Neurology & Pain Management Coding Alert

Lost revenue might not be the only price you pay for down coding.

When your neurologist or pain management specialist sees patients in the office, you know to look for more specific details in order to justify reporting higher-level codes such as CPT 99204 or 99214. Don't fall into the trap of "being on the safe side" by undercoding, however. Reporting lower-level codes 99203 or 99213 doesn't just lower your provider's reimbursement -- you could be setting yourself up for an audit.

Could You Be Triggering an Audit?

The top reason many practices undercode is because they don't want to "trigger an audit." However, coding all lowlevel E/M codes is sure to get a payer's attention, because the claims reviewers will be wondering why you never provide high level evaluations to your patients.

When claims reviewers study "bell curves" to determine whether a practice is coding outside the norm, they're looking at trends across the board. This means that a practice with all lower level codes will be vulnerable during audits, because nearly every practice sees more complex patients requiring high level E/Ms at least once in a while.

Template tip: One easy way to ensure that providers document the E/M visit components is to create templates they can follow. If you are finding that your providers are forgetting to document the various systems they reviewed with the patient, have your providers reference a patient and/or staff-completed ROS form in the dictation, and initial and date the form.

"I think that a good template should really prompt the physician to put in the information specific to his practice," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-OBGYN, CPCCARDIO, manager of compliance education for the University of Washington Physicians and Children's University Medical Group Compliance Program. It should remind him to accurately document the review of systems work that he has performed (or remind him to refer to 'that patient questionnaire' that they have every patient fill out). It should remind the physician to ask about social history and family history and should lead him away from words like 'non-contributory' or 'unremarkable,' which are not good indicators of the medically necessary service provided."

Result: Incorporating those steps should help you feel more comfortable with choosing the correct level E/M codes.

Consider Compliance Implications

If you're deliberately undercoding Medicare or Medicaid claims to stay under the radar, you're technically violating the False Claims Act because you are knowingly submitting a false claim. "It's a violation just as much as deliberate upcoding is a violation," says John B. Reiss, PhD, JD, a health care attorney with Saul Ewing, LLP in Philadelphia.

"What I'm seeing isn't that physicians are reporting a level four code when they've documented a level five -- they're maybe downcoding one level to be conservative," says Daniel C. Oliverio, JD, who heads the False Claims Act Practice Group at Hodgson Russ, LLP, in Buffalo, N.Y. "In many cases, the doctors are playing it safe because they aren't sure they've met the criteria to report the higher code. If there are shades of gray, they're going to play it safe and code lower rather than higher."

Determine How Much Revenue You're Losing

Downcoding claims might be costing your practice more than you realize. "If a practice is undercoding just one level, they're probably leaving a massive amount of money on the table over the course of a year," Reiss says.

Example: If your physician's documentation justifies billing a level-four new patient office visit (99204) but she downcodes it to a 99203 because she isn't confident that she has adequate notes for the 99204, you've just forfeited about $56.00, which is the difference in average  reimbursement between the two codes. If just one physician at your practice does this twice a day over the course of a year, you've written off nearly $30,000 annually.

Best practice: Educate your physicians about how to accurately document the E/M services they provided and select the most accurate code based on that documentation.