Neurology & Pain Management Coding Alert

Pay special attention to claims with modifiers 25 and 59

If you-re not conducting internal chart audits for your neurologist, you may be giving up thousands of dollars that your practice is rightfully entitled to.

Uncover Potential Problems Through Audits

-Not only will a chart audit uncover documentation and coding errors, but missed revenue is often found -- services that should have been reported but were not captured,- says Deborah Grider, CMA, CPC, CPC-H, CPC-P, CCS-P, CCP, EMS, president of Medical Professionals Inc. in Indianapolis and American Academy of Professional Coders National Advisory Board president-elect.

Example: -The billing staff at one [physician practice] failed to report any modifiers for office encounters, costing the practice $30,000 in unpaid services that year,- says Curtis Udell, CPAR, CPC, CMPA, senior advisor with Health Care Advisors Inc. in Annandale, Va.

Udell also remembers one audit that uncovered improper modifier assignment, and the practice had no claims correction or appeals processes. -It cost the practice $450,000 in revenue in one year,- he says.

Audit Your Most-Used Procedure, E/M Codes

When you are conducting your internal audit, focus on the billing issues that will most likely disrupt the office's cash flow or cause compliance issues.

Internal audits should largely focus on the following areas, according to Ian S. Easton, PhD, head of Applied Technology at Coastal Georgia Community College in Brunswick:

- areas the HHS Office of Inspector General (OIG) plans to target in its Work Plan. These include level-five consults, level-two follow-up hospital care, and level- four follow-up office visits. See http://oig.hhs.gov/authorities/docs/physician.pdf to stay up-to-date on the OIG's Work Plan.

- higher-level E/M codes.

- high-cost procedures that the practice performs often. EMGs and Botox injections are two of the biggest -- and most common -- neurology procedures you should always watch closely to ensure correct reporting.

Starting point: Base your audits on your neurologist's utilization patterns and the billing areas the insurance carrier is concerned with, Grider says.

For example: An audit of the reporting practices of Provider B for the last six months indicates that Provider B has reported 20 level-five new patient E/Ms (99205, Office or other outpatient visit for the E/M of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; medical decision-making of high complexity) and only seven level-three new patient visits (99203, ... a detailed history; a detailed examination; medical decision-making of low complexity).

The audit shows that Provider B's coder could be reporting some services incorrectly. In this instance, make sure that Provider B can justify the E/M levels, or the office might be marked with -billing outlier- status -- meaning that many of the physician's services are being coded -outside the norm.-

Tip off: Having so many high-level E/M services is unusual for most groups, so there is a very good chance that Provider B is overcoding some 99205 services.

Clue in to These Hot Spots

When you are considering which types of services and procedures to focus on during the audit, know that payers are paying closer attention to some types of claims than others. Because of this, experts recommend that you give special attention to these areas during your internal chart audits:

- New and established patient E/M visits. Don't neglect auditing these E/M visits because practitioners often fail to fulfill all of the requirements necessary for the care level they choose.

-Many times, you will find services that the practitioner did not document enough history to reach a higher level, but the complexity for the higher level was evident,- Grider says.

In many of these cases, the practitioner reports the higher level inappropriately, and you-ll want to eliminate this pattern with your audit.

Also, an audit of E/M visits might show opportunities for more reimbursement, says Susan Hvizdash, CPC, CPC-EMS, CPC-EDS, physician educator for the University of Pittsburgh Physicians department of surgery and AAPC National Advisory Board member.

Internal E/M audits often uncover -middle-of-the-road- coding, which occurs when the practitioner chooses level-three codes almost exclusively, instead of taking advantage of opportunities to report level-four or level-five codes.

Example: Dr. X conducts a comprehensive history and exam on a patient, along with high-complexity medical decision-making. Although this is a level-five service, a -middle-of-the-road- coder would still report a level-three E/M code.

- Use of modifier 25 (Significant, separately identifiablefiable E/M service by the same physician on the same day of the procedure or other service) on claims. Many providers do not perform extensive enough E/M services to rightfully report an E/M with modifier 25, Hvizdash says.

- Reporting modifier 59 (Distinct procedural service). Modifier 59 use also sticks in payers- crosshairs because the modifier -essentially has the ability to override all edits in its path,- Hvizdash says. Because of this, always support your modifier 59 claims with substantial documentation.

- Consultation coding (99241-99255). Payers always pay close attention to consults because of the associated service value.

-Consults have higher RVUs (relative value units) and are paid about 25 percent higher than the comparable new patient office visit codes (99201-99205), so they are a constant target,- Udell says.

Make it easier: Use templates to make your job easier during an internal audit. Whether you use paper-based or electronic charting and filing, templates help guide you through the process.