April 8, 1998

Jane M. Orient, M.D.
Executive Director
Association of American Physicians and Surgeons Inc.
1601 N. Tucson Blvd. #9
Tucson, AZ 85716-3450

Dear Dr. Orient

I want to invite you to work with the AMA, state medical associations, county medical societies, and national medical specialty leaders on developing new Evaluation and Management Documentation Guidelines that meet the needs of the medical profession. As you know, the AMA leadership recognized last fall that the proposed 1997 Documentation Guidelines should not be implemented. We moved swiftly to convince HCFA to grant a six month grace period to provide time for the development of substantial revisions of the proposed guidelines.

Our goal is to draft a revised set of guidelines with a dramatic reduction in the reporting burden for physicians. We also want to provide more time educating physicians and Medicare carrier staff on the proper use of the guidelines. Third, we want to separate the discussion of establishing appropriate documentation guidelines from fraud and abuse. We believe a joint effort by organized medicine to develop revised guidelines will produce better long-term results than filing a lawsuit. Suing the government may be a useful device for membership recruitment but practicing physicians will not be better off if new "black box" requirements are developed in a vacuum by HCFA staff or Medicare carrier directors.

We are pleased that you will attend the April 27 meeting in Chicago to review and respond to a new and more simple framework for documenting Medicare E & M services.

Some of your recent communications on the 1997 documentation guidelines contain serious misconceptions that demand correction. For example, the suggestion that compliance with documentation guidelines will violate patient confidentiality is an absolute red herring. The AMA has been a visible and effective advocate for protecting the confidentiality of patient records.

Documentation requirements are not new or unique to the Medicare program. For years, Medicare and every other insurance program have conducted medical and utilization reviews that require some level of information to substantiate claims. Medicare E & M documentation guidelines have been operative since 1995. The proposed 1997 guidelines were developed in response to arbitrary decisions by Medicare carriers to deny physician payment for level 4 and 5 visit codes. Guidelines provide physicians with criteria to prevent arbitrary denials or down-coding by Medicare carriers. Moreover, we believe that guidelines developed with formal input by the profession, known to all physicians, are the antithesis of the secrecy you decry.

The proposed 1997 guidelines were not a product of the AMA alone. We convened broad-based panels of practicing physicians in the development process. Every major national medical specialty society and nearly all major subspecialties were involved in the review process.

The AMA has repeatedly sought clarification from Members of Congress and enforcement agencies that physicians will not be subject to criminal or civil penalties for inadvertent billing or coding errors. The AMA has successfully blocked attempts by the Department of Justice and the HHS Inspector General to lower the knowing and willful intent standard for prosecutions. AMA lobbying resulted in the attached letter from the Chairmen of the House Judiciary, Commerce and Ways and Means Committees which states that Congress did not intend to subject physicians to criminal and civil penalties for inadvertent billing or coding errors. We are not aware of a case where a physician has been prosecuted for inadvertent billing errors or failing the 100% compliance test. Please let us know immediately if you are aware of such a case.

There are many aspects of the Medicare program and the larger health care delivery system that the AMA would like to see modified. At times we may differ on the most effective course for advancing the interests of patients and their physicians. However, we should be very careful about challenging the integrity of fellow physicians and our respective organizations.

I look forward to seeing you at the April 27 meeting and urge you to reconsider the merits of working with your colleagues to enable physicians to provide patient care, receive appropriate payment with the minimum amount of paperwork and administrative burden.


Thomas R. Reardon, M.D.
Chair, AMA Board of Trustees