Ob-Gyn Coding Alert

The increasing scrutiny from third-party payers of coding in general, and Evaluation and Management (E/M) Services in particular, make the possibility of an outside audit an uncomfortable reality. Physicians, coders and practice managers all will rest easier knowing they can pass an audit, and one of the best ways to achieve this peace of mind is by conducting regular self audits. But beyond alleviating fear, regular self audits also may improve your collection rate, according to Jan Rasmussen, CPC, a coding consultant and instructor for Med Learn, a medical practice management training and consulting firm. Many coding consultants believe physicians often undercode rather than overcode. Regular self audits can help you identify when you might ethically be entitled to greater reimbursement. Here are some tips to help you conduct an efficient self-audit to prepare your practice in the event you are ever formally audited.

1. Review Productivity and Utilization Reports. Most coding software allows you to print out reports that show which codes are being used by each physician. Rasmussen recommends going back six months if you havent done an audit in a while, and thereafter running reports and conducting a mini-audit every month. Once you have printed out reports for the time period you are auditing, examine the reports for each physician. Take a look at what codes are being used and at what frequencies, and look for red flags that will guide you into deeper investigation.

2. Search for "Red Flags."

As you look at the utilization reports for each caregiver (physician, CNM, PA, NP, etc.) take note of anything that stands out. Compare the reports to each other.

You want to notice "spikes" in frequency or codes that are being overused. For example, if you discover that nearly all office visits by a certain physician are being coded at level 2 and for another physician there is a spike in the use of level 4s and 5s, you may have a case where one is undercoding and the other is overcoding. Typically, you will see higher levels of coding in specialties such as ob/gyn, but a consistent run of the high levels of services warrants a look to be sure that those codes are justified.

Look for the frequencies of the use of consultation codes (99241-99245) vs. new patient codes (99201-99205). According to Rasmussen, this is an area where E/M service codes are being misunderstood and misused and one that might raise the attention of an outside auditor. (See article on page 9 on correctly utilizing consultation codes.)

Take note of whether or not Preventive Medicine Codes (99381-99397) are being used. This is especially important in gyn practices, because many women are coming in primarily for preventive care. Often preventive visits are coded incorrectly using the Office/Outpatient Codes (99211-99215). This is due to the fact that during the course of preventive exams the patient mentions a problem and the physician does work on that problem. When a preventive medicine service is provided, however, it should be coded as such. In addition, not reporting Preventive Medicine Codes can raise red flags for managed care contracts that require quotas for preventive care.

3. Investigate the Chart. Hopefully, you will not find many red flags, but the ones detected need to be investigated. For the next step in your self-audit of E/M Services, you need to pull 3-5 charts for each physician, including some from your red flag search. If you did not find any red flags, you still need to look at charts as part of the audit. For each chart, look at the superbill, the HCFA 1500, the encounter form, the medical record and the explanation of benefits (EOB). Here is where you will discover how well you are doing. As you examine these documents consider the following questions:

Was the category or subcategory of E/M service coded correctly? First of all, compare the encounter form with the bill and the documentation, to assess whether the right category and code was used. For example, was the service correctly slotted as being an Office or Outpatient Service, a Consultation, or a Preventive Medicine Service? Also, make sure the right subcategory such as New or Established patient was used.

Are the billed codes supported by the documentation? For example, if a 99204 or 99205 is coded for a new patient, make sure the key components of comprehensive history and comprehensive examination (including a Review of Systems) and a moderate or high complexity of medical decision-making is documented. If an office visit and a procedure are coded, does the documentation support both? Was time a factor in coding the service? In the cases in which counseling and/or coordination of care dominates more than 50% of an encounter, time also is considered a key controlling factor in qualifying the visit for a particular level of E/M service. Finally, make sure that the diagnosis codes on the billing form are supported by the documentation. Frequently, the specificity of the diagnosis codes on the billing form is not supported by what actually appears in the record.

Which codes could have been justified if the notes had been more complete? Here you want to identify where you may have been able to rightfully code for a higher level of service. For example, an office visit by a 29-year-old female who was seen for PID and coded at 99212. The documentation for the visit shows a detailed history and a problem-focused examination. You know from experience that the patient probably received a detailed exam, but you were unable to code at the 99214 or 5 level because the documentation only supported the 99212 -- in which case your practice just lost money.

4. Provide Feedback. Once youve completed your audit of E/M services and identified trends and individual problems, its time to provide feedback. An audit without feedback wont improve compliance or the bottom line. According to Rasmussen, this is the sticky part of a self-audit. She recommends making sure you have done all your homework and thoroughly understand what is required. Then, with chart in hand, provide face-to-face feedback in which you can demonstrate where improvements can be made.

Evaluate Your Insurance Denial Youve coded for a vaginal hysterectomy, BSO and an anterior & posterior colporrhaphy all done in the same operative session, and the insurance company denies payment. Should you just accept the denial and move on? Not if you still believe you are entitled to payment. So its time to investigate the denial. The following is a brief process for evaluating insurance denials. Step 1: Identify the Reason for the Rejection It may sound obvious, but the first step in evaluating denials is to look at the EOB and see if you can pinpoint why the claim was denied. Was it a problem with the coding or was the claim not covered in the patients insurance contract? If the reason for the denial is unclear, dont guess. Go back to the insurance company. Before you can change the claim you need a clear understanding of the why it was denied. Step 2: Investigate the Coding With the reason for the denial in mind, take a look at the coding. Do the diagnosis codes match up appropriately with the procedure or service codes? Make sure everything makes sense in light of the services provided and the insurance companys evaluation of benefits. Was the claim bundled inappropriately? See if there is a way in which you could code it differently. Is an explanation or report needed that was not provided that will make a difference if it is resubmitted? Step 3: Correct, Resubmit or Accept Now that you understand the denial and how it was coded, determine if there is a way to resubmit the claim that will improve your chances of reimbursement. Correct obvious coding errors, but also consider if there is any possible way to code the claim differently that will address the payers concerns. An explanation or more data may be all that is needed. If you are without answers but believe you are still entitled to reimbursement, consider asking a coding expert. Finally, if you are sure that resubmission is a lost cause, its time to consider passing on this liability to the patient.