Neurosurgery Coding Alert

Can the nurse document the history? Read this advice.

Neurosurgeons are known for their surgical encounters, but any seasoned neurosurgery coder will tell you that E/M visits make up a generous portion of their day's work, and miscoding these claims could sink a neurosurgery practice.

To ensure that you're reporting the right code based on your doctor's documentation, check out the following questions, along with answers directly from CMS or Medicare Administrative Contractors (MACs). All of the citations from Medicare were published within the last month so you can be sure they're not only relevant, they're also timely.

FAQ 1: Know Where to "Count" Exam Elements

Question: Our doctor doesn't always use headings in his exam documentation, so how do we know where to put a bullet like "lungs clear to auscultation?" Would that go under chest, or respiratory?

Answer: If the doctor doesn't use a heading in his medical record, "the coder may decide where to use a specific piece of documentation as long as the coding follows E/M guidelines and only use each piece of documentation once to support an E/M required element," Part B MAC Palmetto GBA said during a March 2017 "Ask the Contractor" teleconference.

"Medicare reviewers will use all of the documentation within a record that is not listed under a specific provider given header to determine if a provider's documentation meets the documentation requirements," Palmetto said. "If a provider uses headers, Medicare will consider the information under a given header for that category only. By the rules, you can use either. It's your choice. The difficulty is you can't combine them."

For instance, Palmetto said, the eyes count as an organ system (ophthalmologic). However, you could instead count eyes as head for body area, "since the head is a part of the body containing the organs of special sense," Palmetto said. Likewise, "Lungs clear to auscultation" and "cardio-regular rate and rhythm" could be counted as 'chest' for body areas or as respiratory and cardiovascular for organ systems."

When it comes to abnormal and negative findings for a certain body area, Palmetto says that listing "abnormal" for a system or body area does not constitute sufficient documentation. Instead, you "need to describe/document what the abnormal finding is," the MAC advises. However, you can use "negative" or "normal" for an unaffected area/system "as long as it not used for the entire system," Palmetto advises. "Each list of sub systems has to be addressed to be given credit."

Resource: The information from Palmetto's "Ask the Contractor" teleconference can be viewed at http://www.palmettogba.com/palmetto/providers.nsf/vMasterDID/AK9QUP4025.

FAQ 2: Don't Check Off Every Element Just Because EHR Prompts You

Question: Our neurosurgeon bills almost all level four and five exams, which he can justify for established patients because he documents detailed or comprehensive histories and exams. Sometimes we don't see the justification of him performing things like six bullets within the genitourinary section when the patient just presents for carpal tunnel syndrome. He says his EHR prompts him to enter all of this information and gives him the code to report at the end of the encounter. Is this okay?

Answer: No, the neurosurgeon is probably upcoding some of these claims if you don't see a medically necessary reason to perform these exam and review of system (ROS) elements in the documentation.

"Medicare has said that medical necessity should always be the overarching factor that your doctors use to select the E/M service level," says biller Anna Charlon, who handles the billing and practice management departments for three medical practices in Atlanta, Ga. "Just because the doctor completes a higher-level history and examination doesn't mean he always should report a higher-level code."

Medical necessity should drive the components that the physician performs, Charlon says. Comorbidities, the need for diagnostic testing, the plan of care, and so on, may complicate the encounter and increase medical decision-making, and warrant additional history and exam as well. In addition, each note (no matter how it is created) should be specific to the patient, the encounter, and the problem.

"The volume of documentation should not be the primary influence upon which a specific level of service is billed," CMS said in Transmittal 178 - but it's clear that there are still many practitioners who aren't heeding that advice. On March 29, 2017, Part B carrier Cahaba GBA published the results of its recent pre-payment audit of CPT^® code 99214, which revealed that across the three states in the review area, the average error rate for this code was an abysmal 35.28 percent.

One of the main problems that Cahaba found among these claims was a lack of medical necessity to support 99214. "The information provided does not support the level of service as shown on the claim," Cahaba said in its explanation of the audit findings. Therefore, the MAC downcoded the claim to a lower level of service, and likely asked for a refund for the difference between the income the practice received for 99214 and what it should have collected for the lower code.

In short: Ensure that the physician only documents the medically necessary exam elements, which should be selected on a case-by-case basis to evaluate the patient's specific concern.

Resource: The results of Cahaba's recent audit of 99214 can be found at https://www.cahabagba.com/news/widespread-targeted-review-results-part-b-99214-office-outpatient-visit-evaluation-management-established-patient/.

FAQ 3: Who Can Record History Elements?

Question: We usually have our nurses record the ROS and the past, family and social history (PFSH) sections of the history, and then we also have patients complete a form where they check off information about their current conditions as well. Can we count that toward the E/M level, or does the doctor have to do all that instead?

Answer: You can continue to operate as you have been. According to the 1995 E/M Documentation Guidelines, ancillary staff may record the ROS and/or PFSH section of the history component of an E/M. "There must be a notation by the physician supplementing or confirming the information recorded by the ancillary staff," Part B MAC Novitas Solutions said in its "FAQs: Evaluation and Management Services (Part B)" fact sheet, which the payer updated on March 6, 2017.

In addition, you can use the information from the sheets the patients complete, as long as the physician notes that he has reviewed the forms. "It is also appropriate for the physician to note in the medical records any additional information obtained during the face-to-face encounter," Novitas adds.

Resource: Novitas' FAQs are available at http://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00005056.