Evaluation & Management Auditing

Megan Weis, RHIA

Bridging the Gaps: IaHIMA Annual Meeting in Partnership with Iowa HiMSS

May 2-3, 2016

Megan Weis, RHIA

• Megan has called the healthcare field home for 11 years. During this time she’s worked as

• a certified medical coder for a large multi-specialty clinic;

• a business analyst for a clearinghouse, helping develop and support physician analytic tools;

• a Health Information Technology Instructor at a community college, starting the program from scratch;

• and currently as the Manager of Coding and Reimbursement for Medical Associates Clinic in Dubuque, Iowa. In this position, Megan has developed a coding & documentation audit program. She works closely with physicians regarding revenue integrity to be sure they’re capturing all potential revenue as well as have supporting documentation for current revenue.

• mweis@mahealthcare.com

Session Objectives

• Understand the 3 key components of E/M services

• Identify common audit concerns

Disclaimer

• Every reasonable effort has been taken to ensure the information contained in this presentation is accurate and current. However, because the Medicare program is constantly changing, it is the responsibility of each provider/supplier to remain abreast of the Medicare program requirements

Authoritative Sources

• CMS 1995 Documentation Guidelines for Evaluation and Management Services

• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf

• CMS 1997 Documentation Guidelines for Evaluation and Management Services

• http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/referenceII.pdf

• CMS Evaluation and Management Services Guide • http://www.cms.gov/Outreach-and-Education/Medicare-Learning-

Network-MLN/MLNEdWebGuide/

• WPS Medicare Evaluation and Management • http://www.wpsmedicare.com/j5macpartb/resources/provider_types/e

valandmngmnt.shtml

• AMA’s CPT – Evaluation and Management

E/M Coding

• Evaluation and Management (E/M) codes describe the complexity of the professional services that a provider renders during a visit.

Two sets of guidelines

• 1995 Documentation guidelines

• 1997 Documentation guidelines

Components of E/M Services

Key Components

• History

• Exam

• Medical Decision Making (MDM)

Contributory

• Counseling

• Coordination of Care

• Nature of Presenting Problem

• Time

History – 3 components

• HPI – History of Present Illness

• ROS – Review of Systems

• PFSH – Past Medical, Family and Social history

HPI – History of Present Illness

• Clear documentation of problem(s) since last visit

• Status of chronic conditions

• If “NEW” Problem, should be clearly stated

• Physician must document HPI

• This is the patient’s story/interview

ROS – Review of Systems

Definition - An oral or written account of symptoms experienced by the patient

Three Levels -

• Problem Pertinent

• Extended

• Complete

PFSH – Past, Family & Social History

• Four Levels of PFSH

• Problem Focused

• Expanded Problem Focused

• Detailed

• Comprehensive

History Example

EXAM

• Four Types of Exams

• Problem Focused

• Expanded Problem Focused

• Detailed

• Complete

Definition - An oral or written account of symptoms experienced by the patient

EXAM

• Statement of “abnormal” is inadequate

• Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented.

• Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or organ system(s) should be described.

• A brief statement or notation indicating “negative” or “normal” is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s).

Exam Example

Medical Decision Making

• Diagnosis & Treatment Options

• Amount & Complexity of Data Reviewed

• Risk

MDM Example

New vs Established Patient

• "New patient" is defined as:

• A patient who has not received any professional services (face-to-face) from the physician within the previous three years. • This does not include reading an EKG, interpreting an x-ray or any other

diagnostic test.

• It does include ER visits, hospital visits, surgical services, office visits and any other face-to-face service provided and billed using a CPT code.

• Helpful references:

• http://wpsmedicare.com/j5macpartb/departments/enrollment/specialty_codes.shtml

• http://wpsmedicare.com/j5macpartb/resources/new_providers/newvsestpatient.shtml

• http://wpsmedicare.com/j5macpartb/resources/provider_types/mid-level-providers-qanda.shtml

Put it all together

New Office Visit or Consult (need 3 of 3) Established Office Visit (need 2 of 3)

HISTORY ☐ PF ☐ EPF ☐ D ☐ C ☐ C HISTORY

☐

Nurse

Visit

☐ PF ☐ EPF ☐ D ☐ C

EXAM ☐ PF ☐ EPF ☐ D ☐ C ☐ C EXAM ☐ PF ☐ EPF ☐ D ☐ C

MDM ☐ SF ☐ SF ☐ L ☐ M ☐ H MDM ☐ SF ☐ L ☐ M ☐ H

LEVEL ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 LEVEL ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5

Time Based Billing (in minutes) Time Based Billing (in minutes)

New Office ☐ 10 ☐ 20 ☐ 30 ☐ 45 ☐ 60 Est Office ☐ 5 ☐ 10 ☐ 15 ☐ 25 ☐ 40

Off. Consult ☐ 15 ☐ 30 ☐ 40 ☐ 60 ☐ 80

Time Based Billing • If the physician documents total time and suggests that

counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, or risk education.

• TIME: If ALL responses regarding time are "Yes," billing may be based on time.

• Does documentation reveal total face-to-face time?

• Does documentation discuss the content of counseling or coordination of care?

• Does documentation reveal that more than 50% of the time was spent on counseling or coordination of care?

1 2 3 4 5

Office

Established 5 10 15 25 40

New 10 20 30 45 60

Inpatient

Initial (Admission) 30 50 70 - -

Subsequent 15 25 35 - -

Compliance

• Periodic Audits

• Physician Feedback

• Claims Denial

• CERT Reviews

• Develop policy

• Provide Training

Auditing/Monitoring

Questions ?