General Surgery Coding Alert

History and exam alone won't sustain your claim

If you are a victim of the -E/M loophole- myth, you could be severely miscoding your E/M levels and collecting thousands more in payment than you deserve -- and that could lead to dire consequences down the line.

MDM Matters Most, CMS Says

The argument: Some physicians and coders reason that CPT guidelines allow reporting 99215 for an established patient based on a -comprehensive- history and a -comprehensive- examination, even if the medical decision-making (MDM) is low risk and there is no data to review.

Therefore, the argument goes, you may report 99215 for any E/M visits during which the physician documents a comprehensive physical and exam, even if she treats a minor problem.

The big question: Do the CPT E/M guidelines offer physicians a legal -loophole- by allowing them to ignore medical necessity?

The answer: -Absolutely not,- says Stephen R. Levinson, MD, author of the AMA's Practical E/M: Documentation and Coding Solutions for Quality Health Care. -CMS guidelines explicitly state, -Medical necessity is the overarching criterion for payment in addition to the individual requirements of a CPT code.-

-The nature of the presenting problem is CPT's measure of medical necessity for E/M services,- Levinson says, -and this important contributory factor is included for every level of every type of service that measures care using the three key components. Additionally, the Clinical Examples in Appendix C of CPT have been developed and approved by our own specialty societies to illustrate the level of care warranted by representative patient problems, and CPT directly tells us that the clinical examples -are provided to assist physicians in under-standing the meaning of the descriptors and selecting the correct code.- -

-CPT says that for established patients, only two out of the three components need to be met to code the service. However, there is a big overriding factor -- medical necessity,- says Suzan Hvizdash, BS, CPC, CPC-EMS, CPC-EDS, physician education specialist for the department of surgery UPMC Presbyterian-Shadyside in Pittsburgh.

-If medical necessity is not evident in the documentation,- she says, -the charge could be downcoded and would be considered abusive behavior.-

History Must Be Relevant

If your physician still balks at coding simple, uninvolved visits using 99212 or 99213, refer him to the E/M documentation guidelines, which make several references to medical necessity, says Erica D. Schwalm, CPC-GSS, CMRS, billing and coding educator in Springfield, Mass. Schwalm refers to the following references from the 1995 E/M guidelines:

Must have: -The documentation of each patient encounter should include: reason for the encounter and relevant history, physical examination findings and prior diagnostic test results.-

-The key word here is -relevant,- - Schwalm says. -If the patient presented with a runny nose, a comprehensive history and exam would not be relevant to the reason for the encounter.-

Rely on presenting problem: -The extent of examinations performed and documented is dependent upon clinical judgment and the nature of the presenting problem(s).-

-The clear message here is that the history, exam and medical decision-making performed should correlate with the presenting problem(s),- Schwalm says.

Insurers Look at Bell Curves

Remember that an auditor will look at any billed E/M services against the medical necessity, so your documentation will have to speak for itself, Severino says.

And an unusually high number of upper-level services will almost surely draw your payers- attention. If your physician bills all 99214s and 99215s, -you could set off a -red flag- to your insurer, not to mention the complaints you will get from your patients, which could also hurt your bottom line in the long run,- Schwalm says.

-Local carriers use -bell curves- or utilization data by specialty to target practices for audits,- Schwalm says. -If you start billing out a majority of your E/M services at higher levels, your utilization data will be well above what is considered the norm, which could make you a target for an audit.-

Spread the Word

If your surgeon tries to code to the -loophole,- you should show him CPT's clinical examples of which visits warrant which E/M codes (found in CPT's Appendix C). Also, show him the E/M guidelines that explain medical necessity must drive the code choice.

-I approach my physicians with documentation and let them know that I work at keeping their money in their pockets, unlike an auditor, who will not come in and look at the records and say, -I know what you meant when you failed to document this ...,- - Severino says.

In addition, you can use the opportunity to explain that although coding at higher levels may increase your income inappropriately, it can bring on a whole slew of new problems that you don't want to deal with. Instead, you should examine other ways you can increase your accounts receivable.

-When you review an office's EOBs [explanations of benefits] and you find a lot of visits not meeting medical necessity, it opens the door to discussion on how and where they can improve,- says Christine Goans of Coding Smarter Office Support Plus. -When a physician complains that his accounts receivable is poor, it is the opportunity to take the discussion further.-

Time Can Offer a Clue

One thing that can help quantify medical necessity for a visit is how long the surgeon spends with the patient. CPT states that 99214 or 99215 normally require 25 and 40 minutes of physician time, respectively. Obviously, most physicians are not spending this kind of time treating minor problems.

You should also look at how frequently the physician needs to take a comprehensive history. -If a patient comes in, say, three times a year, how can you document medical necessity or risk for all complete histories and physicals?- says Merrilee Severino, CPC, a physician practice coder in Florida.