Medicare Compliance & Reimbursement

Could your payer be using the '4x4 method' to calculate your exam elements?

Understanding the nuances of E/M visits can be tricky, especially with conflicting advice everywhere you turn. Most of the time, your best bet is to contact CMS or your Part B MAC directly to get the real scoop on how to bill these services.

One Medicare Part B MAC, Novitas Solutions, recently made its E/M guidance public during the Nov. 2 teleconference, "New Patient Guidelines and Coding." Read on to discover five tips that will help you code these visits.

Tip 1: Procedural Services Count Toward "New Patient" Rules

As most practices are aware, CPT^® clearly defines what qualifies as an established patient: "An established patient is one who has received professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years."

Many practices take this to mean that if a patient has never had an E/M visit at the practice before, then he is automatically considered a new patient, but there are some types of face-to-face services that fall outside of that. In fact, if a practitioner performs a procedure, such as a bronchoscopy, on a patient in the hospital and then sees her a year later at his practice, that patient would be considered established, even if they never spoke or had an E/M encounter before.

"Surgical procedures require a face-to-face encounter between the physician and the patient," said Novitas' Serena Hempkins during the webinar. "A patient is not considered new if a surgical procedure is performed and billed within the preceding three years by the same physician or a physician from the same specialty in that same group practice."

If, however, the doctor simply interpreted a diagnostic test (e.g., a radiological or lab test) for the patient but never saw her face-to-face, in that case you should qualify for a new patient visit, Hempkins said.

Know where NPPs stand: Visits with non-physician practitioners (NPPs) count toward the three-year rule, Hempkins added. "NPPs assume the specialty of their group practice and a new patient visit by an NPP counts as a new patient visit for all practitioners of that group practice," she advised.

Tip 2: Switching Practices Doesn't Change Status from 'Established' to 'New'

Suppose a physician joins a new group practice and brings along some patients from her previous practice, whom she has seen within the last three years.

Although the new group practice has never seen these patients before, the patients are still considered established, said Novitas' Tasha Bishop. "Remember, once established to one physician, then established to all physicians in the same group with thesame specialty," she advised. "The physician bringsthe statusof the patient with them to the newpractice."

Tip 3: You May Be Defining 'Double Dipping' Improperly

Although the myth has persisted for years, most payers don't agree that practices are barred from using one documented statement toward both the review of systems (ROS) and the history of present illness (HPI).

"It's not considered double-dipping to use the systems addressed in the HPI for credit in the ROS, because review of systems inquiries are questions concerning the systems directly related to the problem identified in the HPI," Hempkins said. "So you can receive credit in two places with a single statement."

Tip 4: Avoid The Blanket Statement 'Complete ROS Negative'

When documenting the review of systems, you can't take credit for reviewing multiple systems if you haven't documented any pertinent information about them. "Some physicians believe they can say 'Complete ROS negative' and get full credit. This is not true," Hempkins said. "Providers must document the pertinent positives and/or negatives of some systems and then state, 'all others negative,'" Hempkins said.

In addition, while you're in the history section of the note, make sure that your past family and social history (PFSH) portion isn't missing any elements. "The PFSH requires all three categories to be documented for new patient visits - past, family and social history - however, the family history is often missing," Hempkins said. "We understand that an advanced age Medicare patient may be the only surviving family member but the guidelines are specific, to score a complete, [you] must document family history."

Tip 5: Know How Your MAC Calculates Physical Exams

Although all payers recognize the 1995 and 1997 E/M guidelines, some use specific scoring models to tally your E/M elements when auditing your records. Novitas uses what's called the "four by four" method when using the 1995 Guidelines. "Our medical staff will automatically score a detailed exam if you have four or more items noted in the medical record for four or morebody areas or systems," Hempkins said. However, less detail than that can be considered on a case-by-case basis, based on that reviewer's clinical judgement, she added.

Hempkins offered this example of how the "4x4" scoring system works: A patient presents with a blood pressure of 135/82, temperature 98.2, pulse 80 and resp. 24. Lungs continue to have decreased breath sounds bilaterally with wheezing, productive cough, and crackles in the bases bilaterally. Heart normal sinus rhythm, no murmurs, rubs, or gallops. Abdomen obese, soft and non-tender, normal bowel sounds.

The auditor would count four tick marks for constitutional, four for respiratory, four for gastrointestinal, and four for cardiovascular. "So we've got four exam items in four organ systems, which would qualify for a detailed exam" using the "4x4" method, she said.