EM Coding Alert

Hint: Always check the medical decision-making.

Unfortunately, you may be one of the ranks of practices whose 99215 claims were denied or reduced, and if you’re scratching your head as you wonder why, then help is here.

To make sure you avoid the costly errors covered in the E/M Coding Alert Vol. 5 No. 7 article “55 Percent of 99215 Claims Incorrect, NGS Review Reveals,” take a look at this invaluable guidance from our experts.

Make Time for Physician Education

As you are selecting code(s) based upon the physician’s documentation, you should query your physician for him to add an addendum to clarify or include missing information, and think of this as a teaching opportunity, says Linda Martien, CPC, COC, CPMA, AAPC Fellow, consultant at Revenue Cycle Management Consulting in Mexico, Missouri.

“Any of us who have worked with physicians and providers know they usually just want to do the right thing when it comes to documentation, but the problem is, they don’t always know what that is,” Martien says. “Even when they have been given the information, or received instruction of the documentation requirements, like us all, they have to be reminded from time to time.”

Jodi Dibble, CPC, medical record coder II of physician services at the Florida Hospital New Smyrna in New Smyrna Beach, Florida, agrees that education is key.

“Educate your physicians on what documentation is required to meet the levels they intend to bill and the importance of providing appropriate documentation for good patient care,” Dibble says. “A well-documented record supports the quality and continuity of care for the patient and allows the physician theability to provide the best care possible for his patients, as well as to protect him in a legal situation.”

Look at Individual Components

When working with physicians, don’t focus on the entire issue at once, Martien says.

“As with the ICD-10 transition, we discovered it was far more effective and less threatening to focus on particular components and not the entire issue as a whole,” according to Martien.  

Martien advises that in one session you discuss the key elements of the history. And at other meetings, address the issue of time-based coding or the Review of Systems (ROS).

“Provide them with their own documentation specifically identifying examples within that documentation and how it meets (or fails to meet) the criteria,” Martien says. “I have had physicians basically audit their own documentation, and it has always been an effective and eye-opening practice.”

Always Strive for Accuracy

“The coder has the awesome responsibility of assuring the claim submitted for any patient on any given date of service is accurate and best describes the services provided,” Martien says. “To do otherwise places undue risk on the coder, provider, and the practice as a whole.”

Reminder: A false claim contains several components, not just the false claim itself.

“If electronically submitted, there is wire fraud in addition to the false claim itself,” Martien says. “If the claim is mailed, then mail fraud is a consideration.”

Bottom line: As the coder, while you are not responsible for the quality of the documentation, you are responsible for the content of a claim, according to Martien.

Check Medical Decision-Making and Medical Necessity

“If the physician intends to bill a 99215 (Office or other outpatient visitfor the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity …) and neglects to document something as simple as family history and a comprehensive exam, then the documentation would not meet that level, even if the medical decision-making was appropriate for a 99215,” Dibble says.

Physicians must understand how medical decision-making is determined. Just because the physician is a specialist does not mean he should be billing the highest-level E/M on each patient, according to Dibble.

In addition, reviewing the documentation requirements for E/M levels is vital.

“They need to learn what documentation is required for each level of E/M and how that would relate to the medical necessity of the patient’s encounter,” Dibble says. “Coders should review the physician’s documentation prior to billing to make sure it meets the E/M level billed, discuss with the physician any discrepancies and only submit charges that are supported.”

Voluminous Documentation Does Not Drive Higher Service Level

“Again, with the information in an electronic medical record [EMR] available to pull into the note, a physician might pull in too much information and the medical necessity is lost,” says Suzan Hauptman, CPC, CEMC, CEDC,  AAPC Fellow, senior principal at ACE Med Group in Pittsburgh. “The information should represent the specific encounter for that specific patient and the current condition.”

Hauptman adds that if lab values are not related to the current issue, they don’t need to be added to the note.

“If the patient’s review of systems (ROS) is old, just because it is complete, doesn’t mean it should be dragged into the note,” Hauptman says. “The information for the current visit should be fresh and appropriate for the immediate problem being addressed.”