April 15, 1998

Mark Segal, Ph.D.
Vice President, Strategic Market Program
American Medical Association
515 State St.
Chicago, IL 60610

Dear Dr. Segal:

Thank you for your letter dated April 13.

In an announcement of the AMA dated February 9, 1998, Chairman Thomas Reardon, M.D., described when "the revised guidelines are made mandatory" [emphasis added]. Your letter of April 13 seems to be in direct conflict with Chairman Reardon's declaration, which has remained posted on the AMA web site since February.

Your letter simply quotes from the Foreword of the E&M Documentation Guidelines and from the AMA's 1997 CPT Assistant publication. Your first quotation expressed a "mutual goal [of the HCFA and the AMA]." Your second quotation predates formal adoption of the Guidelines, and thus has little significance now. You concluded that you "expect [these statements] to remain in effect for the next, much improved version," and characterized your view as "our understanding of the intent of the guidelines."

On reviewing the Guidelines, I found numerous statements that appear to be contrary to what you "expect." For example, there are 27 occurrences of the word "require" or "requirement," and 16 occurrences of the word "must." None of the following words appears even once: suggest, recommend (except in "physician recommended return [visit]"), optional, preferable, choice, choose, decide, privacy, confidential, or consent. Moreover, nowhere do the Guidelines themselves state that they are not intended to be a law or rule.

We believe that the intent of the Guidelines is of little significance. We are interested in the actual effect. To be consistent with the stated intent, I trust you will agree that the foregoing references in the Guidelines be changed to reflect the view that they are merely suggestions or recommendations, to be implemented or not, in whole or in part, according to the professional judgment of the individual physician. Moreover, the AMA should make it clear that the exercise of a professional judgment to disregard the Guidelines should not subject the physician to risk of punitive sanctions.

I would welcome your support for the implementation of necessary changes. Alternately, I would like a clarification of your position. Are the guidelines regulations now, or not? If not now, will they be at some future time? Will they then be of legal force or effect?

Sincerely yours,

Jane M. Orient, M.D.
Executive Director