Medicare Compliance & Reimbursement

If your physician bills a lot of high-level office visits, he may be at risk of an audit -- which may not be cause for concern -- if his documentation justifies his code choices.

"Some physicians believe their patients are sicker than others', so they feel they're justified using more 99215s, when in fact that may not be the case," says Crystal S. Reeves, CPC, CPC-H, consultant with Coker Group in Alpharetta, Ga. "The CPT manual outlines the requirements of the E/M codes, there are clinical examples in the back of CPT, and CMS publishes a Table of Risk that can help guide you, so use all of those resources to determine whether you're billing properly," she advises.

Training is key: If you advise your physician that he is overbilling the high-level codes and he says, "But all of our patients are really sick," show the doctor CMS's Table of Risk, "which can be an eye opener for physicians," Reeves says.

When it comes to MDM for high-level E/M services, "look for how many diagnoses or management options the doctor is treating," Reeves says. "If a patient presents with a brain tumor and is on chemotherapy but is doing well, his condition may ultimately be terminal but this visit may not qualify for a level five. But if a patient has COPD, hypertension, degenerative disc disease, pneumonia, and diabetes, there will be more data to review, which may qualify for a higher MDM level."

Make diagnosis coding a priority: If your claim doesn't convey the status or complexity of the condition, an auditor won't be able to infer it, advises Stephanie L. Fiedler, CPC, ACS-EM, director of revenue management with YAI in New York, N.Y. "The best way to do this is to report your diagnosis codes to the highest level of specificity."

If a diagnosis code isn't listed on your superbill, research to find it rather than just using one that you do list on your encounter form.

"Certain diagnoses may not be listed on a physician's superbill, so the doctor may just circle the closest unspecified code," Fiedler says. For instance, a physician might circle the standard controlled diabetes code on a superbill because it's there, "but any time there are renal, peripheral vascular, or ophthalmic complications, those are the ones they have to go back to the coding book for -- and oftentimes, they don't," she says.

"Without the more specific code, the physician isn't conveying the acuity of what he's doing, so the diagnosis may not support the claim."