# Questions resulting from recent educational audit



## hkatie

We recently completed an in-house documentation review and several questions came up which I'm hoping you folks help me with.  If you would prefer to just point me in the right direction, that's fine too.



1. Is CPT's "Decision Tree for New vs Established Patients" absolute?  If a doctor saw a patient four years ago, but would still like to bill the patient as an established patient, is that okay?  I found CMS' statement on it, but I'm wondering what others' perspective is.  I have a physician who would like to  to choose.


2. I recently took an auditing workshop run by the AAPC during which I was given a rough guide to selecting risk from the DG's Table of Risk.  It was suggested (as a starting place only) to put surgeries with a 10 day global period in the "Low" category and those with a 90 day global period in the "Moderate" category.  I have one physician who has deep misgivings about this approach and feels that "Moderate" is a better starting place for all surgeries, including liquid nitrogen destructions (we are a derm practice.)  Any thoughts?



3. Although prescription drug management falls on the "Moderate" level of the Table of Risk, would it be fair to put Accutane, methotrexate, and gabapentin on the "High" level given that they are used for "one or more chronic illnesses with severe... side effects of treatment"?



4. In determing complexity of MDM, we used the Marshfield tool.  One physician wanted to know if there was anywhere he could "score" more points when he invites his partners into an exam room to discuss a challenging case.  Any thoughts?



5. In counting exam bullets, can a bullet be counted as complete if some, but not all, of the elements of that bullet are documented?  (i.e. would I count "eyelids" if that is all that is documented or does it specifically have to say in the chart "eyelids and conjuctivae"?)

Thanks in advance for any help.  I do so appreciate it.


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## andersee

1. Wow - normally people want to bill higher, not lower, than they should. I would question why the physician wants to short change himself. And, yes, those rules are absolute. It would be considered a coding error in an audit.
2. That's an interesting proposal but I don't think it would work for all scenarios.
3. Accutane, methotrexate, etc could fall under drugs intensive monitoring. Use of these drugs usually requires frequent, ongoing labwork to check for toxicity.
4. I don't know what the Marshfield tool is but he might be able to get a point under data with "discuss results with testing dr" if that is applicable. That's a tough one to get "credit" for.
5. Funny enough, I just read in the Coding Answer book about this very question. Check out page 15316 for the answer. Basically the answer is "yes but".

Erin


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## hkatie

Erin, 

Thanks so much for your reply.  I don't have access to Coding Answer book, but I'll find something to bring to my physician.  2009 was quite a year for me, professionally speaking.  I've spent a lot of time in various departments, including billing, in my derm office over the years, but I felt uncomfortable about my lack of solid knowledge when I started working with the coding sets.  I went from simply requesting increased education in March 09 to certified coder by August.  I've learned a lot just by reading these boards-I don't have an on-site mentor so I'm taking as many webinars, seminars, and classes as I fit in.  Thanks again for your help.

Katie


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## andersee

Here is the passage from CAB: " For example,'examination of the spleen was unremarkable, examination of the liver was deferred" would not fulfill the requirements for the element "examination of liver and spleen," whereas "examination of the spleen was unremarkable" would fulfill the documentation requirements." Pretty tricky, eh?


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## fredabrinson

*Great discussions!*

Hey Katie,

Isn't it funny how we can work in this field and yet still get stumped by situations on an almost daily basis?!  I understand exactly how you feel!

Regarding your specific questions:

1.  AMA states and CMS agrees that a patient can be considered new if not seen in the previous three years.  That being said, if your physician doesn't want to bill an established patient as a new patient, I would not "force" him/her to do so, but what I would force would be that this be made into a written policy and that it is applied to every single patient.  The physician cannot decide which patients would get the established charge and which would get the new patient charge.  That would be very wrong. 

Regarding your questions on MDM, this is one area that is entirely up to the physician or physician extender.  I would certainly allow a physician to make those decisions.  As coders and auditors, we should not tell a physician what the MDM level is.  As long as their documentation supports their decision, I would always allow this to be the MDM level.

I would also allow for the bullet to be counted if most of the elements within the bullet are met.   

Please understand that these are my opinions!

Good luck!!


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## codecrazy

*Coding Answer Book?*

What is the "Coding Answer Book"?  I never heard of it, but it sounds very interesting.


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## FTessaBartels

*I'll try to answer*

1. It's clearly a new patient ... more work is involved in taking the history and exam and in your medical decision making because you haven't been following the patient regularly. That being said, if your doc insists ... be sure to have a written policy in place that you consider "established" patients to be anyone who has received face-to-face services within the last x years (can't be LESS than what CPT says ... so at minimum 3 years) and apply that standard uniformly to all patients.

2. The table of risk is pretty clear. "Minor surgery with no identified risk factors" is LOW.  The physician must specify the risk factors (risk to the patient for surgery, not just risk OF performing surgery ... e.g. diabetes or previous problem with anesthesia or bleeding disorder).

3.  I'm usually in the minority here, but to me "*intensive* monitoring" is the kind provided in a hospital or office suite with continuous monitoring over a period of time.  ANY drug needs to be monitored for toxicity ... even Tylenol will kill you if you overdose. 

4. Check the Data points - 2 data points awarded for "discussion of case with another health care provider"  Or, on the table of risk - Moderate for "undiagnosed new problem with uncertain prognosis" might fit the scenario.

5. That's why I like the 1995 guidelines!  When 1997 guidelines use the word "and" it means everything must be done to count the bullet. 

Remember though, that the guidelines are just that - guidelines -* not *law.  They are open to interpretation. Your practice should have a compliance plan in place that includes any specific guidelines that you follow. Any outside auditor will always ask to see that plan and your own practice protocols.  Have them in writing, and follow them consistently. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## abishard

See answers below:



khanninen said:


> We recently completed an in-house documentation review and several questions came up which I'm hoping you folks help me with.  If you would prefer to just point me in the right direction, that's fine too.
> 
> 
> 
> 1. Is CPT's "Decision Tree for New vs Established Patients" absolute?  If a doctor saw a patient four years ago, but would still like to bill the patient as an established patient, is that okay?  I found CMS' statement on it, but I'm wondering what others' perspective is.  I have a physician who would like to  to choose.
> 
> Answer: I agree with the above. It would be incorrect to report an established patient code as the criteria is not met.
> 
> 2. I recently took an auditing workshop run by the AAPC during which I was given a rough guide to selecting risk from the DG's Table of Risk.  It was suggested (as a starting place only) to put surgeries with a 10 day global period in the "Low" category and those with a 90 day global period in the "Moderate" category.  I have one physician who has deep misgivings about this approach and feels that "Moderate" is a better starting place for all surgeries, including liquid nitrogen destructions (we are a derm practice.)  Any thoughts?
> 
> Answer: I was always told a minor surgery is a surgery with 0 or 10 days. This is consistent with Medicare's guidelines. Now if the patient has cancer or there is some risk involved, that could definitely affect the level of risk for the presenting problem. However, for a minor surgery with no identified risk factors, that is a low level of complexity.
> 
> 
> 
> 3. Although prescription drug management falls on the "Moderate" level of the Table of Risk, would it be fair to put Accutane, methotrexate, and gabapentin on the "High" level given that they are used for "one or more chronic illnesses with severe... side effects of treatment"?
> Answer: If the patient has a chronic illness with severe exacerbation, then a high level of complexity is appropriate. The risks associated with taking the medications would not count though.
> 
> 
> 4. In determing complexity of MDM, we used the Marshfield tool.  One physician wanted to know if there was anywhere he could "score" more points when he invites his partners into an exam room to discuss a challenging case.  Any thoughts?
> Answer: Under the data reviewed, a provider could get two points for discussing the case with another provider. Just make sure it is documented.
> 
> 
> 5. In counting exam bullets, can a bullet be counted as complete if some, but not all, of the elements of that bullet are documented?  (i.e. would I count "eyelids" if that is all that is documented or does it specifically have to say in the chart "eyelids and conjuctivae"?)
> Answer:  This is a good question. I always counted it even if they only stated conjunctivae. I am thinking it could be interpreted either way. There are some aspects of E/M that are subjective and this could definitely be one of them.
> 
> Thanks in advance for any help.  I do so appreciate it.
> 
> Katie Hanninen, CPC, CPCD


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## valleycoder

regarding #3, i have always heard that only black box drugs qualified for the toxicity level in MDM....has anyone else heard that?


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## hkatie

Thank you so much to everyone who took the time to reply.  It's just terrific to read well thought out, logical explanations for different interpretations.  You've all given me great perspectives to sift through.

Thanks,

Katie


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## SCanterbury

1. The patient should be coded as new. It would be incorrect to do otherwise.

2. The risk table makes a clear distinction between four types of procedures:

a) minor procedures w/ NO identified risk factors --> LOW Risk
b) minor procedures WITH identified risk factors--> MODERATE Risk
c) major procedures w/ NO identified risk factors-->MODERATE Risk
d) major procedures WITH identified risk factors--> HIGH Risk

First determine if a procedure is minor vs. major. Then determine if any risk factors specific to this patient and indicated in the record exist for the procedure. 

3. If the "presenting problem" RISK is already HIGH due to the presence of severe exacerbation/side effects, you already have a HIGH overall Risk level (which is determined by the highest Risk subcomponent level.) No need to debate whether certain rx drugs can be bumped to a higher level than indicated on the table.

4. According to the Marshfield tool, 2 "Amount/Complexity of Data" points can be assigned for the summarization of a discussion with another provider.

5. 1997 Exam bullets can be credited in almost all cases when only one component of the bullet has been performed. Documentation of a finding regarding the eyelids would receive credit for the bullet. True, the bullet says "conjunctiva _and_ lids," but the "and" just refers to the fact that this single bullet includes credit for examining both the conjunctiva and lids. No separate credit is given for each. It does NOT mean that both must be documented to receive credit for the bullet. The only exception to this rule is a case where the bullet has a specific numeric requirement, as with the vitals bullet in the Constitutional system, which requires "any three of the following seven..." 

This is not a point requiring interpretation. It is given in black-and-white in the guidelines. To confirm this, access the 1997 E/M Doc. Guidelines here, and refer to the 2nd paragraph on p. 13 which says:

Documentation for each element must satisfy any numeric requirements (such as “Measurement of any three of the following seven...”) included in the description of the element. Elements with multiple components _but with no specific numeric requirement _(such as “Examination of liver and spleen”) require documentation of _at least *one* _component. 

Seth Canterbury, CPC, ACS-EM


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## seayres@yahoo.com

Tessa,

I recently had a provider ask me if a new immunization given could be counted as "moderate risk".  I'm inclinded to say minimum risk, but what do you think?

Thanks, 

Susan Ayres, CPC


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## hkatie

Seth,

From the bottom of my heart, Thank you!  I'm so happy and relieved to have that paragraph pointed out to me.  I'm actually looking forward to the memo I'm sending my docs this morning that will start out with "I was quite mistaken..."  Thanks again.

Katie


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