Evaluation and Management Coding Risk Revisited
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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
- 3. Page 2August 21, 2013 Prepared for Northeast GA Local Chapter AAPC Risk Factors Provider • Documentation • Coding Coder Biller Auditor • Billing • Education Payor State • Audit • Risk Guidelines Education Interpretation
- 4. Page 3August 21, 2013 Prepared for Northeast GA Local Chapter AAPC Provider Auditor Coder Biller Incentives
- 5. Page 4August 21, 2013 Prepared for Northeast GA Local Chapter AAPC 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
- 6. Page 5August 21, 2013 Prepared for Northeast GA Local Chapter AAPC Factors Influencing Provider Coding Physician Behavior Incentives: Work RVU Based Compensation Compliance Risk Financial Risk
- 7. Page 6August 21, 2013 Prepared for Northeast GA Local Chapter AAPC Work RVU Based Compensation Impact to E/M • Financial Risk – Up-coding – Increase Frequency of Visits • Ineffective Resource Utilization – NPP practice flow
- 8. Page 7August 21, 2013 Prepared for Northeast GA Local Chapter AAPC 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
- 9. Page 8August 21, 2013 Prepared for Northeast GA Local Chapter AAPC Compensation Mitigating Risk • Work RVUs the Wrong Incentive? • Mitigating Risk – Quality Metric Bonus Structures – Routine Audits – Overpayment Deductions
- 10. Page 9August 21, 2013 Prepared for Northeast GA Local Chapter AAPC Provider Documentation Coding Billing Risk
- 11. Page 10August 21, 2013 Prepared for Northeast GA Local Chapter AAPC General Medical Record Documentation • Methods – Handwritten – Scribe – Dictation (Dictaphone, Dragon) – EHR
- 12. Page 11August 21, 2013 Prepared for Northeast GA Local Chapter AAPC Templates • Overall – Treated as a checklist • Handwritten – Checkboxes • Scribe – Knowledgebase • Dictation (Dictaphone, Dragon) – Errors – Conflicts • EHR – Dictation/Scribe/Dragon – Over-documentation – Conflicts – Copy/Paste
- 13. Page 12August 21, 2013 Prepared for Northeast GA Local Chapter AAPC 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
- 14. Page 13August 21, 2013 Prepared for Northeast GA Local Chapter AAPC 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
- 15. Page 14August 21, 2013 Prepared for Northeast GA Local Chapter AAPC 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.
- 16. Page 15August 21, 2013 Prepared for Northeast GA Local Chapter AAPC 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.
- 17. Page 16August 21, 2013 Prepared for Northeast GA Local Chapter AAPC 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.
- 18. Page 17August 21, 2013 Prepared for Northeast GA Local Chapter AAPC 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
- 19. Page 18August 21, 2013 Prepared for Northeast GA Local Chapter AAPC 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
- 20. Page 19August 21, 2013 Prepared for Northeast GA Local Chapter AAPC 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
- 21. Page 20August 21, 2013 Prepared for Northeast GA Local Chapter AAPC 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
- 22. Page 21August 21, 2013 Prepared for Northeast GA Local Chapter AAPC Coder Biller Auditor Guidelines Payor State Education
- 23. Page 22August 21, 2013 Prepared for Northeast GA Local Chapter AAPC 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
- 24. Page 23August 21, 2013 Prepared for Northeast GA Local Chapter AAPC 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)
- 25. Page 24August 21, 2013 Prepared for Northeast GA Local Chapter AAPC 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
- 26. Page 25August 21, 2013 Prepared for Northeast GA Local Chapter AAPC 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
- 27. Page 26August 21, 2013 Prepared for Northeast GA Local Chapter AAPC Auditor vs. Auditor Auditor Auditor
- 28. Page 27August 21, 2013 Prepared for Northeast GA Local Chapter AAPC 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
- 29. Page 28August 21, 2013 Prepared for Northeast GA Local Chapter AAPC E&M Elements Key Elements • History • Exam • Medical Decision Making Contributory Elements • Counseling • Coordination of care • Nature of presenting problem • Time
- 30. Page 29August 21, 2013 Prepared for Northeast GA Local Chapter AAPC 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
- 31. Page 30August 21, 2013 Prepared for Northeast GA Local Chapter AAPC Tip: If unable to obtain history, note reason.
- 32. Page 31August 21, 2013 Prepared for Northeast GA Local Chapter AAPC 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
- 33. Page 32August 21, 2013 Prepared for Northeast GA Local Chapter AAPC 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
- 34. Page 33August 21, 2013 Prepared for Northeast GA Local Chapter AAPC 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
- 35. Page 34August 21, 2013 Prepared for Northeast GA Local Chapter AAPC Payor State Rules Audit Findings Oversight Responsibility Education
- 36. Page 35August 21, 2013 Prepared for Northeast GA Local Chapter AAPC 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
- 37. Page 36August 21, 2013 Prepared for Northeast GA Local Chapter AAPC 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)
- 38. Page 37August 21, 2013 Prepared for Northeast GA Local Chapter AAPC 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.
- 39. Page 38August 21, 2013 Prepared for Northeast GA Local Chapter AAPC 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.
- 40. Page 39August 21, 2013 Prepared for Northeast GA Local Chapter AAPC 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 .
- 41. Page 40August 21, 2013 Prepared for Northeast GA Local Chapter AAPC 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
- 42. Page 41August 21, 2013 Prepared for Northeast GA Local Chapter AAPC 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
- 43. Page 42August 21, 2013 Prepared for Northeast GA Local Chapter AAPC Questions?
- 44. Page 43August 21, 2013 Prepared for Northeast GA Local Chapter AAPC 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
- Modifier
- http://www.cahabagba.com/part-b/education/evaluation-and-management-services-information-center/
- 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
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