# Help I Need some Advice



## jfuller@cwc4women.com

We have an EMR system and the physicians pretty much code their own visits.  They are OB/GYN's.
Recently, I received a request from Insurance for the office notes.  The visit had already been paid and it was for a preventive visit (ie; well woman exam).  Upon reviewing the visit I noted that the patient actually came in for chief complaint of "infertility".  The HPI was all about her infertility.  The comments were all about her infertility. Although the physician did an exam, including breast, pelvic and a pap.  The only mention of well woman exam was her diagnosis code and the cpt code.  There was no age appropriate counseling.
I brought this to her attention and asked her what was up. 
Her reply was that she could not do anything for the infertility and the patient was due for an annual, so she did it.  I told her she should have documented this fact somewhere in the visit.  
Our new practice administrator intervened and said "the notes look fine to me" and the exam meets the preventive well woman exam, so she over rode my recommendations and told the doctor I was wrong.
I fear a savvy auditor will take back payment and request we code this as an E/M with a diagnosis of "infertility" and of course the patient does not have coverage for this.
I had other billers/coders blind code the chart and none of them came up with a well woman exam.
Am I correct to be concerned?
Thanks, 
Joni Fuller


----------



## btadlock1

jfuller@cwc4women.com said:


> We have an EMR system and the physicians pretty much code their own visits.  They are OB/GYN's.
> Recently, I received a request from Insurance for the office notes.  The visit had already been paid and it was for a preventive visit (ie; well woman exam).  Upon reviewing the visit I noted that the patient actually came in for chief complaint of "infertility".  The HPI was all about her infertility.  The comments were all about her infertility. Although the physician did an exam, including breast, pelvic and a pap.  The only mention of well woman exam was her diagnosis code and the cpt code.  There was no age appropriate counseling.
> I brought this to her attention and asked her what was up.
> Her reply was that she could not do anything for the infertility and the patient was due for an annual, so she did it.  I told her she should have documented this fact somewhere in the visit.
> Our new practice administrator intervened and said "the notes look fine to me" and the exam meets the preventive well woman exam, so she over rode my recommendations and told the doctor I was wrong.
> I fear a savvy auditor will take back payment and request we code this as an E/M with a diagnosis of "infertility" and of course the patient does not have coverage for this.
> I had other billers/coders blind code the chart and none of them came up with a well woman exam.
> Am I correct to be concerned?
> Thanks,
> Joni Fuller





For a visit to be considered a Preventive exam, there has to be age and gender appropriate counseling/anticipatory risk factor reduction interventions documented, per CPT definition. Period. Without that, all you have is a problem-oriented E/M for infertility, which wouldn't warrant anything higher than a 99212. Now, what qualifies as "counseling" may be open to interpretation. Sometimes I see notes that just say "Counseled patient regarding current medications", or if they suggested a diet/exercise regimen, suggested that the patient quit smoking, or advised them to watch out for future heath issues (and it's documented, of course), then I'll give credit for it. I'd have to see evidence of a routine/annual exam, such as routine labs, and also an extensive history and exam. The "comprehensive" definition of preventive visits isn't equivalent to "Comprehensive" for sick visits, so it's difficult to quantify, but I would expect to see the usual elements, such as ascultation of heart and lungs, at least. 

The physician should use caution when changing visit-types halfway through, to ensure that they meet all of the documentation requirements for the exam that they're going to bill. If an auditor reviews a chart and gets the impression that the doctor was just trying to spin a non-covered service and label it a 'well check', they will downcode it to whatever it scored, at minimum. If they decide that the doctor was intentionally aiming to deceive the insurer to collect improper payment, the doctor could be inviting a fraud investigation from the OIG. 

I imagine that this doctor probably views documentation requirements as a pointless and time-consuming formality, which is unfortunate. I haven't seen the records, but I understand your position. In my experience, it's difficult to get some physicians to understand why good documentation is so important - beyond their own self-interests (re: payment). The best you can do is get the clinical coverage criteria for a routine/well woman exam from the patient's insurer (its usually on their website), and point out how your doctor's note falls short, if it eventually does. If they still want to gamble their practice over the price of an office visit, there's not much else you can do - it's their money.


----------



## melzinser

I agree with everything except the comment, "all you have is a problem-oriented E/M for infertility, which wouldn't warrant anything higher than a 99212."  I don't understand how infertility automatically equals a low level visit.  The work-up, including history and exam, can be quite extensive, as well as complex medical dedision making, involving ordering additional testing and discussing different courses of treatment.  Even if it is a non-covered diagnosis, I would code the visit based on the services documented.


----------



## btadlock1

Medical necessity is the overarching criterion when determining the level of service, in addition to the key components required by the CPT descriptor. It wouldn't be appropriate to bill a higher level of service than was medically necessary to address the nature of the presenting problem, even if the documentation requirements have been satisfied. Inferitility is not an acute illness or injury that poses significant risk to the patient's life or bodily functions if untreated. The visit described here has straightforward MDM - the doctor couldn't do anything about the infertility. Had the doctor scheduled the patient for diagnostic procedures, prescribed _some_ sort of treatment, or done_ anything _more than just basically having a chat with the patient about her infertility, then the visit _might_ have qualified for a 99213. I wouldn't assign this type of minor problem a 99214 or 99215 in any situation, without further complications documented (like a co-morbidity to consider, if a prescription was given), because Trailblazer (our MAC) has explicitly said to never assign a level 4 or 5 E/M, unless the patient's condition has at *least *a 50/50 chance of worsening without treatment.


----------



## jfuller@cwc4women.com

*thank you*

Thank you very much for the confirmation.  I agree.  Always like to have more than just my professional opinion when dealing with others with billing experience.  Much of what I do is automatic and judgement calls from years of experience and knowledge, and yes mistakes along the way.
So thank you again.
Joni


----------



## eadun2000

btadlock1 said:


> Medical necessity is the overarching criterion when determining the level of service, in addition to the key components required by the CPT descriptor. It wouldn't be appropriate to bill a higher level of service than was medically necessary to address the nature of the presenting problem, even if the documentation requirements have been satisfied. Inferitility is not an acute illness or injury that poses significant risk to the patient's life or bodily functions if untreated. The visit described here has straightforward MDM - the doctor couldn't do anything about the infertility. Had the doctor scheduled the patient for diagnostic procedures, prescribed _some_ sort of treatment, or done_ anything _more than just basically having a chat with the patient about her infertility, then the visit _might_ have qualified for a 99213. I wouldn't assign this type of minor problem a 99214 or 99215 in any situation, without further complications documented (like a co-morbidity to consider, if a prescription was given), because Trailblazer (our MAC) has explicitly said to never assign a level 4 or 5 E/M, unless the patient's condition has at *least *a 50/50 chance of worsening without treatment.



I got this link from my local chaper for CEUS.  Heck, free CEU's.. for sure!!!!!  Anyways I went to it and it was VERY informative on leveling visits.  Everybody might want to look at it.. and you get free CEU's.  There are two of them just on leveling and both offer 1 free CEU each.  The link is:  https://www.highmarkmedicareservices.com/cptdisclaimer.html 
I hope this helps somebody.  

Emily


----------



## RebeccaWoodward*

I can tell you that infertility is not straightforward.  These type of visits can result in lengthy, complicated counseling sessions.  We have a fertility practice and I personally audit these records.  Grant it, the session does include recommendations for complicated testing and treatment. Many of these visits are coded based on time due to the length of the counseling sessions.


----------



## btadlock1

*I think I'm miscommunicating here...*

I'm not saying that _every_ infertility visit is simple and straightforward...just *this one*, and only because the doctor didn't actually do anything to try to address it. 

Here's where I'm getting all of this:
http://www.trailblazerhealth.com/Publications/Questions and Answers/E-MWBTQA09-30-09.pdf
"Question: Referring to the “Coding Evaluation and Management Services” notice dated September 11, 2009, do we need three or four distinct medical conditions to bill the highest two codes in any family?
Answer: Medical necessity is a requirement for Medicare payment of all Evaluation and Management (E/M) services (with few exceptions). Level of service is affected by medical necessity. Even if key component work or time/counseling and coordination (when appropriate) are documented for a higher level of service, do not report a high code if medical necessity for the higher code is not demonstrated. The nature of the patient's presenting problem and the related conditions for which the physician performed E/M work drive the medical necessity determination. Accordingly, severity of illness and number of illnesses dictate complexity of work required by the physician.

Do not consider reporting the highest two codes of any code family (levels four and five in five-level families, or levels two and three in three-level families) when:
The physician evaluated and managed fewer than three distinct medical conditions/complaints during the encounter and no one problem evaluated and managed, without appropriate intervention, conferred at least a 50/50 likelihood of worsening, disability or death between the time of the current encounter and the next physician encounter.

Do not consider reporting the highest code (level five of five-level families or level three of three-level families) of any code family when:
The physician evaluated and managed fewer than four distinct medical conditions/complaints during the encounter and no one problem evaluated and managed, without appropriate intervention, conferred at least a 50/50 likelihood of worsening, disability or death between the time of the current encounter and the next physician encounter."

and...

http://www.trailblazerhealth.com/Publications/Job Aid/DocumentingComponentsEOV.pdf

"Medically Reasonable and Necessary
The law requires all payments (with only a few exceptions) made by Medicare to be for medically reasonable and necessary services. Medicare determines “medically reasonable and necessary” separately from determining that the work described by a reported CPT code was performed. For E/M services, the medical record documentation must demonstrate that the practitioner performed the reported E/M service as it is described in the CPT book and as required by CMS E/M Documentation Guidelines. Additionally, it must support the intensity and frequency of the E/M service met but that it did not exceed the patient's clinical needs. Information within the medical record about the patient's condition, not the diagnosis alone, determines the level of service payable by Medicare. In keeping with federal law, Medicare must deny or downcode E/M services that, in its judgment, exceed the patient's documented needs.

Documenting Medical Necessity
The patient's condition (severity, acuity, number of medical problems, etc.) is the key factor in determining medical necessity for Medicare payment for services. Providers who report E/M services for Medicare payment must ensure their records describe the patient's condition and reason for the visit in enough detail for a reasonable observer to understand the patient's need. Providers must also ensure the nature of the patient's presenting problem and/or status is consistent with the level of service reported. Unfortunately, practitioners often include unnecessary material while failing to record clinically pertinent information needed todetermine medical necessity of the service. The service should be coded based on the clinical needs of the patient.

Level of Service
The E/M code chosen must reflect both work performed and medical necessity. Though an E/M service may code to a high level based on the documentation of key component work, it is inappropriate to request Medicare payment when the patient's effective management does not require the code's work.

Because of this unique dependence on the information contained in the MDM component, even though a medical record might contain a perfectly complete history and examination, without a correspondingly complex MDM there may be no justification for payment of a high-level E/M service. In fact, without adequate record of physician impressions and planned diagnostic/therapeutic intervention, the encounter might be rendered of no clinical benefit at all and not payable at any level."


----------



## rthames052006

eadun2000 said:


> I got this link from my local chaper for CEUS.  Heck, free CEU's.. for sure!!!!!  Anyways I went to it and it was VERY informative on leveling visits.  Everybody might want to look at it.. and you get free CEU's.  There are two of them just on leveling and both offer 1 free CEU each.  The link is:  https://www.highmarkmedicareservices.com/cptdisclaimer.html
> I hope this helps somebody.
> 
> Emily



Highmark Medicare is my carrier as well but this info in the link may not be of help to other coders who are not in J12, they must follow their carriers advice.  I know Trailblazer is pretty tough on their requirements for e/m.  

Although I do feel that anyone in the J12 districts would benefit from the HMS link you've provided.


----------



## RebeccaWoodward*

btadlock1 said:


> I'm not saying that _every_ infertility visit is simple and straightforward...just *this one*, and only because the doctor didn't actually do anything to try to address it.
> 
> Here's where I'm getting all of this:
> http://www.trailblazerhealth.com/Publications/Questions and Answers/E-MWBTQA09-30-09.pdf
> "Question: Referring to the “Coding Evaluation and Management Services” notice dated September 11, 2009, do we need three or four distinct medical conditions to bill the highest two codes in any family?
> Answer: Medical necessity is a requirement for Medicare payment of all Evaluation and Management (E/M) services (with few exceptions). Level of service is affected by medical necessity. Even if key component work or time/counseling and coordination (when appropriate) are documented for a higher level of service, do not report a high code if medical necessity for the higher code is not demonstrated. The nature of the patient’s presenting problem and the related conditions for which the physician performed E/M work drive the medical necessity determination. Accordingly, severity of illness and number of illnesses dictate complexity of work required by the physician.
> 
> Do not consider reporting the highest two codes of any code family (levels four and five in five-level families, or levels two and three in three-level families) when:
> The physician evaluated and managed fewer than three distinct medical conditions/complaints during the encounter and no one problem evaluated and managed, without appropriate intervention, conferred at least a 50/50 likelihood of worsening, disability or death between the time of the current encounter and the next physician encounter.
> 
> Do not consider reporting the highest code (level five of five-level families or level three of three-level families) of any code family when:
> The physician evaluated and managed fewer than four distinct medical conditions/complaints during the encounter and no one problem evaluated and managed, without appropriate intervention, conferred at least a 50/50 likelihood of worsening, disability or death between the time of the current encounter and the next physician encounter."
> 
> and...
> 
> http://www.trailblazerhealth.com/Publications/Job Aid/DocumentingComponentsEOV.pdf
> 
> "Medically Reasonable and Necessary
> The law requires all payments (with only a few exceptions) made by Medicare to be for medically reasonable and necessary services. Medicare determines “medically reasonable and necessary” separately from determining that the work described by a reported CPT code was performed. For E/M services, the medical record documentation must demonstrate that the practitioner performed the reported E/M service as it is described in the CPT book and as required by CMS E/M Documentation Guidelines. Additionally, it must support the intensity and frequency of the E/M service met but that it did not exceed the patient’s clinical needs. Information within the medical record about the patient’s condition, not the diagnosis alone, determines the level of service payable by Medicare. In keeping with federal law, Medicare must deny or downcode E/M services that, in its judgment, exceed the patient’s documented needs.
> 
> Documenting Medical Necessity
> The patient’s condition (severity, acuity, number of medical problems, etc.) is the key factor in determining medical necessity for Medicare payment for services. Providers who report E/M services for Medicare payment must ensure their records describe the patient’s condition and reason for the visit in enough detail for a reasonable observer to understand the patient’s need. Providers must also ensure the nature of the patient’s presenting problem and/or status is consistent with the level of service reported. Unfortunately, practitioners often include unnecessary material while failing to record clinically pertinent information needed todetermine medical necessity of the service. The service should be coded based on the clinical needs of the patient.
> 
> Level of Service
> The E/M code chosen must reflect both work performed and medical necessity. Though an E/M service may code to a high level based on the documentation of key component work, it is inappropriate to request Medicare payment when the patient’s effective management does not require the code’s work.
> 
> Because of this unique dependence on the information contained in the MDM component, even though a medical record might contain a perfectly complete history and examination, without a correspondingly complex MDM there may be no justification for payment of a high-level E/M service. In fact, without adequate record of physician impressions and planned diagnostic/therapeutic intervention, the encounter might be rendered of no clinical benefit at all and not payable at any level."



This is good information but you have to remember one thing...Infertility isn't going to be driven by Medicare's guidelines; although many carriers hold Medicare as the golden standard.  Infertility is a unique specialty and the guidelines will be driven by commerical carriers; if at all since many carriers do not provide coverage for infertility beyond the first visit.


----------



## MMAYCOCK

*Infertility medical management*

I agree with Rebecca.

Brandi, what are the guidelines in your district for timebased coding? I do not see any mention of that in your post. I could have missed it. 

Even if you are only going to cling to Medicare guidelines, I would think that infertility is exactly the type of DX that was in mind when they came up with the time-based coding guidelines. 

There are times when the "medical necessity" as defined cannot be identified however the treatment/counseling is no less complex and detailed. 

We make it a practice to first check for a medical necessity code and when the scope of the work cannot be documented and billed under that, we owe it to the providers and the patients to fairly code it based on time if the factors are there.

This may garner some feedback, but in my opinion, especially in reading posts on this site, some coders seem to take pride in "keeping it low". 

Unreasonable and ill-defined reasoning for that goal is one of the chief reasons there is often such friction between coders and providers. 

Even though there is a way to achieve a better reimburseemnt for the provider it is ignored in favor of defending a lower code. That is not, in my opinion, the way a coder should function. 

Let's be a part of the solution


----------



## btadlock1

MMAYCOCK said:


> I agree with Rebecca.
> 
> Brandi, what are the guidelines in your district for timebased coding? I do not see any mention of that in your post. I could have missed it.
> 
> Even if you are only going to cling to Medicare guidelines, I would think that infertility is exactly the type of DX that was in mind when they came up with the time-based coding guidelines.
> 
> There are times when the "medical necessity" as defined cannot be identified however the treatment/counseling is no less complex and detailed.
> 
> We make it a practice to first check for a medical necessity code and when the scope of the work cannot be documented and billed under that, we owe it to the providers and the patients to fairly code it based on time if the factors are there.
> 
> This may garner some feedback, but in my opinion, especially in reading posts on this site, some coders seem to take pride in "keeping it low".
> 
> Unreasonable and ill-defined reasoning for that goal is one of the chief reasons there is often such friction between coders and providers.
> 
> Even though there is a way to achieve a better reimburseemnt for the provider it is ignored in favor of defending a lower code. That is not, in my opinion, the way a coder should function.
> 
> Let's be a part of the solution



I get the feeling that I'm offending some of you - sorry! I'm really not trying to. I don't disagree with Rebecca, and I'm not looking for an argument, but I'm not going to back down on my opinion of this issue. Somehow we've gotten off of the topic of the original post, which was a single visit about infertility that morphed into a well-check at the last minute; I didn't mention anything about coding based on time, because it's not a factor in *this particular situation* - the point of the post was that the provider documented NO counseling. However, if that kind of information were documented, I'd be _all for _assigning a code that would appropriately describe the services rendered. 

"Keeping it low" should not be a goal for coders - 'keeping it _accurate_', should. If the doctor did the work and documented it correctly, then they should be compensated fairly; but we should not try to make any encounter out to be _greater_ than it actually was, for the sake of reimbursement. Although Medicare won't be adjudicating this claim (probably not any claim relating to infertility, really - I can't think of too many 65 year olds trying to get pregnant, but I'm sure they're out there...), the fact remains that commercial payers recognize and utilize CMS documentation guidelines in their payment policies, and their requirements are certainly not more forgiving. Coding a visit at a higher level just because CMS is never going to see it isn't a practice I'd recommend. Abusive billing practices are abusive billing practices, no matter which arena they're in.

To be perfectly clear, I'm talking about _this_ encounter, not all encounters. I have no problem with doctors getting paid. But, if* this patient *came in for infertility, and the provider didn't document *any* counseling, or the amount of time spent in a discussion, or anything that suggested that their medical decision making had even the slightest degree of complexity, such as plans to find the cause of, or manage the infertility - then it would not be appropriate to assign a high level problem-oriented E/M, or a preventive E/M...even if most encounters for infertility _usually_ warrant a higher level of service. Documentation requirements aren't arbitrary rules created to make doctors' jobs harder - they are designed to make sure that the *minimum* amount of information needed to understand the patient's problem, and the doctor's impressions and treatment plan for that problem, are recorded at *every *visit, in case someone else ever needs to know, and they're not around to ask. The only way to enforce those (perfectly reasonable) rules, is to link them to reimbursement. If the doctor feels that they should be paid more, then they should reflect that in their documentation, and not rely on coders to 'get creative' with their code assignments. It's part of their job, whether they like it or not; it's not our place to help them find a way to circumvent the system and get paid full price for only doing half of the work they're supposed to do. We're coders, not corporate tax attorneys.


----------



## MMAYCOCK

"It's part of their job, whether they like it or not; it's not our place to help them find a way to circumvent the system and get paid full price for only doing half of the work they're supposed to do. We're coders, not corporate tax attorneys. "

That's the attitude I'm referring to. If we are the ones who study it, why wouldn't it be our job to help them? Why would you consider it circumventing the system to help the provider learn how to make the necessary documentation changes? Why is that even the assumption made from my post? Are the only choices you see "keep it low" or "circumvent the system"? 
Imagine if we went to a doctor with the same perspective on care. 
This superior attitude is really at the root of the problem between providers and coders. I'm not offended and I'm not looking for a fight either. Just that the root of the issue in the responses here is so often reflected in other posts that I wanted to address it.


----------



## btadlock1

MMAYCOCK said:


> That's the attitude I'm referring to. If we are the ones who study it, why wouldn't it be our job to help them? Why would you consider it circumventing the system to help the provider learn how to make the necessary documentation changes? Why is that even the assumption made from my post? Are the only choices you see "keep it low" or "circumvent the system"?
> Imagine if we went to a doctor with the same perspective on care.
> This superior attitude is really at the root of the problem between providers and coders. I'm not offended and I'm not looking for a fight either. Just that the root of the issue in the responses here is so often reflected in other posts that I wanted to address it.



The only choice I see it 'do it right'. Not keep it low, not circumvent the system - code based on what is there, not what _should_ be there. It is our job to educate providers on documentation requirements, not to help them by ignoring the requirements.

But you're right; it's not fair for me to assume that you were advocating upcoding in your post. There has to be a balance between maximizing reimbursement and maintaining compliance, and no one-size-fits-all attitude will ever be able to achieve that goal. One should not be sacrificed in the interest of the other, and sometimes that means that there will be disagreements between providers and coders, as to whether or not the documentation makes the grade to reach the reimbursement that's desired. If having that belief makes me an elitist who's part of the problem, then I guess I know where I stand. But I'm not going to apologize for thinking that rules weren't made to be broken, and I'm sure that I'll continue to convey that 'superior' message in future posts. You're welcome to disagree - it's a free country, and you're entitled to your opinion, too.


----------



## MMAYCOCK

I never doubted you would continue in your vein. You make it sound very noble. Happy coding to everyone!


----------



## btadlock1

Duly noted.


----------

