Medicare Compliance & Reimbursement

Are your cardiology or specialty practice's evaluation and management services garnering fair Medicare payment -- or are they a ticket to potential reimbursement recoupments and worse? The answer can lie in the details that both keep the cash flowing and your compliance record on the high road.

A costly assumption: "Some cardiologists will assume that they have sicker patients and can bill higher level E/M codes ...," says Leatrice Ford, RN, founder of ConsultCare Partners in Louisville, Ky. "But a family practice physician managing a cardiac failure patient in and out of the hospital will potentially have sicker patients, as the patient usually has other issues, such as renal impairment and diabetes."

"If a physician is consistently coding level 5s, that will trigger the MAC to take a look," counsels Sandy Fuller, CPC, MCS-P, HIS supervisor and compliance officer for Cardiovascular Associates of East Texas.

The good news: If a cardiologist or other specialty physician provides that level of service -- and has the documentation to back it up -- he or she should be home free if an auditor does review claims and documentation.

Focus On 5 Pivotal Areas To Make Your Case for Fair Payment

1. Review the components for billing various levels of an E/M code. For example, Fuller often finds that the visit does reflect the level of medical decision-making to support a higher level code. "But if your documentation doesn't support it, then you can't support the level billed," she stresses. For instance, suppose a cardiologist sees a heart patient and decides to prescribe medication. The doctor "may have to take into account the patient's other chronic illnesses and medications," says Deborah Dorton, JD, MA, CPC, editor of Cardiology Coding Alert (www.codinginstitute.com).

"The doctor should be sure to document the other diagnoses. They may support a higher-level E/M code because of the more complex medical decision making required."

Resource: To review the requirements for billing various levels E&M services, go to www.cms.hhs.gov/MLNProducts/Downloads/eval_mgmt_serv_guide.pdf.

2. Home in on these often overlooked elements. Fuller most often sees physician miss documenting in the areas of review of systems (ROS), history, and the exam. And "if you miss one item in ... those things, it brings you from a level 4 or 5 to a level 3," she warns.

Reasoning: "The only difference between a 4 and 5 is the risk to the patient -- that is, how sick the patient is. The documentation requirements are identical until you get to the decision-making," Fuller points out. "And if you miss one exam or ROS or history element, it brings you down two full levels."

3. Learn the applicable "buzzwords" to expedite documentation of services provided, suggests Jim Collins, CCC, CPC, CHCC, president of CardiologyCoder.Com Inc. in Saratoga Springs, N.Y. "The million dollar statement" Collins likes to recommend cardiologists use: "The patient denies any associated symptoms including chest pain and shortness of breath with or without exertion."

That verbiage "is pertinent to virtually every cardiology patient encounter," says Collins. And "it's chock full of buzzwords: two recognized history of present illness elements (associated signs/symptoms and modifying factors) and two review of systems elements (cardiovascular and respiratory)."

4. Let time be your guide. CPT has approximate numbers of minutes for different E/M level codes, notes Ford. And while these aren't timed visits, they do provide "ball-park figures."

Example: Suppose a physician is only with a patient for five minutes and believes the visit warrants a level 5 code. "Normally," says Ford, "you'd think that a level 5 would be approximately 40 minutes for an established patient, and a 60-minute visit for a new patient." Thus, "the physician in that case might re-evaluate whether he or she really did a level five in five minutes." Ford notes she's just using that as an example, and "it's not about how much time you spent, but about what you did in that time." Even so, "looking at the approximate time of a visit is a good rule of thumb."

5. Know how to document consultations. As of Jan. 1, 2010, Medicare fee-for-service no longer pays for physician consultations, unless Congress provides legislative relief. Some Medicare Advantage plans say they will continue to honor the codes, however, Fuller reports. Specialists such as cardiologists who perform consultations can bill Medicare fee-for-service for a new patient, if they haven't seen the patient for three years, she notes.

Otherwise, they bill for a follow-up visit. "The highest consult code is 110 minutes and there's no E&M code that is that long. So you can't crosswalk a level 5 consult code to a new patient visit code in that way." Instead, you can select a CPT code for the extended time (99354-99356), Fuller advises.

Don't miss: The physician must document what he discussed with the patient when billing for the time, Fuller counsels. The documentation should also indicate that the physician spent more than half the visit time doing "counseling and coordination of care."