PYA Consulting Manager Valerie Rock's presentation covers the factors that impact E/M documentation and coding risk; current issues and concerns surrounding physician documentation; and perspectives and interpretations that can impact coding, education, and auditing.
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Evaluation and Management Coding Risk Revisited
1. Page 0August 21, 2013
Prepared for Northeast GA Local Chapter AAPC
Evaluation and Management
Coding Risk Re-Visited
Northeast GA Local Chapter AAPC
August 21, 2013
2. Page 1August 21, 2013
Prepared for Northeast GA Local Chapter AAPC
Session Objectives
• Increase awareness of factors that impact
E/M Documentation and Coding Risk
• Learn current issues and concerns
surrounding physician documentation
• Learn how perspective and interpretations
can impact coding, education, and auditing
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Risk Factors
Provider
• Documentation
• Coding
Coder
Biller
Auditor
• Billing
• Education
Payor
State
• Audit
• Risk
Guidelines
Education
Interpretation
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Provider
Auditor
Coder
Biller
Incentives
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Factors Influencing Provider Coding
Providers: Physicians/Non-physician Practitioners (NPPs)
• Education
– Knowledgebase of educator
– Time allowance/Attention span
– Method of teaching
» Shadowing, Web-Based, In-person, Individual, Group
– Method of learning
» Repetitive, Personal
• Incentives
– wRVU based compensation
– Bonuses
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Factors Influencing Provider Coding
Physician
Behavior
Incentives: Work RVU Based Compensation
Compliance
Risk
Financial
Risk
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Work RVU Based Compensation
Impact to E/M
• Financial Risk
– Up-coding
– Increase Frequency of Visits
• Ineffective Resource Utilization
– NPP practice flow
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Work RVU Based Compensation
Monitor for Increased Frequency of Visits
• Patient’s treatment schedule does not necessitate
visits with the MLP or physician.
• Document medical necessity for all visits, orders,
treatment
• Visits should be rendered at a frequency recognized
as standard of care.
• Confirmation for day’s treatment: Bundled
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Compensation
Mitigating Risk
• Work RVUs the Wrong Incentive?
• Mitigating Risk
– Quality Metric Bonus Structures
– Routine Audits
– Overpayment Deductions
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Provider
Documentation
Coding
Billing
Risk
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General Medical Record
Documentation
• Methods
– Handwritten
– Scribe
– Dictation (Dictaphone, Dragon)
– EHR
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Templates
• Overall
– Treated as a checklist
• Handwritten
– Checkboxes
• Scribe
– Knowledgebase
• Dictation (Dictaphone,
Dragon)
– Errors
– Conflicts
• EHR
– Dictation/Scribe/Dragon
– Over-documentation
– Conflicts
– Copy/Paste
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General Medical Record Guidelines
• Documentation
– Should Be Complete and Legible
• Handwritten: Office or Facility with no EHR
• EHR: Missing required elements (ROS, Signature)
– The documentation/note/record for each date of
service should support (alone or by reference) the
CPT and ICD-9-CM codes reported on the claim form
or billing statement.
• Dictation and EHR templates missing DOS
• DOS not dictated
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General Medical Record Guidelines
• Documentation should Include:
– Reason for encounter and relevant history
– Physical examination findings and prior diagnostic test results
– Assessment, clinical impression or diagnosis
– Plan for care
– Date and legible identification of the observer (handwritten or
electronic signature; no stamps)
– Rationale for ordering diagnostic and other ancillary services
– Past and present diagnoses
– Appropriate health risk factors
– The patient's progress, response to and change in treatment, and
revision of diagnosis
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Electronic Health Record
Documentation
Chief Complaint (CC)
• A concise statement describing the symptom,
problem, condition, diagnosis or other factor
that is the reason for the encounter, often
stated in the patient’s own words
Tip: Clearly document chief complaint.
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Electronic Health Record
Documentation
Chief Complaint (CC)
– Risk: CC pulled into note by selection of diagnoses or
entry from schedule or Nurse documentation.
– Requirement: CC must be documented by the
physician/NPP.
– Solution: Add language to chief complaint that will point
auditor to HPI for today’s visit.
• “Other conditions and symptoms indicated in HPI.”
• Document the reason for the visit and conditions and
symptoms presented in HPI section.
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Electronic Health Record
Documentation
Copy Forward
– Limit sections that can be copied forward in
system
– Select ROS and Exam elements that are
pertinent positives and negative performed
– Select diagnoses assessed during that
encounter.
– Ensure all documentation is current or dated and
not conflicting from one section to the next.
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Time
• Time may be the key or controlling factor to qualify the use
of a particular E/M service provided certain conditions
have been met.
• Necessary Criteria
– Counseling and/or coordination of care dominates (more than
50%) the patient encounter
– Applies to E/M services only
– Must be face-to-face time in office; floor time in the hospital or
nursing home setting
– Documentation supports counseling/COC
– Documentation of total visit time and time spent in counseling
or coordination of care
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Time: Risk
• Using time as a work around to documenting
• Combining E/M time with the time spent
performing other procedures/services
– Psychiatric codes
• Not documenting time
– Assuming time captured in EHR
– Too difficult to keep up with
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Bottom-Line: Document
• Why did you see the patient today?
• What was planned vs unplanned?
• What did you do today?
– Diagnoses assessed, history taken, exam performed
• What medical decision making was required?
– Lab results, values
• What is the update from the previous visit?
• What plan resulted?
– orders, prescriptions, other plan – and WHY?
ICD-10
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Physician Coding
• Document to the highest level of specificity
• Educate toward awareness of the code language
and guidelines
– Record training and materials
• Code to the highest level of specificity and accuracy
(CPT and ICD-9/10)
• Utilize technology to assist in proper coding; not in
the place of education
– Electronic Superbills
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Coder
Biller
Auditor
Guidelines
Payor
State
Education
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Coding: Payor Guidelines
Medicare Correct Coding Policy
The principles for the correct coding policy are:
• The service represents the standard of care in accomplishing the overall
procedure;
• The service is necessary to successfully accomplish the comprehensive
procedure.
• Failure to perform the service may compromise the success of the
procedure; and
• The service does not represent a separately identifiable procedure
unrelated to the comprehensive procedure planned.
Pub 100-04, Ch 12, Sect. 30 - Correct Coding Policy
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E/M Coding
Correct Coding
• Medical necessity of a service is the overarching criterion for
payment in addition to the individual requirements of a CPT code
• It would not be medically necessary or appropriate to bill a higher
level of E/M service when a lower level of service is warranted
• The volume of documentation should not be the primary influence
upon which a specific level of service is billed
• Documentation should support the level of service reported
• The service should be documented during, or as soon as
practicable after it is provided in order to maintain an accurate
medical record
Pub 100-04, Ch 12, 30.6.1 - Selection of Level of Evaluation and Management
Service (A. Use of CPT Codes)
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Coding: CPT vs. Payor GuidelinesE/MCategoriesmaybe
determinedby:
Who is the patient?
New vs. Established patient
criteria
What type of service?
Consult or referral?
Key Component criteria per code
description
Where was the service rendered?
Inpatient/Observation/
Outpatient/ED
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Billing Risk: Payor Guidelines
• Date of Service
• Place of Service
– POS identifier
– Provider-Based, Office
– Outpatient Hospital, ASC, Home
• Inpatient vs. Outpatient
• Physician or NPP
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Auditor vs. Auditor
Auditor
Auditor
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Auditor Risk: Coding
Auditors
• Interpretations
– Gray zones: Policies
– Education: Record training and materials
– Experience
– Employer
• Risk
– Using headers instead of the body of the note
» ROS in HPI
» A/P containing history
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E&M Elements
Key Elements
• History
• Exam
• Medical Decision Making
Contributory Elements
• Counseling
• Coordination of care
• Nature of presenting problem
• Time
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E&M Elements
Nature of Presenting Problem
Minimal Problem not requiring presence of physician but service is provided under
the physician's supervision
Self-limited or
Minor
Problem that runs a definite and prescribed course, is transient in nature,
not likely to permanently alter patient's health status, has good prognosis
with management and compliance
Low Severity Problem where risk of morbidity without treatment is low; little or no risk of
mortality without treatment, full recovery without functional impairment
Moderate
Severity
Problem where risk of morbidity without treatment is moderate; moderate
risk of mortality without treatment; uncertain prognosis or increased
probability of functional impairment
High Severity Problem where risk of morbidity without treatment is high to extreme;
there is a moderate risk of mortality without treatment or high probability
of severe, prolonged functional impairment
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Tip: If unable to obtain history, note reason.
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Hospital Care Codes
Subsequent Hospital Care (2 out of 3)
Level History Exam DecisionM Time
99231 Prob Focus Prob Focus Straight/Low 15
99232 Expanded PF Expanded PF Moderate 25
99233 Detailed Detailed High 35
31
Initial Hospital Care (3 out of 3)
Level History Exam DecisionM Time
99221 Detailed Detailed Straight/Low 30
99222 Comprehensive Comprehensive Moderate 50
99223 Comprehensive Comprehensive High 70
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Facility Time
Unit/floor time (hospital observation services, inpatient hospital
care, initial inpatient hospital consultations, nursing facility):
• Intraservice time, (unit/floor time) includes the time:
– present on unit and bedside rendering services for that patient
– to establish and/or review the patient's chart, examine the patient,
write notes, and communicate with other professionals and the
patient's family
• Pre- and post-time, includes time:
– spent off the patient's floor performing such tasks as reviewing
pathology and radiology findings in another part of the hospital
– Not included for coding based on time
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Biller: Coding Risk
• Biller modifications
– Not getting physician approval
– Prompted by physicians
– Treating payment as approval
• Biller interpretations
– Billing vs. Coding
– Correct for Payor and against coding guidelines
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Payor
State
Rules
Audit
Findings
Oversight
Responsibility
Education
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Payor: Coding Guideline Risk
Payors
• Guidelines and Interpretations
– CPT
– Private Payor Policies/Contracts
– CMS and Medicaid Manuals
– Carrier Policies/FAQs
– E/M Guidelines
» Marshfield Clinic Method followed by almost all payors
• Calculating MDM
» State Rules and Laws
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Medicare Resources
• Medicare Pub.100-4, Medicare Claims
Processing Manual
– Ch. 12, Physicians/Non-physician Practitioners
• Correct Coding Policy
– 30.6 Evaluation and Management (E/M)
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Cahaba GBA FAQs
• How can I justify Medical Necessity to bill if there is no current
complaint, but yet Medicare requires the visit? Also require visits
every 60 days after the initial 90 day period. No acute problem.
• E and M and Skilled Nursing Facilities:
– Physician goes into Skilled Nursing Facility/ Nursing Facility to see
residents. They fall within the required 30/60/90 period.
Current Complaint: No Acute problems are noted.
No labs or x-rays to review
Not receiving any current Therapies
Does Physical Exam: Detailed
Gives Current Dx’s
Plan of Treatment: Continue current Medication (lists Medications) and
treatment regimen; evaluate labs and treat accordingly; monitor overall
status closely; follow up routinely.
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Cahaba GBA FAQs
• Management of the patient’s chronic condition would be acceptable
documentation.
• Reimbursements for physician visits in a skilled nursing facility are made
under the Medicare Part B physician fee schedule for federally mandated
visits. Following the initial visit by the physician, payment shall be made
for federally mandated visits that monitor and evaluate residents at least
once every 30 days for the first 90 days after admission and at least once
every 60 days thereafter. The federally mandated E/M visit may serve
also as a medically necessary E/M visit if the situation arises (i.e., the
patient has health problems that need attention on the day the scheduled
mandated physician E/M visit occurs). The physician/qualified NPP shall
bill only one E/M visit.
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Cahaba FAQ/Medicare vs. State
• Medicare Part B payment policy does not pay for additional E/M visits
that may be required by State law for a facility admission or for other
additional visits to satisfy facility or other administrative purposes. E/M
visits, prior to and after the initial physician visit, that are reasonable and
medically necessary to meet the medical needs of the individual patient
(unrelated to any State requirement or administrative purpose) are
payable under Medicare Part B.
• For information on Evaluation and Management services and nursing
facilities refer to the Claims Processing Manual, Pub. 100-04; section
30.6.13 – Nursing Facility Services (Codes 99304 – 99318) at
http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf .
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E/M Guidelines
• 1995 vs. 1997
• 1995: Subjective can be beneficial in defense
• 1997: More quantitative
– Have to support medical necessity of providing elements
• Source: http://www.cms.gov/Outreach-and-Education/Medicare-
Learning-Network-MLN/MLNEdWebGuide/EMDOC.html
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E/M Risk Recap
• Be aware of Key Stakeholders in E/M
Documentation, Coding, and Billing
• Know common interpretations to guidelines
and apply guidelines consistently
• Educate Key Stakeholders regularly
• Document/Record education sessions and
materials
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Questions?
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Contact Information
Valerie G. Rock, CHC, CPC, ACS-EM
Manager
PYA GatesMoore
(404) 266-9876
vrock@pyagatesmoore.com
www.pyapc.com
Editor's Notes
Incident to vs shared visit
Date of service on TCMPOS rule on technical componentProvider-based, no incident toIncident To” ServicesMedical Review: Appropriate Medical Record Documentation to Support “Incident To” ServicesPosted May 2, 2012 in Part B Data analysis and medical record review of Evaluation and Management (E&M) Services, conducted by the Part B Medical Review department, has shown a continuous increase in provider documentation errors of “Incident To” services. The following errors were identified for inappropriate documentation to support “Incident To” services.E&M services were documented by the physician assistant; there was no indication that the physician was present in the office and/or that there was physician involvement in the patient’s care.There were no physician signatures that identified physician involvement in the patient’s treatment.When reviewing medical records, in additional to the reviewer’s clinical judgment, CMS rules and regulations regarding “Incident To” services and the 1995 and 1997 Evaluation and Management Services Documentation Guidelines are referenced.For “Incident To” services, the medical record must document:Services must be provided by office personnel whom the physician directly supervises and who represents a direct financial expense.Physician review of the qualified practitioner’s chart notes in order to monitor treatment progress.Physician signature indicating the physician is actively involved in the patient’s course of treatment.Physician must be present in the office suite.Solo practitioners must directly supervise the care.In group practices, any physician of the group may provide direct supervision.Cahaba GBA’s goal is to reduce Comprehensive Error Rate Testing (CERT) claim payment errors and address billing errors concerning coverage and coding through provider education. Providers can assist in lowering claim payment errors by documenting thoroughly and appropriately in the medical record and then submitting correctly coded claims to support all billed services. For additional information on “Incident To” Services, Evaluation and Management Services and the Comprehensive Error Rate Testing (CERT) program, refer to the following web site links:Medicare Benefit Policy Manual, Pub. 100-02, section 60.1 – 60.4.1: Incident To Physician’s Professional ServicesMedicare Claims Processing Manual, Pub. 100-04, Chapter 12, Section 30.6: Evaluation and Management Service Codes – General (Codes 99201 – 99499)The 1995 and 1997 Evaluation and Management Services Documentation GuidelinesComprehensive Error Rate Testing (CERT) Reports, Newlines, Sample Letters, etc./Page last updateMarch 9, 2009
Auditor and the physician must be educated to understand what time is counted toward counseling and coordination of care to count toward the code level. Intraservice time is used to count toward the code. That is face-to-face in the office setting and present in unit or beside in the facility. The time off the floor in other parts of the hospital are not counted toward that time.With EHRs physicians often believe that the system is recording the time. Typically that is not true, so it needs to be documented as total time and % or amount of time counseling on what. Also need to confirm what the documentation looks like printed. That can be different than on the screen.
ModifiersSetting differencesCapitated Medicare HMO or prospective payment RHC