Medicare Compliance & Reimbursement

Case in point: A practice recently noted that one of its new physicians has been billing almost all 99215s for his E/M visits, which the EHR calculates based on the information that the physician enters into it. The practice manager pointed out that the vendor who sold her the EHR told her that its E/M calculator was auditproof, so she had been submitting the 99215s without checking the documentation. But she recently reviewed a claim and realized that the physician was sometimes examining body systems that weren't medically necessary for the condition, making his codes automatically register for higher levels than the patients' diagnoses warranted. This habit could become problematic for this medical practice.

"In addition to needing to fulfill the 'bullets,' you very much need to demonstrate medical necessity," says Chip Hart with Physician's Computer Company. "A 99215 is not justifiable for an otitis recheck except in the most exceptional cases. It's not even justifiable in most visits, even complex ones, for a reason."

In black and white: "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code," CMS says in Section 30.6.1 of the Medicare Claims Processing Manual. Therefore, any documentation of a comprehensive history and exam in an EHR may cause the system to automatically assign 99215, but that doesn't mean your documentation will back up that code selection.

Keep this in mind: "The number one suggestion I have," Hart says, "is don't use your EHR to do your E/M coding. It can't judge the medical decision-making aspect. The fact is, when you get audited, the EHR won't be on the stand in your defense. The EHR won't pay your $50,000 take-back. It's YOUR name on the claim, not theirs. Just because the EHR says you have enough bullets to bill a 99215 doesn't mean it's a valid 99215."

Additional consideration: "If you report only level four and five E/M codes, your practice will end up being an outlier," says Patrick J. Hurd, Esq., with LeClair Ryan in Norfolk, Va. "The Medicare and Medicaid contractors can run a very simple computer program and they'll see that you differ from the norms. They'll ask for you to send them certain randomly-selected charts."

Example: A patient presents with a chief complaint (CC) of sinusitis, which is also the only ICD-9 code that the physician reported: 461.1 (Acute sinusitis; frontal). Although the physician technically could have performed and documented the elements necessary for a comprehensive history and comprehensive examination, the CC of sinusitis probably wouldn't warrant 99215, without any additional comorbidities or complicating factors.

Submitting all high-level E/M codes and telling an auditor that your "audit-proof" EHR selected the code will not absolve you from having to repay Medicare for any overpayments that your MAC sends to you, says Michael F. Schaff, Esq., with Wilentz, Goldman and Spitzer in Woodbridge, N.J. "Nothing is audit-proof, because the information going into the system has to be accurate or the system can't generate an appropriate code," he says.

Recommendation: "When you enter into a contract with an EHR vendor, ensure that the contract includes appropriate representations and guarantees," Schaff says. "Make sure there is no limit of liability provision in the contract, and make sure the vendor has the appropriate insurance to cover the potential liability should any issues come up."