Evaluation and Management Coding Risk Revisited

August 21, 2013

Prepared for Northeast GA Local Chapter AAPC

Evaluation and Management Coding Risk Re-Visited

Northeast GA Local Chapter AAPC

August 21, 2013

August 21, 2013


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

August 21, 2013


Risk Factors

Provider• Documentation• Coding

Coder Biller

Auditor

• Billing• Education

Payor State

• Audit• Risk

Guidelines EducationInterpretation

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Provider

Auditor

Coder

Biller

Incentives

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Factors Influencing Provider CodingProviders: 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

August 21, 2013


Work RVU Based Compensation

Impact to E/M

• Financial Risk

– Up-coding

– Increase Frequency of Visits

• Ineffective Resource Utilization

– NPP practice flow

http://www.google.com/url?sa=i&rct=j&q=payment+reforms&source=images&cd=&cad=rja&docid=jRHa_RY5U9ITBM&tbnid=HgL8W_cnc5Bn7M:&ved=0CAUQjRw&url=http://www.piperreport.com/blog/2009/11/19/health_care_payment_reform_considerations_for_global_payments_in_medicaid/&ei=K5hAUcvAHdO20AGM8oGIAw&bvm=bv.43287494,d.dmg&psig=AFQjCNEgB3-m1XlgNEoVAGN7mNK7Y7nZ5w&ust=1363274153568836

August 21, 2013


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

August 21, 2013


Compensation

Mitigating Risk

• Work RVUs the Wrong Incentive?

• Mitigating Risk

– Quality Metric Bonus Structures

– Routine Audits

– Overpayment Deductions

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Provider

Documentation

CodingBilling

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 RecordDocumentation

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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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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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

August 21, 2013


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

August 21, 2013


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

August 21, 2013


Coder Biller Auditor

August 21, 2013


Coding: Payor GuidelinesMedicare 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 CodingCorrect 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/M Categories may be determined by:

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

August 21, 2013


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 ElementsKey Elements• History

• Exam

• Medical Decision Making

Contributory Elements• Counseling

• Coordination of care

• Nature of presenting problem

• Time

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E&M ElementsNature 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

32

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 TimeUnit/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

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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 reviewNot receiving any current TherapiesDoes Physical Exam: DetailedGives Current Dx’sPlan of Treatment: Continue current Medication (lists Medications) and treatment regimen; evaluate labs and treat accordingly; monitor overall status closely; follow up routinely.

http://www.cahabagba.com/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/




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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.

August 21, 2013


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 .

http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

August 21, 2013


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

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html




August 21, 2013


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?

August 21, 2013


Contact Information

Valerie G. Rock, CHC, CPC, ACS-EM

Manager

PYA GatesMoore

(404) 266-9876

[email protected]

www.pyapc.com

Evaluation and Management Coding Risk Revisited

Health & Medicine

Transcript of Evaluation and Management Coding Risk Revisited