Medicare Compliance & Reimbursement

Ward off common documentation errors to ensure coding success.

There are some coding errors that plague even the most experienced coders — and E/M mistakes are at the top of the list. Avoid these pitfalls for two common E/M coding errors and give your E/M accuracy a boost. 

Error 1: Watch for Incomplete or Insufficient Documentation

You use your provider’s notes when coding and that’s where issues may start. You can only code what is in the record, so missing or inaccurate notes will lead to coding that may not reflect what your provider actually did. Unsigned forms, lack of detail, and missing treatment orders are just a few examples of documentation errors that could wreak havoc on your coding. Look at the documentation to see if there’s room for future improvement.

“Bottom line, it is the provider’s responsibility to produce a medical record that is credible, with good documentation,” says Sharon A. Morehouse, MPA, IA, owner of Beyond Basics Medical Billing Service, LLC of Honeoye Falls, N.Y. “However, the coder does have the ability to ‘spot check’ the provider’s documentation against what she has billed out to the insurance carrier.”

You have to code from what the provider gives you. If you feel the service was more comprehensive than what was documented, certainly ask the provider. But it can’t be coded to the more comprehensive level if the documentation doesn’t substantiate. Generally the theory is that “if it wasn’t documented, it wasn’t done.”

Tips: There are things you can do to help lower the percent of payment errors blamed on insufficient documentation. You can:

• Educate yourself on when your physician’s signature is needed or when he needs to provide forms;
• Educate your physicians on documenting everything they do during an encounter to ensure you can code what they actually did;
• Spot check the physician’s documentation looking for consistent errors for which you can provide education.
• Do a pre-bill review either periodically or until you have a comfort zone for the physician’s documentation supporting the billed services.

Example: An established patient comes to your office for a B12 injection. Your family physician (FP) sees the patient prior to the injection and performs an unrelated E/M service because the patient says he has an allergic rash. Your physician tells you he examined the patient and prescribes an antihistamine; however, the history, exam, and MDM only relate to the injection. The doctor’s notes don’t mention the allergic skin condition or prescription.

Therefore, you can only report the B12 injection 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular). Because there are no notes to support the problem-oriented encounter, you cannot separately report an E/M service for the rash evaluation and treatment.

Error 2: Spot Frequent Reporting of Highest Codes in a Range

Some providers feel that they should always bill the highest level of service, such as 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity ...) or 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 ...) for the work they perform. If the notes don’t support the use of the highest level code, however, you cannot bill that code, even if your provider feels that is what he performed.

Example: The physician wrote a 99205 in a patient’s records for notes that only support an expanded problem focused history and exam with straightforward medical decision making (MDM). Without documented comprehensive history, comprehensive exam, and high complexity medical decision making or appropriate time-based documentation, you cannot report 99205 even if your physician states the patient was very sick and he spent a lot of time with her.

In this example, you should code 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making ...), which is what the notes support. Speak to your physician to explain why you have to code at a lower level to give him the opportunity to improve his notes next time.

Watch out: Be on the lookout for physicians who code high on a regular basis. In the May 2014 release of the OEI-04-10-00181, the Office of Inspector General (OIG) reported that “physicians increased their billing of higher level codes, which yield higher payment amounts, for E/M services in all visit types from 2001 to 2010.” That means OIG, CMS, and other payers are carefully scrutinizing your high-level E/M claims to see if they are really supported.

Tip: If you see a pattern of only the highest code level being reported by your physician, talk to your physician. Explain to him that if his notes don’t support the highest codes in a code range, you code only what is documented and that the components that he provides are what come together for you to reach a level of service.

“Most providers need to understand the components that are in place for determining what constitutes a higher level visit,” adds Morehouse. “It is the coder’s responsibility to bring this to the provider’s attention, particularly if there is a large volume of these services being billed on a given day.” It’s not to say that your provider doesn’t see complicated patients, perhaps it’s just that the documentation must support the high level care code.

Pointer: If your provider’s documentation doesn’t meet the proper history, exam, or MDM levels for the high-level code he is reporting, check to see if he is trying to bill based on time alone. But be careful. You should only code an E/M service based on time alone if at least 50 percent of the visit was spent on counseling or coordination of care, and this fact must be noted in the documentation.

The documentation must contain the following three elements:

• Notation of the total time spent on the encounter
• Notation of the total time spent on counseling and/or coordination of care or the percentage of the visit spent on counseling/counseling and/or coordination or care (CoC)
• The reason for/topic of the counseling/CoC.