EM Coding Alert

Find out why under-coding is just as bad as over-coding.

Falling into common E/M coding pitfalls can turn your bottom line red and fill your inbox with denials.

In the first article of this two-part series, “Key Elements: Avoid 5 Common E/M Errors with These Expert Tips” in the Volume 2, Number 11 issue of E/M Coding Alert, you learned two common E/M errors are insufficient documentation and always coding high. You also walked away with tips to avoid these pitfalls. 

Now, in Part 2, read about three more errors and tips, such as when you need to educate the healthcare professionals in your practice, so you avoid under- and over-coding.

Error 3: Halt Using 99213 as a Default Code 

Some healthcare professionals use CPT® code 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity ...) as a default code because they consider it to be “safe.” The 99213 code is in the middle of the 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient, …) range so by choosing it for everything, some coders and physicians think they will avoid scrutiny because they are not over-coding. 

“We all know that providers feel that using a 99213 will prevent them from being audited by the heavy hitters, such as Medicare,” shares Sharon A. Morehouse, MPA, IA, owner of Beyond Basics Medical Billing Service, LLC of Honeoye Falls, N.Y. “This is not true, as auditors tend to look for patterns, and when a provider consistently bills a ‘safe’ code such as a 99213, this sends up as many red flags as consistently billing higher level visits.”

The problem: You should always report the code that corresponds with the history, examination, and medical decision making (MDM) in your provider documents. Not every patient or every encounter is the same, so always reporting 99213 is not likely to be accurate all the time. Using 99213 frequently for established patients, suggests that you may be under-coding or over-coding some of the claims.

Example: If your provider documents a comprehensive history and exam with a high complexity MDM, and puts 99213 in his notes, his coding is incorrect. The appropriate code would be 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity…). By coding 99213 instead of 99215, not only are you miscoding, you are costing your practice $71.29 for this encounter (multiply the relative value units [RVU] for 99215 [4.03] times the national unadjusted conversion factor of 35.8228 and subtract the RVUS for 99213 [2.04] times the conversion factor). If you do this twice a day, and your doctor works four days a week, 50 weeks out of the year, you’ve lost $28,516 over the course of the year. 

Tip: When you think a physician is coding in the middle of CPT® code ranges in order to avoid scrutiny from the payers, it’s time to educate her as to how you code according to procedures she performs and help her improve her notes.

Error 4: Keep an Eye on Notes Not Supporting Medically Necessity

Without medical necessity, your claim will positively be denied by your payers. You should not be coding and billing for procedures that were not medically necessary. To find medical necessity, you’ll turn to the provider’s notes. Often the diagnosis code you report will help prove medical necessity to the payer. 

If your claims are paid in error, the payer may recoup the reimbursement in the future. The denial explanation may be “non-covered service” or “not medically indicated.”

Example: A mother brings her daughter in for her four-year-old wellness visit. The physician performs the well child check-up. During the encounter, the mother states that the patient has been having congestion and headaches. The physician documents an expanded problem-focused history and exam with a low complexity MDM related to the problem. The diagnosis is a sinus infection (461.9, Acute sinusitis unspecified). 

You’ll report the problem-oriented portion of the visit with 99213 and diagnosis code 461.9. Then, you can report 99392 (Periodic comprehensive preventive medicine reevaluation and management of an individual…) for the well child check-up with diagnosis code V20.2 (Routine infant or child health check). Attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to 99213 to indicate the payer should reimburse you separately for these services. 

The separate diagnoses help prove medical necessity for both services during one encounter. Without proper documentation to support separately billing the problem-oriented encounter, you would only be able to report the preventive service. 

Tip: Check the diagnosis codes your physician is noting. Speak to your doctors to help them write complete and concise notes that support all of their procedures and services.

Error 5: Look for Support of Split/Shared Visits

CMS has found that split/shared E/M service encounters are a source of common billing errors due to insufficient documentation supporting both healthcare professionals performing portions of the service.

The definition of a split/shared service is an encounter in which a physician and a non-physician provider (NPP), such as a nurse practitioner or physician assistant, perform a portion of a face-to-face E/M visit with the same patient on the same date of service.

Example: Your NPP visits and examines a patient in the hospital for the first time during the stay. The NPP appropriately documents a detailed history, detailed exam, and low complexity medical decision making. Later that day, the doctor examines the patient and documents his face-to-face encounter that includes additional information about treatment plans and answering of questions with the patient. The doctor also links to the note written earlier by the NPP. 

You can add the documentation together to achieve a level of service. Bill the 99221 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity…) service under the doctor’s national provider identifier (NPI) for 100 percent reimbursement rather than 85 percent by billing under the NPP’s NPI.