Topics for Today’s Discussion - University of Florida · PDF file ·...

1

MASTERING THE COMPLEXITIES OF E & Ms

(EVALUATION AND MANAGEMENT SERVICES)

M A R S H A S . D I A M O N D , C P C , C O C , C C S , C P M A2 0 1 6 C O D I N G F I E S TA

G A I N E S V I L L E L O C A L A A P C C H A P T E RO C T O B E R 2 2 , 2 0 1 6

Topics for Today’s Discussion

• Why Correct E/M Assignment is Important

• Basic Review E/M Code Assignment Process

• Complexities of Selecting Correct E/M Types

• E/Ms based on Time

• E/Ms with Modifiers

• Overarching Criteria

• Documentation in the EMR/Electronic Record

• Compliance and E & Ms

WHAT YOU WON’T LEARN TODAY!

• No “basics” – we will be discussing the difficult issues

• Not a “how to” assign E/M codes – assume average attendee knows basic E/M concepts

Mastering the Complexities of E & Ms (Evaluation and Management Services) October 22, 2016

Coding Fiesta 2016 Marsha S. Diamond, CPC, COC, CCS, CPMA

2

WHY EVALUATION AND MANAGEMENT IS SO

IMPORTANT

WHY CORRECT E/M ASSIGNMENT IS SO IMPORTANT

Significant Error Rate• CMS Statistics from CERT Statistics (Medicare Comprehensive Error Rate

Testing)• OIG Coding Trends of Medicare Evaluation and Management Services

2014

Fines, Penalties• Medicare regulations allow for penalties up to $11,000 for each service

billed that providers should have known were not medically necessary or incorrect based on documentation, 3 times the amount claimed and exclusion from federal and state health care programs

Significant Percentage Services/Revenue• Constitutes a large percentage of provider services and revenue stream• Constitute 33% of the average provider’s revenue from carriers

Medicare/RAC Focus Item

THE STAGGERING STATISTICS…

VOLUME OF E/Ms• Nearly 1/3 of all Part B payments involve E/M services• Up to 63% of E/M claims for established patient office/outpatient

visits

IMPROPER PAYMENTS• Improper payments for E/Ms result in over $7 billion to the

Medicare program annually• 42% of claims for E/M services incorrectly coded• Medicare payments for E/M services increased by 48%

INCREASE IN E/M LEVELS 2000-2010• 99214/99215 levels of service increased 17% while 99211-99213

decreased• Number of E/Ms increased from 346 million to 392 million visits

OIG Coding Trends of Medicare Evaluation and Management Services, Released 2014



3

CHANGE IN E/M DISTRIBUTION OFFICE/OUTPATIENT VISITS 2000-2010

OIG/Coding Trends of Medicare E/M Services Report, 2014

CHANGE E/M DISTRIBUTION OFFICE/OUTPATIENT VISITS 2000-2010

(OIG/CODING TRENDS OF MEDICARE E/M SERVICES 2014 REPORT)

Code 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Difference 2001-2010

99211 6% 6% 6% 5% 5% 5% 4% 4% 4% 4% -2%

99212 16% 15% 13% 12% 12% 11% 10% 10% 9% 9% -7%

99213 54% 54% 53% 53% 52% 51% 50% 49% 48% 46% -8%

99214 21% 22% 24% 26% 28% 30% 31% 33% 34% 36% +15%

99215 3% 3% 3% 3% 3% 4% 4% 4% 4% 5% +2%

TOP 10 PHYSICIAN SPECIALTIES WITH HIGHEST E/M LEVELS

Specialty % Physicians Higher E/M Levels1- Internal Medicine 19.8%

2 – Family Medicine 12.2%

3 – Emergency Medicine 9.9%

4 – Nurse Practitioner 4.4%

5 – Obstetrics & Gynecology 4.3%

6 - Cardiology/CV Disease 4.0%

7 - Orthopedic Surgery 3.9%

8 - Psychiatry 3.8%

9 - General Surgery 3.2%

10 – Ophthalmology 3.2%

E & M LEVELS OF DISTRIBUTION (BELL CURVE)

New Patient Office Visits99201 Level 1 1%99202 Level 2 16%99203 Level 3 45%99204 Level 4 30%99205 Level 5 7%

Established Patient Office Visits99211 Level 1 4%99212 Level 2 4%99213 Level 3 48%99214 Level 4 40%99215 Level 5 4%

MGmmm

MGMA Statistics 2012 – Medical Group Management Association



4

FRAUD POTENTIAL

E/M represents one of the biggest areas of interest for potential fraud allegations

• 18 U.S.C. Section 1347:Prohibits knowingly and willfully executing or attempting to execute a scheme or artifice to defraud any health care benefit program, or obtain by means of fraudulent/false pretense, representation of promises any of the money or property owned or under the custody of control of any health care benefit program

**Proof of actual knowledge or specific intent to violate the law is NOT required under this federal legislation

PENALTIES FOR NON-COMPLIANCE

• Triple the amount of the charges for the line item(s)

• Up to an $11,000 fine per line item

• Penalties and interest based on the date of service and date of discovery

• Exclusion from participation in all Federal health care programs

EXAMPLES OF E & M PENALTIES

Example of a “targeted” CMS E & M audit result:

• Practice identified by level of service distribution irregularity

• CMS determines audit will consist of 100 charts

• Audit reveals that 40/100 charts do not meet level criteria

• CMS will request 40% of ALL such services billed during specified period



5

CALCULATIONS OF AUDIT FINDINGS

10 providers X 15 visits/day X 22 days/month =3,300 visits monthly39,600 visits annually

40% of visits incorrect = 15,480 visits incorrect15,480 visits @ $300/visit (average $100 charges X 3)

$4,644,000 incorrect payments/refund

Penalties, fines and interest may be added$5,000-$10,000 per line item = Additional $77,400,000

BASIC REVIEWE/M CODE ASSIGNMENT

BASIC REVIEW E/M CODE ASSIGNMENT PROCESS

• Identify Type/Locations of Service

• Determine New/Established Patient

• Identify Level of Service based on 95/97 guidelines

• Determine if Overarching Criteria determines appropriate level

• Determine if Modifier Code Applicable or Service bundled



6

TYPE/LOCATIONS OF SERVICE

Outpatient/Office Visits (99201-99215)• Applies to office as well as outpatient hospital

(EX: Hospital clinic visits)• Only one E & M visit per day (with some exceptions such as critical care)• If admit/ER visit same provider group/same day may combine documentation

from office/outpatient visit for higher level of hospital E/M• Face-to-face time if E & M based on time appropriate for visit

Observation Care Visits (99217-99226) (99234-99236)• Must be observation “status” at time of visit• Not utilized for postoperative recovery• Initial observation only for initial care by admitting/supervising provider• Other observation care providers should use consultation or subsequent

observation care• Inpatient admit/observation same date, assign inpatient admit only• Admit/discharge from observation same date, utilize 99234-99236 series• Do not report observation discharge/inpatient admit for same date

TYPE/LOCATIONS OF SERVICE (CONTD)

Hospital Inpatient Services (99221-99239)• Admit/discharge same date utilize 99234-99236• Time based code assignments based on unit/floor time• Initial hospital code (99221-99223) utilized by admitting physician only• Other initial care by non-admit provider, utilize subsequent hospital care

codes• Takes precedence over other E & M services same date (with exceptions such

as critical care codes)• Discharge code utilized for time spent preparing patient for discharge• 99239 requires documentation of time to qualify

Consultations (99241-99255)• Assigned based on patient status – outpatient (99241-99245)/inpatient (99251-

99255)• Requires 3 R’s – (R) equest, (R) eferring professional and (R) eport• Only one consultation per admission per consultant• Purpose to request expert opinion or determine whether to accept

responsibility for ongoing management of patient’s care• Consultant may initiate diagnostic/therapeutic services• A “referral” does not necessarily constitute a consultation• If transfer of care occurs prior to conclusion of encounter, not a consultation

Emergency Room (99281-99285)• New/Established Patients• 99284/Urgent Evaluation 99285/Urgent Treatment• 99285 may be util if hx/exam documented as not possible due to pts cond

Critical Care Services (99291-99292)• Requirements different for facility/physician side• Minimum time requirements must be documented, based on unit/floor time• Critically injured/critically ill• Illness/injury that impairs one> vital organ systems with high probability of imminent or life

threatening deterioration pts condition• Time may Not be counted for:

- time not spent on floor/unit- time on activities not directly to treatment of patient- time spent performing separately identifiable billable services

• May be performed in any setting as long as definition of critical care met• Location of intensive care unit does not qualify as critical care based solely on location



7


Nursing Facility/Domiciliary, Rest Home/Home Services• New/Established Patients• Initial Nursing Facility/admit to facility• Hospital Discharge may be reported on same date as Initial Nursing Facility

visit

Prolonged Services (99354-99359)• With direct patient contact (99354-99357)• Without direct patient contact (99358-99359)• Based on documented time• Reported in addition to E/M service• Prolonged services < 30 minutes not reportable

Care Plan Oversight Services (99374-99380)• Reported separate from E/M services• Based on documented time• Home-Domiciliary-Rest Home/Home Health/Hospice


Preventive Services (99381-99397)• New/Established Patient• Age assigned• Can assign preventive medicine and E/M with modifier 25 if treat/evaluate a

separate medical problem

Neonatal/Pediatric Care (99466-99482)• Neonatal based on initial/subsequent and patient status

(low birth weight, recovering neonate)• Neonate – 28 days or younger• Intensive care versus critical care

Complex Chronic Care/Transitional Care (99487-99495)Chronic Case Coordination based on :

- Time spent staff care coordination-Time calculated based on calendar month-Services such as communication with caregivers, family, home health

agenciesTransitional Care

-Comprised of one face-to-face visit with specified timeframe to transition from one facility type care to another

-Code based on E/M medical decision-making components

NEW/ESTABLISHED PATIENTNew patient – not seen by practice or specialty within multi-specialty practice in past three (3) years

Established patient- seen by practice or specialty within multi-special practice in past three (3) years

• New patient to physician does not necessarily indicate new patient

• On call physician assumes the identify of provider covering• Location of service does not indicate new patient• ARNP/PA, physician extenders assume identify of the

practice/specialty of physician



8

LEVEL OF SERVICE ELEMENTSChief ComplaintChief reason for encounter as stated by the patient at the time of arrival/triage

HISTORY ELEMENTSAll 3 elements of history must be met for level assignedCC, ROS and PFSH may be listed as separate elements of history or included in description of HPI

HPI – History of Present IllnessDOCUMENTATION REQUIREMENTS:Information taken from the patient regarding details of the chief complaint such as:

- Duration - Timing - Associated Signs/Symptoms- Location - Quality - Modifying Factors- Severity - Context

• May be taken from HPI, ROS areas of History, but not PMH, FH, SH• Need not be stated in HPI section in order to count• No need to state twice in order to count as HPI and ROS elements

LEVEL OF SERVICE ELEMENTS(CONTD)ROS – Review of Systems

Questions asked and/or questions answered by patient about presenting problem/chief complaint and/or pertinent signs/symptoms present

DOCUMENTATION REQUIREMENTS:• Chief complaint may be utilized as ROS if restated in ROS section• May be taken from nursing notes if doc as reviewed by provider• May be taken from patient history form if doc as reviewed by provider• System(s) addressed in HPI may be utilized for ROS• Minimum of one (1) system pertinent/related to chief complaint must have minimal

statement to qualify as ROS• All others may be marked as:

all others negative otherwise negativeunremarkable otherwise unremarkable“0” negativeNo further remarkable none

• If one of above comments made in ROS without a minimum one (1) system (affected) identified as outlined above, no ROS elements are counted

• ROS obtained during earlier encounter does not need to be re-documented if evidence provider reviewed/updated previous information. May be documented by:

- describing any new ROS information or noting “no change”- noting the date/location of the earlier ROS

LEVEL OF SERVICE ELEMENTS (CONTD)

PFSH – Past Medical, Family, Social HistoryInformation taken regarding pertinent past historyPast Medical: Surgeries, hospitalizations, allergies, medicationsPast Social: Exposures, family living arrangements, sexual historyPast Family: Hx ca in family, other family hereditary conditions/problems

DOCUMENTATION REQUIREMENTS:• Must be pertinent to chief complaint in order to count

EXAMPLE: Chief complaint/HPI: Coronary artery diseasePFSH:

Maternal grandparents - + CAD, grandfather deceased 69Parents – father + heart attack age 51, deceased 57, heart attack

• May NOT be taken from HPI, ROS areas of History• May be taken from nursing notes or patient history form if doc as reviewed by provider• PFSH obtained during earlier encounter does not need to be re-documented if evidence

provider reviewed/updated previous information. May be documented by:- describing any new PFSH information or noting “no change”- noting the date/location of the earlier PFSH



9

LEVEL OF SERVICE ELEMENTS (CONTD)EXAMINATION ELEMENTS“Hands On” or observation of patient documented by provider

- 95/97 guidelines different for exam component, however, below guidelines should still be followed

- Either 95/97 guidelines may be utilized for a patient encounter, but not a combination of the two

DOCUMENTATION GUIDELINES:• Abnormal, relevant negative findings of the affected or symptomatic body area(s) or

organ system(s) should be documented• Notation of “abnormal” alone without elaboration is not sufficient• Brief statement of “negative” or “normal” sufficient for normal findings of pertinent

unaffected areas(s) or system(s)• Body systems should only be counted when clear that system was examined, otherwise,

count as body area(s)• Statement “deferred” for exam area will not be considered sufficient• Minimum of three (3) vital signs counts as exam area “constitutional” if documented as

reviewed by provider• Detailed exam requires “detailed” (minimum 2-3 statements) regarding affected

system(s) and additional statements regarding other systems (minimum of 2)*• Comprehensive exam requires minimum of eight (8) systems (not body areas) or

complete exam of one system as well as detailed exam requirements

* varies by carrier/statement


MEDICAL DECISION-MAKING ELEMENTSCulmination of the “thought” process of the provider comprised of:

- Diagnosis/Management Options- Amount/Complexity of Data- Risk of Mortality/Morbidity

2/3 elements must be met

DOCUMENTATION GUIDELINES:Diagnosis/Management OptionsFor each diagnosis/condition, an assessment, impression should be documented. If established problem, should indicate stable or worsening.Self Limited Does not require physician intervention

(no labs, x-rays, prescriptions)EX: Insect bite

Suture RemovalDressing Changes

Established Problem Previously diagnosedNo further tests/workup beyond physician evaluation to validate diagnosisWorsening – problem has increased in severity/intensityStable – problem same or improved


MEDICAL DECISION-MAKING ELEMENTS

DOCUMENTATION GUIDELINES: Diagnosis/Management Options (continued):

New Problem Problem not previously presentPrescriptions new and/or old do not constitute new problem

Treated as New Problems:- Chronic problem with new manifestations- New patient to Treating Provider and diagnosis not

assumed

Categorized as:No Additional Workup (no diagnostics ordered/performed))Need Additional Workup



10


MEDICAL DECISION-MAKING ELEMENTSDOCUMENTATION GUIDELINES: Amount/Complexity of Data Reviewed:Diagnostic/Therapeutic testing and/or reviewed w/documented medical necessity

Elements:LaboratoryRadiologyOther DiagnosticDiscussion Dx results with Performing MD

-Discussion of contradictory or unexpected tests resultsDecision to Obtain Records/Discussion of Case with Other than patient

-Discussion for purposes of obtaining additional history/informationReview/Summarization of Old Records/Discussion of Case with Other ProviderIndependent Visualization Image, Tracing, Specimen

-Personally review image, tracing or specimen to supplement information from physician who prepared interpretation/report

• Simple Notation “WBC elevated”, “Chest x-ray unremarkable” acceptable• Review of Dx/Ther may be documented by initialing/dating report that contains test results

acceptable• “Old Records Reviewed” or “Additional history from family” with no elaboration not sufficient

LEVEL OF SERVICE ELEMENTS (CONTD)MEDICAL DECISION-MAKING ELEMENTS

Risk of morbidity/mortality- Presenting Problem- Diagnostic Procedure(s)- Possible Management Options

Highest level of risk in any of the 3 categories (listed above) determines overall risk

DOCUMENTATION GUIDELINES: • Surgical or invasive dx procedures ordered, planned or scheduled that are documented

may be considered

• Prescription drug management may be counted as long as the documentation clearly indicates that decision-making took place whether discontinuing, changing, changing dosage or continuing medication

• Non-prescription strengths/medications would not be considered prescription drug management

All level of services information taken from:Medicare Learning Network – Evaluation and Management Services Guide1995/1997 Medicare Evaluation and Management GuidelinesOIG Coding Trends of Medicare Evaluation and Management Services, Released 2014

COMPLEXITIES OF SELECTING CORRECT E/M

TYPES/LEVELS



11

OTHER DOCUMENTATION DETERMINING E/M LEVEL

Not determined by “point” system alone. AlsoInvolves documentation of:

• Clinical judgment

• Standards of practice

• Chief complaint(s)

• Acute exacerbations/onsets of conditions/injuries

• Stability/acuity of patient

• Multiple medical co-morbidities

• Management of patient for specific date

• Overarching criteria

COMPLEXITIES OF TIME-BASED E/MS

COMPLEXITIES OF TIME-BASED E/M

DIFFERENT TYPES OF TIME-BASED E/Ms• E/Ms based solely on Time

• Codes Based on Time Duration of Counseling/Coordination of Care

• Average Time for E/M Visits



12

COMPLEXITIES OF E/MS BASED SOLELY ON TIME

Codes Driven Solely by Time• Critical Care• Discharge Services• Prolonged Services

Documentation Requirements• Specific guidelines must be met• Time must be documented by provider

Codes Based on Time Duration

Counseling/Coordination of Care

• Face to Face Visits• Non Face to Face Visits

Documentation Requirements:• Total Time Spent with Patient in conjunction with medical

decision-making involved

• Total time spent Counseling/Coordinating Care

• Description of coordination of care or counseling provided

Medicare Claims Processing Manual Chapter 30.6.1D

Average Time for E/M Visits

• CPT lists time guidelines for each E/M level of service

• These times do not determine the levels of coding except when instances of counseling/coordination of care are met

• Suggest average amount of time to provide a specific E/M service

• Assist physician in recognizing when prolonged services are provided for coding purposes



13

AVERAGE DURATION TIME FOR OFFICE/HOSP VISITSOFFICE HOSPITAL INPATIENT

AverageMinutes

New Patient

Established Patient

5 9921110 99201 9921215 9921320 9920225 9921430 9920340 9921545 9920460 99205

AverageMinutes Initial

Care

Subsequent Care

15 99231

25 99232

30 99221

35 99233

50 99222

70 99223

COMPLEXITIES OF E/MS WITH MODIFIERS

MODIFIER 25 OIG FOCUS ITEM

“Significantly separately identifiable E/M service when performed at the same time as another service/procedure”

• Documentation must support separate E/M after procedural notes are excluded

• Documentation of pre-operative/post-operative evaluation considered part of procedure

• May wish to document procedure separately from the E/M service to assist in distinguishing as “separately identifiable”

• Utilized for “minor procedures” (typically less than 30 day follow up – varies by carrier)



14

MODIFIER 25 (CONTINUED)Per CPT Assistant, March 2012, Volume 22, Issue 3, Page 4:

Common Overlapping Services (between procedure/visits)• Review Chart/Greet Patient• Review Results of Progress since Last Visit• Provide/Confirm Order based on progress• Provide follow-up instructions• Complete chart documentation

Modifier 25 Usage Checklist:- Was the physician’s E/M of the problem significant and

beyond the normal preoperative/postoperative work? E/M-25 appropriate

- Was the procedure/service scheduled before the patient encounter?E/M-25 not appropriate

MODIFIER 24 “Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period”

• E/M services performed during “global period”

• Other injuries/illnesses not related to the global period procedure

• Not “normal” uncomplicated postoperative care, typically diagnosis for the complication not the reason for the surgical procedure

• Medicare typically does not allow

MODIFIER 57 OIG FOCUS ITEM

Decision for Surgery• E/M service that resulted in initial decision to

perform “major” surgery

• Typically not paid by Medicare



15

COMPLEXITIES OF OVERARCHING CRITERIA

OVERARCHING CRITERIA

“Medical necessity of a service is the overarching criteria for payment in addition to the individual requirements for a CPT code. It would not be

medically necessary or appropriate to bill a higher level of evaluation and management 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.”

(Medicare Claims Processing Manual, Chapter 30)

ESTABLISHING AN OVERARCHING CRITERIA

Based on the following:• Elements of Levels of Service

- History, Exam and MDM- Presenting Problem

• Clinical Vignettes that correlate with similar medical scenarios

• Isolate characteristics that differentiate each level

• Develop practice-specific Overarching Criteria

• Receive provider input/approval

• Incorporate into practice Compliance Plan



16

99211 99212 99213 99214 99215History/Exam None Problem Focused Expanded Prob Focused Detailed ComprehensiveMDM None Straightforward Low Moderate High

Presenting Self-Limited/Minor Self-Limited/Minor Low to Moderate Severity Moderate to High Severity HighProblem Does not require presence

of MD

Vignettes -Vitamin B12 Injection -Mild skin cond on topicals -New skin outbreak on topicals -Generalized dermatitis -Mult chronic conditions w/

-Removal of Sutures -Ear pain w/drainage -Sched f/up stable chronic cond -New Onset Abdom Pain complaints,exacerbation-Lost Prescription -Chronic otitis media -Suspicious lesion, hx of malig -Increased pain/pain mgt pro -Ca for disc of treatment opt-Dressing Change -Eval for return to work -Surg follow up after PO period -Headaches on treatment -Onset syncopal episodes-Allergy Injection -Fup ENT Infection -Recurrent prostatitis -Extensive skin disorder -Progressive disease w/-Needs med documentation -Sore throat/Headache -Symptomatic lesion -Enteritis, Diarrhea, Fever symptoms-Return to work cert -Resolving M/S Sprain/Strain -Inflammation req change of meds-New Onset LBP -Chronic cond w/increasing-Check accuracy of home -Hemorrhoid complaints -HTN, mult med for recheck of BP -Hx Spine Surg w/back pain symptoms or increasing lack

equipment (BP/glucose) -Effectiveness of Rx Treat -Bleeding, Heavy Menses -Progressive Deformity of control-Supervised drug screen -Stable angina with calf pain -BPH/bladder obstruction -S/P surgery w/recurring

-Read TB skin test -Chronic cond w/unrel problemto discuss med

management or new symptoms-Prescription Refill -IDDM w/recent insulin changes -Sudden onset eye floaters-Instruction in Use of -S/P Angio, new onsethome equipment (peak

flow) extremity claudication-Chronic cond eval treatment-Sch f/up chronic condition

w/new related complaint

Level No Treatment/No Rx Body area focused prob Limited Treatment (EX: Rx only) Moderate Treatment Comprehensive/Mult TreatmentCharacteristics No Diagnostics Minimal Treatment (EX: Rx only) Workup Req for Diagnosis

Limited/No MD Involve No Diagnostics or to eval/re-evaluate condition Extensive Diagnostics Comprehensive DiagnosticsIn/Out, No Workup No Workup Needed to (lab, x-ray and/or EKG) (Plain Film X-ray, and Lab (Plain Film X-Ray, Lab, EKG

Determine Dx and/or EKG OR AND Others or MultipleRechecks MRI, US, CT) Referral to SpecialistWound Checks Multiple System Eval Comprehensive System EvalImmunRX OnlyDressing Changes Extensive labs pertinent to

Multiple Chronic or CurrentProblems Being Evaluated

COMPLEXITIES OF E&M DOCUMENTATION IN THE EMR/ELECTRONIC RECORD

COMPLEXITIES OF DOCUMENTATION IN THE EMR/ELECTRONIC RECORD

• Copy and Paste

• Cloning

• Information Gathered During Current Encounter/Previous Encounter



17

CLONING AND EMRS

With the introduction of EMR (electronic medical records) the capability of “carry over”, repetitive “fill ins” and cloning has become prevalent

• Only medically necessary information is considered

• Cloning is defined as “when each entry in the record is worded exactly like or similar to previous entries”

• Cloning also occurs when medical documentation is exactly the same from one patient to another

• Cloning of documentation is considered a misrepresentation of medical necessity requirement for coverage of services.

CLONING AND EMRS (CONTINUED)

Effects of Cloning Records:• “Copy and paste”, “Cloning”, “Carrying forward” –

has the same effect on the integrity of the medical record - contradictions in a patient’s record

• Credibility of the record is compromised. Auditor unable to determine what is accurate/how much work was done on one visit versus another.

• First Coast Service Options (the Florida MAC) prohibits the practice of cloning in the 2006 Medicare Part B newsletter

• First Coast further states that discovery of this type of documentation would “result in denial of services for lack of medical necessity and recoupment of all overpayments made”.

IS YOUR PRACTICECOMPLIANT?

Signs/Symptoms of Non-Compliance• No overarching criteria

• “Bell Curve” outside standard parameters

• Inquiries from carriers for documentation to support level of service assigned

• Routine “downcoding” by carriers

• RAC or other 3rd party requests



18

TOOLS TO INSURE COMPLIANCE

• Method for recording/validating consistency of E & M level assignments

E & M “Leveling” tool (example attached)

• Overarching Criteria

• Practice-Specific Guidelines for E & M Complexities

QUESTIONS????

Contact Information:Marsha S. Diamond, CPC, COC, CCS, CPMA

[email protected]



Topics for Today’s Discussion - University of Florida · PDF file ·...

Documents

Transcript of Topics for Today’s Discussion - University of Florida · PDF file ·...