N. Tucson Blvd. Suite 9
Tucson, AZ 85716-3450
Phone: (800) 635-1196
Hotline: (800) 419-4777
of American Physicians and Surgeons, Inc.
A Voice for Private Physicians Since 1943
Omnia pro aegroto
September 25, 1998
The Honorable Nancy-Ann Min DeParle
Health Care Financing Administration
Department of Health and Human Services
200 Independence Ave. SW
Washington, DC 20201
Dear Ms. DeParle:
In order that I may respond to questions asked by our members, I need some
specific information from your agency.
- May claims be denied on the basis of failure to comply with the 1997
AMA/HCFA E&M Documentation Guidelines, which according to your
office have been indefinitely withdrawn?
- May any "guidelines," rules, or regulations be applied retroactively to services
that were rendered before the "guidelines" went into effect?
- If the answer to #2 or #3 is "no," what recourse do physicians have if carriers
deny claims inappropriately? (Surely, an official, definite answer from you
would help in that process.)
- Does HCFA apply any sanctions to employees or contractors who have a pattern
of inappropriate denials or unlawful behavior? Is there a mechanism that
providers or patients may use to complain of such behavior by claims
processing personnel, perhaps analogous to the toll-free line that beneficiaries
are encouraged to use to complain about their provider?
- What is the correct E&M code to use for a housecall to a patient who is not
homebound but who nevertheless requests the physician to visit? Can you
give an authoritative statement that the physician may cite in case the carrier
challenges him? Or is such a service not covered under Medicare?
Please respond promptly. Certain patients may have to go without needed
medical service pending your response.
Jane M. Orient, MD
cc Senator Jon Kyl