this (CBRs) letter.
b. We recommend a meeting before January 30, 2013 to discuss the coding guidelines, and
the correct audit tool, that will include an audit of no less than ten notes for each
provider. This audit conclusion that we agree to will become the baseline bell curve for
2012 and will be used to continue this audit process for the four quarter review in 2013.
c. The CMS audit tool used to score physician notes is a copy used at the Marshfield Clinic
in Wisconsin. There are no points in Medical Decision Making defined by either the
1995 or 1997 AMA E/M guidelines.
2. We would suggest the (CBRs) letter be revised to acknowledge under coding for fear of audits
after you have time to review our comments and citations. This letter should advise physicians
that audits are a learning process and that CMS would encourage providers to contact CMS for
meaningful educational discussions where agreements are reached about levels of coding. This
should include an expected bell curve that can be evaluated each quarter during the year.
3. We would suggest that an expected Hematology/ Oncology bell curve be created without fear of
audits. As you stated the CERT program recognizes an 8.4% error rate in coding. Therefore we
recommend you use our first audit to create an expected bell curve by specialty that offers
Practice name _____________documented 20% error rate due to fear of audits.
4. Under the Freedom of Information Act please forward the following:
a. A copy of CMS authority to issue this letter that should identify what information CMS
directs the contractor to present in an educational letter to providers.
b. A report that validates your comment that “Providers find these CBRs reports helpful”.
Cite your data base of those physicians who find these letters helpful and not helpful
including those who suggested these letters are scare tactic letters that contribute to
physicians arbitrarily down coding.
c. The Medicare Prescription Drug, Improvement, and Modernization Act, enacted in 2003,
called for in section 941 Policy Development Regarding Evaluation and Management
(E&M) Documentation Guidelines . Requires the Secretary if he wishes to implement
any new modified documentation guidelines, to:
i. Conduct pilot testing of new evaluation and management documentation
guidelines used for physician services;
ii. Develop a program to educate physicians on using the evaluation and
management guidelines;
iii. Conduct a study of simpler, alternative systems of documentation for physician
claims; and
iv. Conduct a study of the appropriate coding for certain extended office visits. 3
a. We are inquiring if CMS ever followed thru with this proposals since we have evidence
that suggest a crises is unfolding with all the Electronic Medical Record systems that the
government is offering incentives will be systems that will offer no meaningful data and
will cause audit crises when the RAC approaches offices with their inappropriate audit
tools.
b. The CERT program report that identifies the 8.4% error rate for under coding and over
coding.
c. I would like the OIG and CMS contacts that directed you to send this CBR report. This
should include the direct phone number, e-mail and mailing address identifying their
authority.
I would like to go on record suggesting that CMS should abandon its PQRI and meaningful Electronic
Medical Records initiative and put its resources to Evaluation & Management education and
improvement initiative. This would be a process to ensure that both provider and CMS are working
together to “have a front line role in assisting CMS in effectively managing Medicare resources.”4 This is
a positive way to build a team so that CMS will meet the goal of effective “management of CMS
resources.” I would like to add that the famous rule of garbage in and garbage out applies here. If
providers continue to add meaningless information to the Electronic Medical Record due to the useless
guidelines they follow, then expect more meaningless provider notes. The OIG has already issued
concerns about the clone notes. It would appear the OIG should look to the core issue of poor E&M
guidelines and should focus their effort to help us throw out these worthless E/M guidelines as
suggested by the American Medical Association. This is the another process to permit providers to have
a “front line role in assisting CMS in effectively managing Medicare Resources”5
The PRACTICE NAME _____________ recommendations agree with the OIG voluntary Compliance
program that Practice name _____________has been following since 2010.
Sincerely;
______________________
Attachments
Comments
Citations
Cc State Oncology Society
3
CMS legislative summary April 2004 Public law 108-173 Medicare Prescription DIMA of 2003
4 Comparative Billing report on E & M Services provided by NPI 1215009287
5 Comparative Billing Report on E&M Services Provided by NPI 1215009287
Medical Society
American Medical Association
CMS and OIG authorities
Department of Insurance
Senator
Senator
Congressman
Summary of Comments
1.
2.
3.
4.
5.
6.
7.
8.
9.
6
This letter is not an educational letter.
Hematology and Medical Oncology providers care for chronically ill patients.
None of the other physicians’ in Practice name _____________received this letter.
Letter does identify the specialty groups from the CMS website identified as Hematology,
Medical Oncology or Hematology and Oncology. The web site is
http://www.cms.hhs.gov/MedicareFeeforSvcPartsAB/04_MedicareUtilizationforPartB.asp#TopOfPage.
a. It is not clear what physician groups are included and the time period may be incorrect
since the graph is comparing Dr ______________2011 data to CMS 2010 data.
i. There is no mention of under coding and or prior educational sessions that
identifies correct coding levels to clinical documented notes.
Medical Oncology doctors typically do not bill CPT 99211, nurse assessment.6
Grant Lewis, M.D. is not coding above his peers.
a. It is a known fact that the majority of physicians included in any national, regional or
local survey would conclude that physicians are down coding to avoid audits.
i.
Dr John Holcomb chair of the Texas Medical Association is quoted recently in
the AMA News as saying “most physicians are not using 99215 , because they
don’t want to be audited.”
Practice Expense is an issue that needs to be recognized as part of any audit, since cancer
specialists’ costs to deliver the care is expected to be higher than a primary care physician
practice that relies on this same coding and same payment for the non-specialty E/M guidelines.
The History, Exam and Decision Making categories of the American Medical Association E/M
coding guidelines reference an expected higher level of coding should occur by the nature of the
disease.
a. The guidelines clearly state that the auditor should score the note with the highest points
from two of three categories defined as history, exam and or Decision Making for
established patients.
b. New patients require highest points in all three categories.
c. The auditor is supposed to give the provider the benefit of the doubt if the overall score
is close.
d. The American Medical Association Evaluation and Management E&M guidelines are
vague and subject to interpretation.
The E/M guidelines are subject to interpretation from coders who may be using inappropriate
audit tools to score the provider notes.
a. The Marshfield Clinic audit tool many CMS auditors use to audit a physician note
assigning points in Medical Decision Making is not appropriate to use to audit a
specialist physician note.
b. Marshfield Clinic Audit Tool Assigning Points in Medical Decision Making with no
hierarchy of points: Add to the confusion there appears to be inappropriate audit tools
used to score a note that are not identified in the guidelines. So how does one follow a
guideline that is vague and subject to interpretation to the auditor who may not realize
that a cancer diagnosis should carry a higher point value than a patient who presents to
the physician office with a sore throat.
CMS 100.4 Transmittal 731 2005 ( copy in citations)
10. Template Notes: The provider notes present the template history and exam that is created by
EMR systems. Don’t get me wrong I don’t like them either, but this information does present
the subjective and objective findings that the provider feels is pertinent to the visit.
a. Auditors are citing the Medicare Learning Network and Medicare Claims Processing
Manual (Pub. 100-4) that the only time a high level visit can be billed is if the patient
presents with a new problem or worsening problem. That is simply not true.
i. These citations auditors rely on in the Medicare guidelines are examples tagged
to the Medicare Learning Network published 1995 Documentation Guidelines for
Evaluation and Management Services, available at
www.cms.hhs.gov/MLNProducts/20_DocGuide.asp#TopOfPage
11.
12.
13.
14.
15.
ii. These vague guidelines do not address the citation as noted in the 1995 AMA
Guidelines they refer the provider to talks about evaluations that are medically
necessary and appropriate when a comprehensive history and or exam
concludes with a stable patient. This comprehensive visit is a typical event in
Hematology and Oncology. The goal of the visit is to keep the patient stable. So
a comprehensive history and exam is expected with a stable patient who is now
cleared to receive infusion therapy. Cancer patients and many Hematology
patients are high risk and the score should be an easy level five service.
iii. Does a patient have to retain the status of the Secretary of State to identify that
Hematology is a complex disease process?
iv. Because of under coding provider notes look like level five care but the provider
is down coding to a level four or three. Now we have level five work reported as
level four and three billings.
Obtaining A Certified Coder Certificate Does Not Qualify One To Audit A Provider Note: We are
concerned that the audits are completed by individuals who take a course and pass a test but do
not hold the clinical credentials to audit a provider note.
The 8.4% error rate should translate to 20% under coding by all specialists.
We all should recognize the AMA coding guidelines are a failure and we should jointly request
the AMA change these guidelines. ( Refer to Citations)
This CBR letter appears to discriminate against those physicians who attempt to code correctly
following the OIG voluntary compliance program for the following reasons.
a. It is expected that Medical Oncologist bell curve should report more level IV and V
services due to the high complexity of care required for Hematology and Oncology
patients.
b. This letter may result in physicians arbitrary down coding without a meaningful process
to determine examples of appropriate coding of the patient visit.
c. The insurance industry and pay for performance process believes that physicians who
evaluate their patients appropriately, to include routine complex evaluations, prevent
unnecessary admission and trips to the Emergency Room. My citation is the various
MedPac reports and other articles published by the government that have addressed
this issue beginning in 2006.
d. It would appear this letter is counterproductive to the Congressional / CMS intent to
provide better care to the patients.
The Audit Process is Not Transparent: The audit process does not permit a discussion with the
auditor and leaves the provider at a disadvantage to what information the auditor relied on to
make the determination after reviewing the provider note. The provider receives a simple
rejection notice stating the service does not meet requirements of medical necessity.
16. Documentation now requires detailed explanation of every issue that is identified in the note as a
number. For example the auditor is not trained to understand what a low lab value presents
unless it is followed up with discussion by the provider. So this makes the provider inefficient
spending more time explaining the why instead of reporting the lab value that concludes with an
action that is presented later in the note as an order of prescription drugs.
17. The Appeal Process is cumbersome and takes months to argue over $40.
a. As you know there are three appeal levels.
b. Providers always lose at level one.
c. Provider has to appeal thru two other levels. There is an 80% win at the second level and
20% at the third level.
18. If the provider wins on appeal, this does not affect future claims so the provider is at a
disadvantage to change behavior at the CMS auditor level.
19. OIG Now Issues an inappropriate concern without looking at all the issues.7
a. Why is the provider at possible fault with all these issued summarized? In addition, add
insult to injury the efficient notes using these vague guidelines are now questioned by
the OIG as inappropriate due to EMR systems. Yet these EMR systems were designed to
make physicians efficient. So who is right and who is wrong. Providers don’t like being
on the point taking the hits from all sides. Yet providers are encouraged to provide
quality care and take time to document the clinical SOAP encounter that has meaning
and value. Providers need this defined. This value cannot be measured in this CBR
letter.
20. I am sure CMS does not expect physicians to lower their standard of care to Medicare and
Medicaid beneficiaries using a bell curve that is not accurate based on physician under coding
for threats of audits that take abnormal amounts of time to appeal. That is how I would
interpret this CBR report.
21. Practice name _____________(PRACTICE NAME _____________) has adopted the OIG voluntary
compliance program in 1010 and PRACTICE NAME _____________ audits conclude that Practice name
_____________physicians are under coding. The primary reasons are due to letters that allege the
physician is coding above their peers as described in this (CBRs) letter attached. However, when we
check around the community of physicians, we find everyone is receiving these letters and everyone is an
outlier
22. The Oncology Coding bell curve should be as follows:
a. Level ii ZERO
b. Level iii 20%
c. Level iv 45%
d. Level v 35%
PUBLISHED ARTICLES THAT SUPPORT THE ARGUMENT THE CODING GUIDELINES ARE
BROKEN
There are many articles about coding concerns and the maladroit guidelines providers rely on to
attempt to score the note that assigns a payment.

7
2002 article published in the AMA news. “E&M guidelines still don’t work; panel says dump
‘em” 8
OIG reports dated March 2006 OIE -09-02-00030, and May 2012 OIE-0410-00180

A 2004 article from the AMA news announces to the reader the following. “Do you tend to
undercode? You’re not alone”9.
o

The article quotes the following: “A study confirms what many doctors already believe –
They don’t give themselves credit for everything they do. That affects fees, and perhaps,
quality measurements.”
The AMA News article in 2005 titled “Medicare zeros in on E&M coding as key source of
payment mistakes.” This article summarizes the CMS report about the need for provider
education of the E&M coding. 10.
o
The 2005 AMA article addresses the CMS report released sometime in 2005 about the
need to educate providers. These article citations suggest the core issue here, is the
Evaluation and Management 1995 or 1997 coding system guidelines that are not specialty
specific that were supposed to be overhauled. 11

MedPac reports over the years have made recommendation to the Congress that has been met with more
resources added to the E&M coding with a goal to encourage physicians and midlevel providers to spend
more time with their patients.
Citations that support our argument why CMS should expect a higher bell curve for
Hematology/Oncology.
1. “For Evaluation and Management (E/M) services, the nature and amount of physician work and
documentation varies by the type of service, place of service, and the patient’s status.”12
2. Professor W.C. Hsiao, author of the Relative Value System (RVU)13 which CMS relies on to
reimburse providers identified four elements of physician work as 1) Time, 2) Mental effort and
judgment, 3) Technical skill, 4) Physical effort, and Psychological stress. This advocates that the
bell curve for the specialty of Hematology/Oncology would be higher due the nature of the nonspecialty guidelines. The best example for Hematology/Oncology coding is a comprehensive
history and exam that concludes with a stable patient cleared for infusion therapy.
3. The AMA guidelines instruction is that time should only be counted as secondary relating to
counseling. Yet auditors keep insisting that a level five service should take 40 minutes.
4.
8
9
CMS rules state that each note needs to “stand on its own “. Therefore by virtue of the
guidelines CMS authority supports the medical necessity of a Hematology or Oncology
AMA News June 10, 2002 Markian Hawryluk
AMA News Nov 22, 2004 Robert Kazel
10
11
12
13
AMA News Jan 3/10 2005 David Glendinning
E/M guidelines still don’t work: panel says dump ‘em AMA News June 10, 2002
1995 AMA Documentation Guidelines for Evaluation and Management Services. II General Principles of Medical Record Documentation page one
September 28, 1988 WC Hsiao the famous Harvard professor who created the RVU system for Medicare
comprehensive evaluation for infusion therapy patients and for patient follow-up to ensure the
patient disease is stable.
5. That is the goal of these two specialties. Support the MedPac reports and CMS initiatives that
CMS believes health care receives more value in a level four or five E&M service compared to
the possible outcome of a patient ending up in the Emergency room. As you know, one of the
CMS goals is to reduce Emergency room care etc. This is backed up by the shift of resources to
the E&M services over the past ten years. There is no benefit to this thinking of paying for
performance if Comparative Billing Reports are presenting the wrong message and incorrect
information.
6. The AMA CPT Book preamble: “Chemotherapy services are typically highly complex and require direct
physician supervision for any or all purposes of patient assessment, provision of consent, safety oversight,
and intra-service supervision of staff.” “a different diagnosis is not required”
a. Since the Evaluation and Management guidelines are not specialty specific one would expect in
Hematology and Oncology to see level five services that require comprehensive history and
exams with stable disease and risk elements that require the order of highly complex drugs or
order of complex scans for restaging or follow-ups. The guidelines do not state the only reason
for a level five is a new problem, a worsening problem, etc. The score of a routine follow-up visit
is based on the score of the highest points in two of three categories as History, Exam or Medical
Decision Making. In addition, “The E/M service may be caused or prompted by the symptoms or
conditions for which the procedure and/or service was provided.” Cancer and Hematology
patients obviously have a condition of a chronic disease that requires a separate evaluation to
determine if their symptoms are such to approve the therapy or to evaluate the patient on an
ongoing basis to keep the chronic illness in a stable condition. So one would expect to see a high
usage of modifier 25 as an evaluation is required a high percentage of the time before an
infusion therapy is to take place. In Oncology there is no such thing as a routine visit. The best
value for any health plan is to reimburse physicians for level Five work that results in a stable
patient. After all that is the goal of health care.
7. Relative Value Units now defined as Resource Based Relative Value units
a. On September 28, 1988 WC Hsiao the famous Harvard professor who created the RVU system for
Medicare said this about merging the visit levels to RVU data “We concluded that a physician’s
work has four major dimensions:
i. time,
ii. mental effort and judgment,
iii. technical skill
iv. physical effort and psychological stress
8. We also cite the CMS Standalone policy that each patient encounter with a provider is separate and
cannot be linked to another service
9.
CMS Legislative Summary, April 2004, Summary of H.R. Medicare Prescription Drug,
Improvement, and Modernization Act of 2003, Public Law 108-173, Subtitle E—
Miscellaneous Provisions Sec. 941. Policy Developments Regarding Evaluation and
Management (E&M) Documentation Guidelines
a.
That the 1995 or 1997 AMA Evaluation and Management Guidelines will be used to audit
provider notes. This requires the auditor to use accurate auditing tools based on the
Hematology/Oncology SOAP audit technique that require specialty point system for auditing
notes and not primary care point systems
10.
CMS 100.04 transmittal 731Date: OCTOBER 28, 2005. Change Request 4032 SUBJECT:
Payment for Office or Other Outpatient Evaluation and Management (E/M ) Visits (Codes 99201 99215)
a. SUMMARY OF CHANGES: This transmittal clarifies and corrects the definition of
"
new patient" and "physician" for billing evaluation and management (E/M) services
currently stated in Medicare Claims Processing, Pub. 100-04, Chapter 12, §30.6.7, and
updates the policy on billing E/M services with drug administration codes. In Change
Request (CR) 3631, carriers were instructed not to allow payment for CPT code 99211
with or without modifier -25 if it is billed with a non-chemotherapy or chemotherapy
drug infusion code or with diagnostic or therapeutic injection codes. This transmittal will
update the E/M manual section indicating Medicare will pay for a medically necessary
office/outpatient visit (when it meets a higher complexity level than CPT code 99211)
billed on the same day as a drug administration service as specified. Modifier -25 must
be appended to the E/M service to identify that a significant and separately identifiable
E/M service (higher complexity than CPT code 99211) was performed. There ardifferent
effective dates for the chemotherapy and non-chemotherapy drug infusions codes from
the therapeutic and diagnostic injection codes.
December 27, 2012
;
Provider Representative
____________________insurance company
Re: Visit to _______________________agenda topic: Discussion about __________letter to Dr
_____________suggesting physician is an “outlier”.
Greetings ______________;
Thank you for the offer to forward the practice name _______________ response to the “outlier” letter.
As I explained in our meeting, the American Medical Association Evaluation and Management, (E/M)
1995 or 1997 guidelines are not specialty specific which may explain one of the reasons for the “outlier”
as PRACTICE NAME _____________ physicians care for Hematology /Oncology chronically ill patients.
The History, Exam and or Decision Making, categories of the E/M coding suggest an expected higher
level of coding should occur by the nature of the disease.
“For Evaluation and Management (E/M) services, the nature and amount of physician work and
documentation varies by the type of service, place of service, and the patient’s status.”14
Professor W.C. Hsiao, author of the Relative Value System (RVU)15 identified four elements of physician
work as 1) Time, 2) Mental effort and judgment, 3) Technical skill, 4) Physical effort, and Psychological
stress. This suggests that the bell curve for the specialty of Hematology/Oncology would be higher due
the nature of the non-specialty guidelines. The best example for Hematology/Oncology coding is a
comprehensive history and exam that concludes with a stable patient cleared for infusion therapy. Time
should only be counted as secondary relating to counseling. Each note needs to “stand on its own “
CMS authority supports the medical necessity of a comprehensive evaluation for infusion therapy and
for patient follow up to ensure the patient disease is stable. That is the goal of these two specialties.
The end point is that CMS agrees health care receives more value in a level four or five service compared
to the possible outcome of a patient ending up in the Emergency room. As you know, one of the CMS
goals is to reduce Emergency room care etc.
Cost is another issue that needs to be recognized, since cancer specialists’ costs to deliver the care is
expected to be higher than a primary care physician practice that relies on this same coding and same
payment for the non-specialty E/M guidelines. PRACTICE NAME _____________ response begins with
recommendations followed by closing remarks and citations that support PRACTICE NAME
_____________ prospective educational plan to correct the fear of the audit bell curve that has been
presented in this “outlier” letter. The PRACTICE NAME _____________ recommendations agree with
14
1995 AMA Documentation Guidelines for Evaluation and Management Services. II General Principles
of Medical Record Documentation page 1
15
September 28, 1988 WC Hsiao the famous Harvard professor who created the RVU system for Medicare
the OIG voluntary Compliance program that Practice name _____________has been following since
2010.
PRACTICE NAME _____________ opinion is this “outlier” letter is not an educational letter as it does not
address any areas of clinical documentation concern.
So I begin with thanking you for reminding us that PRACTICE NAME _____________ physicians continue
to under code based on the internal audits I have completed since 2010. Dr. John Holcomb, chair of the
Texas Medical Association, was quoted recently in the AMA News as saying “most physicians are not
using 99215, because they don’t want to be audited.”
There are many articles about coding concerns and the maladroit guidelines we rely on to attempt to
score the note that assigns a payment. I draw your attention to a 2002 article published in the AMA
news. “E&M guidelines still don’t work; panel says dump ‘em” 16
A 2004 article from the AMA news announces to the reader the following. “Do you tend to undercode?
You’re not alone”17. The article quotes the following:
“A study confirms what many doctors already believe – They don’t give themselves credit for everything
they do. That affects fees, and perhaps, quality measurements.”
This leads to the CMS report released sometime in 2005 about the need to educate providers that I
believe the author was attempting to address in the “outlier” letter. I understand that provider
education is a CMS mandate issued from various OIG and GAO reports, where contractors are instructed
to work with providers on coding issues. We are concerned this “outlier” letter to Dr Goldberg does not
address the core issue of appropriate coding. If physicians are not coding correctly across the US, then
sending graphs that may contain error rates may not be an appropriate educational notice.
The AMA News article in 2005 titled “Medicare zeros in on E&M coding as key source of payment
mistakes.” This article summarizes the CMS report about the need for provider education of the E&M
coding. 18
I have addressed this with our board and Practice name ______________ plans to continue conducting
additional audits that will confirm the correct level of coding. In 2013 PRACTICE NAME _____________
plans to be more proactive by working with ___________insurance and other insurance companies to
review samples of PRACTICE NAME _____________ clinical notes to prospectively confirm our coding.
I extend my appreciation for the very productive visit and the opportunity to respond to the “outlier”
16
AMA News June 10, 2002 Markian Hawryluk
AMA News Nov 22, 2004 Robert Kazel
18
AMA News Jan 3/10 2005 David Glendinning
17
letter insurance ______________ letter sent to Dr _______________ (Copy attached for easy
reference). I will send, under another email, our talking points on the other issues we discussed during
this important meeting.
Recommendations and Request for information

Create a meaningful education and audit process as outlined by the various OIG reports
o
We recommend a meeting before January 15, 2013 to discuss the coding guidelines, and the
correct audit tool, that will include an audit of no less than ten notes for each provider. This
then will become the baseline bell curve for 2012 and will be used to continue this audit
process for the four quarter review in 2013
o
We would suggest the “outlier” letter be revised after you have time to review our
comments and citations.
II.
Under the Freedom of Information Act, please submit the author of this letter and their title.
III.
Under the Freedom of Information Act please forward a copy of CMS authority to issue this
letter that should identify what information WellCare is to present in an educational letter to
providers
Sincerely;
__________________________
Attachments
Comments
Closing remarks
Citations
Comments
1. This letter is not an educational letter.
2. Confirm the date of the letter as suggested by the footnote at the bottom right.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
None of the other physicians’ in the group received this letter.
Letter does identify the specialty groups from the CMS website identified as Hematology, Medical
Oncology or Hematology and Oncology. The web site is
http://www.cms.hhs.gov/MedicareFeeforSvcPartsAB/04_MedicareUtilizationforPartB.asp#TopOfPage.
It is not clear what physician groups are included and the time period may be incorrect since the graph is
comparing Dr Goldberg 2011 data to CMS 2010. There is no mention of under coding and prior
educational sessions that identifies correct coding levels to clinical documented notes.
Medical Oncology doctors typically do not bill CPT 99211, nurse assessment, so the graph may be
reporting an error
Dr. Goldberg is not coding above his peers. It is a known fact that the majority of physicians included in
any national, regional or local survey would conclude that physicians are down coding to avoid
audits. Dr John Holcomb chair of the Texas Medical Association is quoted recently in the AMA News as
saying “most physicians are not using 99215 , because they don’t want to be audited.”
This letter appears to discriminate against those physicians who attempt to code correctly following the
OIG voluntary compliance program for the following reasons.
It is expected that Medical Oncologist bell curve should report more level IV and V services due to the
high complexity of care required for Hematology and Oncology patients
It is not appropriate in this letter to suggest that WellCare will audit only those physicians who
“consistently fall in the highest range of E&M coding distribution variance
This letter may result in physicians arbitrary down coding without a meaningful process to determine
examples of appropriate coding of the patient visit.
The insurance industry and pay for performance process believes that physician who evaluate their
patients appropriately, to include routine complex evaluations prevent unnecessary admission and trips
to the Emergency room. My citation is the various MedPac reports and other articles published by the
government that have addressed this issue beginning in 2006
It would appear this letter is counterproductive to the Congressional / CMS intent to provide better care
to the patients.
I am sure WellCare does not expect physicians to lower their standard of care to Medicare and Medicaid
beneficiaries using a bell curve that is not accurate based on physician under coding for threats of audits
that take abnormal amounts of time to appeal
The educational letter to any provider should conclude that Well Care is aware of under coding as well as
possible over coding and would encourage physicians to code appropriately and one would expect this
bell curve for Medical Oncology to be as follows.
The Oncology Coding bell curve should be as follows:
a. Level ii ZERO
b. Level iii 20%
c. Level iv 45%
d. Level v 35%
Closing Remarks
It is a national tragedy in health care that physicians as a whole are under coding for fear of audits. This “outlier”
letter does not offer objective information about expected coding patterns and does not mention the need for
education and agreement of what is expected in the clinical documentation to code appropriately.
It is our understanding from the OIG reports dated March 2006 OIE -09-02-00030, and May 2012 OIE-0410-00180
that the OIG recommends meaningful educational sessions with physicians. This letter does not address the OIG
and GAO reports on contractor’s obligations to conduct meaningful seminars to educate providers about the need
to appropriately code for the service they provided. The “outlier” letter is not an education letter but instead is a
scare tactic letter comparing the physician data to a national data base that appears to be incorrect since
physicians as a whole are under coding for fear of audits. This letter causes physicians to knee jerk and begin down
coding without a process to audit, discuss, and compare to other notes and to agree what is the appropriate level
of care to code. We believe the OIG and CMS intent was to conduct meaningful educational sessions for
appropriate coding that includes under coding as well as possible over coding.
CMS with MedPac recommendation and Congress agreement have encouraged physicians and midlevel providers
to spend more time with their patients. They have heard the pleas of physicians asking that reimbursement cover
the cognitive services they provide. CMS has heard this plea and continues to increase the Evaluation and
Management payments for the past 12 years. What good does their action mean if “outlier” letters are sent
scaring physicians who then down code again for the fear of audits? This process needs to be an open transparent
agreement and not an “outlier” letter.
It is possible the core issue here, is the Evaluation and Management 1995 or 1997 coding system guidelines that
are not specialty specific that were supposed to be overhauled.19 One only has to Google why there are two sets
of guidelines to understand this major concern that is now causing alerts of possible clone notes and possible
abuse. Several years back I attempted to address this issue with a call to amend the guidelines and create more
meaningful information. Until that is done we have to come together and agree on the clinical documentation
that meets our agreement. This letter and report begins that process. This idea of sending a letter with no
process is simply not acceptable. I am offering some additional information for your review.
Practice name _____________has adopted the OIG voluntary compliance program in 1010 and our audits
conclude that Practice name _____________physicians are under coding. The primary reasons are due to letters
that allege the physician is an “outlier” but when we check around the community of physicians, we find everyone
is receiving these letters. The other reason is the fear of audits from the prospective that the appeal process takes
up to six months for each claim. One attorney informed me it is not worth spending up to six months going thru
three appeal processes to overturn a denial for an extra $40. Our experience and others agree that everyone
losses at the first level of the appeal process and win at the second or third level of appeal. Every time our
compliance program makes progress, along comes these letters that causes doubt and concerns. Therefore
Summit Cancer Care’s goal is to be very proactive in 2013 to ensure that patient care and reimbursement needed
to shelter our cost to provide this care is not compromised.
May we suggest that WellCare begin a process to conduct educational audits to ensure that all physicians who are
also under coding appropriately code for their highly complex physician provider services. I plan to copy this notice
to the Georgia State Oncology Society (GASCO), the Georgia Medical Society so they will send notices to their
members about under coding. I will copy the American Medical Association, the pertinent CMS and OIG
authorities and the department of insurance.
Citations Are Identified Below
The AMA CPT Book preamble
19
E/M guidelines still don’t work: panel says dump ‘em AMA News June 10, 2002
“Chemotherapy services are typically highly complex and require direct physician supervision for any or all
purposes of patient assessment, provision of consent, safety oversight, and intra-service supervision of staff.” “a
different diagnosis is not required”
Since the Evaluation and Management guidelines are not specialty specific one would expect in Hematology and
Oncology to see level five services that require comprehensive history and exams with stable disease and risk
elements that require the order of highly complex drugs or order of complex scans for restaging or follow-ups. The
guidelines do not state the only reason for a level five is a new problem, a worsening problem, etc. The score of a
routine follow-up visit is based on the score of the highest points in two of three categories as History, Exam or
Medical Decision Making. In addition, “The E/M service may be caused or prompted by the symptoms or
conditions for which the procedure and/or service was provided.” Cancer and Hematology patients obviously have
a condition of a chronic disease that requires a separate evaluation to determine if their symptoms are such to
approve the therapy or to evaluate the patient on an ongoing basis to keep the chronic illness in a stable
condition. So one would expect to see a high usage of modifier 25 as an evaluation is required a high percentage
of the time before an infusion therapy is to take place.
In Oncology there is no such thing as a routine visit. The best value for any health plan is to reimburse physicians
for level Five work that results in a stable patient. After all that is the goal of health care.
Relative Value Units now defined as Resource Based Relative Value units
On September 28, 1988 WC Hsiao the famous Harvard professor who created the RVU system for Medicare said
this about merging the visit levels to RVU data “We concluded that a physician’s work has four major dimensions:
1.
2.
3.
4.
time,
mental effort and judgment,
technical skill
physical effort and psychological stress
CMS Legislative Summary, April 2004, Summary of H.R. Medicare Prescription Drug,
Improvement, and Modernization Act of 2003, Public Law 108-173, Subtitle E—Miscellaneous
Provisions Sec. 941. Policy Developments Regarding Evaluation and Management (E&M)
Documentation Guidelines
That the 1995 or 1997 AMA Evaluation and Management Guidelines will be used to audit provider notes. This
requires the auditor to use accurate auditing tools based on the Hematology/Oncology SOAP audit technique that
require specialty point system for auditing notes and not primary care point systems
CMS 100.04 transmittal 731
Date: OCTOBER 28, 2005
Change Request 4032
SUBJECT: Payment for Office or Other Outpatient Evaluation and Management
(E/M ) Visits (Codes 99201 - 99215)
SUMMARY OF CHANGES: This transmittal clarifies and corrects the definition of
"new patient" and "physician" for billing evaluation and management (E/M) services
currently stated in Medicare Claims Processing, Pub. 100-04, Chapter 12, §30.6.7, and
updates the policy on billing E/M services with drug administration codes. In Change
Request (CR) 3631, carriers were instructed not to allow payment for CPT code 99211
with or without modifier -25 if it is billed with a non-chemotherapy or chemotherapy drug
infusion code or with diagnostic or therapeutic injection codes. This transmittal will
update the E/M manual section indicating Medicare will pay for a medically necessary
office/outpatient visit (when it meets a higher complexity level than CPT code 99211)
billed on the same day as a drug administration service as specified. Modifier -25 must be
appended to the E/M service to identify that a significant and separately identifiable E/M
service (higher complexity than CPT code 99211) was performed. There are different
effective dates for the chemotherapy and non-chemotherapy drug infusions codes from the
therapeutic and diagnostic injection codes.
We also cite the CMS Standalone policy that each patient encounter with a provider is separate and cannot be
linked to another service
March 12, 2013
EquiClaim
Ms Kathryn Turnell
535 E. Diehl Road, Suite 333
Naperville, Il 60563
Vice President Audit & Recovery, Payment Integrity Services
Address provided in the February 2013 letter.
Re: EquiClaim letters dated _____________________, Kathryn Turnell, Vice President Audit & Recovery, Payment
Integrity Services. On behalf of Blue Cross ______________ EQC letters _____________________
EquiClaim letter ______________ to ______________, M.D., , modifier 25 and higher percentage of E/M
compared to his peers
Dear Ms. Turnell;
“If you want to see Pay for Performance in action come to Savannah.“
Thank you for adding an address to your letter so we can respond to these very inappropriate letters. I have filed a
complaint with Blue Cross and with the Department of Insurance. I have been trying to reach you since the first
letters arrived in October 2012 dated September 28, 2013.
I have attempted on numerous occasions to contact someone at 866-481-1479 option 4 but have been
unsuccessful. I received one phone call last week that I could not understand the name of the person who tried to
call me. So please ask those who call back to talk slowly and clearly.
The four (4) provider letters and now (2) more provider letters suggest the following:
DR ___________and Dr_____________ are coding above their peers looking at twelve months of office visit claims
paid between May 2011 and April 2012 and now October through December 2012. The letter suggests you are”
identifying those physicians who are billing level 4 & 5 codes significantly more than other than physicians within
the same specialty.” And that these physicians are billing modifier 25 higher than what is expected.
The February letters deliver the same inappropriate message without a basis of fact and specific information to
support your argument. All six physicians see Blue Cross patients and all six physicians code appropriately and
within the bell curve I would expect. Their bell curve does not match nor would I expect it to since they care for
individual patients based on their needs and not some bell curve.
In another letter to Dr ___________, and Dr ____________ for the same time period, the purpose of these letters
is to identify “those physicians who are billing E/M codes with modifier 25 significantly more often than other
physicians within the same specialty. As demonstrated in the attached modifier 25 profile report, the percentage of
E/M codes billed with modifier 25 in conjunction with non-diagnostic procedures billed by your office is considerably
higher than the expected billing distribution as determined by the average billing behavior of other physicians
within your specialty”
We appreciate your notice and would like to offer these explanations.
1.
The graph should not include those Medical Oncologists and Hematologist who practice in location 22
provider base
a.
I am sure you are aware that since 2011 over 50% of the Medical Oncologists have some
arrangement with hospitals. Refer to pie chart on page four. If a physician evaluates a patient in
a hospital setting, the office service is not subject to appending the modifier 25 to the visit. The
reason is the hospital will bill for the drugs, infusions, and other ancillary services. The only
reason the modifier 25 is required is to separate the provider visit from the office base infusion
services that are provided on the same day. Practice name __________ is the billing the modifier
25 correctly as defined by the AMA CPT 1995 Evaluation and Management guidelines.
b.
I am sure you have heard about hospital alleged overcharges since doctors have moved to
hospitals. Letters like this, is what is driving doctors to the hospital that bills and collects more
from Blue Cross. So in effect your letter is causing health care cost to increase by 25% to 35%.
c. My doctors keep asking me if they are doing something wrong. I have to reassure
them they are coding appropriate and saving Blue Cross valuable resources. It is Blue
Cross who is acting foolishly. Instead of looking at cost efficient visits that support the
CMS and Medpac20 process the Blues should be looking at overuse of Aloxi in the
market place. Practice name _____________has the lowest use of this antiemetic
because we don’t take the rebates the drug company offers if you utilize this drug 85%
of the time. Our usage is 15%. I have many other examples of cost savings, like low
utilization of Pet CT etc. Our excellent care plan keeps patients out of the hospital and
keeps them stable. Why? Because we spend time with our patients. That is what
CMS and Medpac has ask us to do. So much that since 2002 CMS has increased the
work relative value unit to the office visits. You are suggesting we should run our
patients thru a cattle chute. We will not bow to what you suggest is inappropriate
coding on our part as suggested in your letter. If you want to see Pay for Performance
in action come to Savannah.
2.
The graph should not include other specialists such as primary care, radiation oncology etc.
a.
3.
As you know the American Medical Association Evaluation and Management guidelines are not
specialty specific so Hematologists and Medical Oncologists are expected to bill a higher
frequency of codes than other physicians.
The overhead of a Hematology/Oncology practice is higher than a primary care physician and the average
time including pre and post physician time spent with a patient is 20 minutes to 45minutes. 21
Practice name _____________is billing the modifier 25 correctly as defined by the AMA CPT 1995 Evaluation and
Management guidelines. Therefore we request your agency review the data base to identify Medical Oncologists
who are practicing in a location 11(private office) and create a similar report?
Practice name _____________has adopted the Medicare Voluntary Compliance Program22 and our audits conclude
the physicians at Practice ____________ are under coding. As CEO and a national consultant for the specialty of
20
21
Medpac Medicare Payment Advisory Commission
Medscape Oncologist compensation report 2011 Web MD http://medscape.com/feature/slideshow/compensation/2011/oncology
OIG Voluntary Compliance Program, oig.hhs.gov/authorities/docs/physician.pd
22
Medical Oncology and other physician groups, I can comment that my audits from 2005 to 2012 suggest that
Medical Oncologist, Hematologist and physicians as a whole are still under-coding. The main reason for under
coding is due to letters such as this, and the fear of audits. So we thank you for bringing this to our attention that
our physicians continue to under code.
Dr John Holcomb chair of the Texas Medical Association is quoted as saying “most physicians are not using 99215
because they don’t want to be audited.”23 I have addressed this with our board and we plan to conduct additional
audits that will again confirm under coding and we plan to work hard in 2013 to correct this situation. I can offer
other citations including several key American Medical Association articles 24. The OIG in its report to the Congress
in 200525 cited that physicians are under coding.
Recommendations and Request for information
1.
We would like to create a meaningful education and audit process with Blue Cross of Georgia who
considers us a valuable partner in their network.
a.
SCC requests a prospective educational plan to correct the fear of the audit bell curve that has
been presented in this EquiClaim letter.
b.
We recommend a meeting before Tuesday April 30, 2013 to discuss the coding guidelines, and
the correct audit tool, that will include an audit of no less than ten notes for each provider. This
audit conclusion that we agree to, will become the baseline bell curve for 2012 and will be used
to continue this audit process for the four quarter review in 2013.
c.
The CMS and Blues audit tool used to score physician notes is a copy used at the Marshfield Clinic
in Wisconsin. There are no points in Medical Decision Making defined by either the 1995 or 1997
AMA E/M guidelines. So if an audit tool is to be used, then both parties will agree on the point
system that will be used.
d.
May we suggest that your agency identify those physicians who are under-coding using this
reporting process using expected coding pattern by specialty? We can offer you the expected
bell curve for Hematologists and Medical Oncologists who do not code appropriately for no less
than 25% of their services for their highly complex physician provider services.
Enclosed is a Historical prospective and citations for your review and education why Blue Cross should expect
Hematology/Oncology to have a different bell curve than other physicians. If your data shows that
Hematology/Medical Oncologist as a whole are under coding then your agency should suggest these specialist look
at their coding patterns. These letters should never limit the scope to allege over coding without commenting
about under coding.
If you are in need of additional records or information please call me at 912 651-5736
AMA News, October 9, 2012 Medicare auditor targets E&M services for review page 5
Do you tend to Under code? You’re not alone”, AMA News Nov 22, 2004 Robert Kazel
25
Medicare Zeros in on E/M coding as key source of payment mistakes” AMA News Jan3/10 2005 David Glendinning
23
24
_____________________
Attachments
Comments
Citations
Cc State Oncology Society
Medical Society
American Medical Association
Department of Insurance
Senator
Senator
Congressman
Enclosed are a Historical prospective and several additional citations for your review and education.
Citations that support our argument why EquiClaim should expect a higher
bell curve for Hematology/Oncology and the routine use of modifier 25 as it
relates to Medical Oncology Services
“For Evaluation and Management (E/M) services, the nature and amount of physician work and
documentation varies by the type of service, place of service, and the patient’s status.”26
Professor W.C. Hsiao, author of the Relative Value System (RVU)27 which CMS relies on to reimburse
providers identified four elements of physician work as 1) Time, 2) Mental effort and judgment, 3)
Technical skill, 4) Physical effort, and Psychological stress. This advocates that the bell curve for the
specialty of Hematology/Oncology would be higher due the nature of the non-specialty guidelines. The
best example for Hematology/Oncology coding is a comprehensive history and exam that concludes with
a stable patient cleared for infusion therapy.
The AMA guidelines instruction is that time should only be counted as secondary relating to counseling.
Yet auditors keep insisting that a level five service should take 40 minutes.
That is the goal of these two specialties. Support the MedPac reports and CMS initiatives that CMS
believes health care receives more value in a level four or five E&M service compared to the possible
outcome of a patient ending up in the Emergency room. As you know, one of the CMS goals is to reduce
Emergency room care etc. This is backed up by the shift of resources to the E&M services over the past
ten years. There is no benefit to this thinking of paying for performance if Comparative Billing Reports are
presenting the wrong message and incorrect information.
The AMA CPT Book preamble: “Chemotherapy services are typically highly complex and require direct
physician supervision for any or all purposes of patient assessment, provision of consent, safety
oversight, and intra-service supervision of staff.” “a different diagnosis is not required”
Since the Evaluation and Management guidelines are not specialty specific one would expect in
Hematology and Oncology to see level five services that require comprehensive history and exams with
stable disease and risk elements that require the order of highly complex drugs or order of complex
scans for restaging or follow-ups. The guidelines do not state the only reason for a level five is a new
problem, a worsening problem, etc. The score of a routine follow-up visit is based on the score of the
highest points in two of three categories as History, Exam or Medical Decision Making. In addition, “The
E/M service may be caused or prompted by the symptoms or conditions for which the procedure
and/or service was provided.” Cancer and Hematology patients obviously have a condition of a
chronic disease that requires a separate evaluation to determine if their symptoms are such to
approve the therapy or to evaluate the patient on an ongoing basis to keep the chronic illness
26
27
1995 AMA Documentation Guidelines for Evaluation and Management Services. II General Principles of Medical Record Documentation page one
September 28, 1988 WC Hsiao the famous Harvard professor who created the RVU system for Medicare
in a stable condition. So one would expect to see a high usage of modifier 25 as an evaluation
is required a high percentage of the time before an infusion therapy is to take place. In
Oncology there is no such thing as a routine visit. The best value for any health plan is to
reimburse physicians for level Five work that results in a stable patient. After all that is the goal
of health care.
In Oncology, the community standard since 1984 has been that the patient needs a separate assessment
before any and all infusion drugs are administered. This applies to injections of all red and white cell
growth factor drugs. MedPAC, and other agency meaningful use authors, all support the clinical
assessment of patients as a way to control health care costs. Medicare shifted reimbursement from
other services to the Evaluation and Management services, suggesting the physician patient visit offers a
better patient experience that offers meaningful value to the Medicare program
Chemo supervision as part of the infusion codes and paid as a physician relative value work unit (RVU)
includes an additional assessment during the infusion episode that may include a confirmation of the
toxicity assessment that was acquired during the patient assessment. These separate ongoing
assessments are critical to ensure an excellent outcome before (the visit), during, and after (the infusion
supervision), the highly complex infusion therapy is administered. This document will explain how the
assessment and supervision RVU are required as part of the high quality of care Medical
Oncology/Hematology provide to their patients.
Physicians have been part of the Medicare Resource Based Health Care System, (RVU) since
the early 1980s and this long standing policy of the patient assessment offers insight from a payment
policy, why a provider visit is always needed and modifier 25 should always be appended to every visit
associated with infusion therapy in a private office. Technically speaking the only reason for the
modifier 25 is to allow the claim to pass the edits when two or more services are billed on the same
claim. In reality, modifier 25 should not be required since this is the policy when the service is billed in a
hospital setting.
In 2005 CMS agreed to add a physician supervision value to the oncology infusion CPT codes, ,when the
Congress declared the AWP drug payment methodology should be eliminated in exchange for the lower
ASP payment. CMS, with the help of interested parties, established new Oncology coding in 2004 with G
codes and then CPT codes in 2005. That process declared that the nurse assessment CPT code value of
$9.00 est. physician work value should be used to set up the work relative value unit in all the oncology
codes to represent supervision during the therapy. Not before the therapy. CMS and the insurance
industry along with the AMA coding panel agreed that the provider assessment using CPT codes 9921299215 should always be billed separately.
In 2005 there was a presentation that CPT 99215 work value should be added to the infusion codes,
instead of CPT 99211 the nurse assessment code. The argument was adding CPT 99215 physician work
to the infusion codes would eliminate the requirement to bill a separate office visit. This idea was
rejected, as the CPT working committee felt strongly that the visit should always be billed separately.
The AMA CPT book
“Chemotherapy services are typically highly complex and require direct physician supervision for any or
all purposes of patient assessment, provision of consent, safety oversight, and intra-service supervision
of staff.”
A separately identifiable service is required as a separate diagnosis is not required28 AMA CPT Book nor
does either the 1995 or 1997 Evaluation and Management guidelines suggest that a new problem or
worsening of a problem is the only time a separate identifiable service should be billed when the patient
require an evaluation on the day infusion therapy.
“The E/M service may be caused or prompted by the symptoms or conditions for which the procedure
and/or service was provided.” Cancer and Hematology patients obviously have a condition of a chronic
disease that requires a separate evaluation to determine if their symptoms are such to approve the
therapy.
American Society of Clinical Oncology ASCO letter copy enclosed that supports the routine use of the
modifier 25 pended to an evaluation on the day of infusion therapy
CMS Legislative Summary, April 2004, Summary of H.R. Medicare Prescription Drug, Improvement, and
Modernization Act of 2003, Public Law 108-173, Subtitle E—Miscellaneous Provisions Sec. 941. Policy
Developments Regarding Evaluation and Management (E&M) Documentation Guidelines
That the 1995 or 1997 AMA Evaluation and Management Guidelines will be used to audit provider notes
using the SOAP audit technique based on specialty point system and not primary care point systems
CMS 100.04 transmittal 731.
We also cite the CMS Standalone policy that each patient encounter with a provider is separate and
cannot be linked to another service
Summary of Comments
Hematology and Medical Oncology providers care for chronically ill patients.
Practice Expense is an issue that needs to be recognized as part of any audit, since cancer specialists’
costs to deliver the care is expected to be higher than a primary care physician practice that relies on
this same coding and same payment for the non-specialty E/M guidelines.
The History, Exam and Decision Making categories of the American Medical Association E/M coding
guidelines reference an expected higher level of coding should occur by the nature of the disease.
28
AMA CPT book preamble under heading Hydration, Therapeutic, Prophylactic, Diagnostic injections and infusions and chemotherapy and
other highly complex drug or highly complex biologic agent administration
The guidelines clearly state that the auditor should score the note with the highest points from two of
three categories defined as history, exam and or Decision Making for established patients.
New patients require highest points in all three categories.
The auditor is supposed to give the provider the benefit of the doubt if the overall score is close.
The American Medical Association Evaluation and Management E&M
guidelines are vague and subject to interpretation.
The E/M guidelines are subject to interpretation from coders who may be using inappropriate audit
tools to score the provider notes.
The Marshfield Clinic audit tool many CMS auditors use to audit a physician note assigning points in
Medical Decision Making is not appropriate to use to audit a specialist physician note.
Marshfield Clinic Audit Tool Assigning Points in Medical Decision Making with no hierarchy of points:
Add to the confusion there appears to be inappropriate audit tools used to score a note that are not
identified in the guidelines. So how does one follow a guideline that is vague and subject to
interpretation to the auditor who may not realize that a cancer diagnosis should carry a higher point
value than a patient who presents to the physician office with a sore throat.
These vague guidelines do not address the citation as noted in the 1995 AMA Guidelines they refer the
provider to talks about evaluations that are medically necessary and appropriate when a comprehensive
history and or exam concludes with a stable patient. This comprehensive visit is a typical event in
Hematology and Oncology. The goal of the visit is to keep the patient stable. So a comprehensive
history and exam is expected with a stable patient who is now cleared to receive infusion therapy.
Cancer patients and many Hematology patients are high risk and the score should be an easy level five
service.
Because of under coding provider notes look like level five care but the provider is down coding to a
level four or three. Now we have level five work reported as level four and three billings.
We all should recognize the AMA coding guidelines are a failure and we should jointly request the AMA
change these guidelines. ( Refer to Published Article Citations)
These EquiClaim letters appears to discriminate against those physicians who attempt to code correctly
following the OIG voluntary compliance program for the following reasons.
It is expected that Medical Oncologist bell curve should report more level IV and V services due to the
high complexity of care required for Hematology and Oncology patients.
This letter may result in physicians arbitrary down coding without a meaningful process to determine
examples of appropriate coding of the patient visit.
The insurance industry and pay for performance process believes that physicians who evaluate their
patients appropriately, to include routine complex evaluations, prevent unnecessary admission and trips
to the Emergency Room. My citation is the various MedPac reports and other articles published by the
government that have addressed this issue beginning in 2006.
It would appear this letter is counterproductive to the Congressional / CMS intent to provide better care
to the patients.
Documentation now requires detailed explanation of every issue that is identified in the note as a
number. For example the auditor is not trained to understand what a low lab value presents unless it is
followed up with discussion by the provider. So this makes the provider inefficient spending more time
explaining the why instead of reporting the lab value that concludes with an action that is presented
later in the note as an order of prescription drugs.
Practice name _____________(SCC) has adopted the OIG voluntary compliance program in 1010 and SCC audits
conclude that Practice name _____________physicians are under coding. The primary reasons are due to letters
that allege the physician is coding above their peers as described in this (CBRs) letter attached. However, when
we check around the community of physicians, we find everyone is receiving these letters and everyone is an
outlier
The Oncology Coding bell curve should be as follows:
Level ii ZERO
Level iii 20%
Level iv 45%
Level v 35%
PUBLISHED ARTICLES THAT SUPPORT THE ARGUMENT THE CODING
GUIDELINES ARE BROKEN
There are many articles about coding concerns and the maladroit guidelines providers rely on to
attempt to score the note that assigns a payment.
2002 article published in the AMA news. “E&M guidelines still don’t work; panel says dump ‘em” 29
A 2004 article from the AMA news announces to the reader the following. “Do you tend to undercode?
You’re not alone”30.
The article quotes the following: “A study confirms what many doctors already believe – They don’t give
themselves credit for everything they do. That affects fees, and perhaps, quality measurements.”
29
30
AMA News June 10, 2002 Markian Hawryluk
AMA News Nov 22, 2004 Robert Kazel
The AMA News article in 2005 titled “Medicare zeros in on E&M coding as key source of payment
mistakes.” This article summarizes the CMS report about the need for provider education of the E&M
coding. 31.
The 2005 AMA article addresses the CMS report released sometime in 2005 about the need to educate
providers. These article citations suggest the core issue here, is the Evaluation and Management 1995 or 1997
coding system guidelines that are not specialty specific that were supposed to be overhauled.32
MedPac reports over the years have made recommendation to the Congress that has been met with more
resources added to the E&M coding with a goal to encourage physicians and midlevel providers to spend more
time with their patients.
31
32
AMA News Jan 3/10 2005 David Glendinning
E/M guidelines still don’t work: panel says dump ‘em AMA News June 10, 2002