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.

1. 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to comply with the 1997 AMA/HCFA E&M Documentation Guidelines, which according to your office have been indefinitely withdrawn?

2. May any "guidelines," rules, or regulations be applied retroactively to services that were rendered before the "guidelines" went into effect?

3. 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.)

4. 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?

5. 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.

Sincerely,

Jane M. Orient, MD
Executive Director

cc Senator Jon Kyl