Orthopedic Coding Alert

These mistakes may cost your practice money and set you up for payer scrutiny.

Many orthopedic practices either are already using electronic health records (EHRs) or are considering implementing an EHR system. An EHR can be a helpful tool to save your orthopedist time and ensure that his documentation is thorough and neat.

But there can be a downside to EHRs if you aren’t careful: They can mislead you into creating documentation you don’t really need or that is not pertinent to the evaluation of the presenting problem(s)— and in some cases, cause you to fail to document items required to support your code choices.

Consider these three EHR myths, all of which are based on questions submitted to Orthopedic Coding Alert, to show you exactly where your EHR system could be leading you astray.

Myth 1: Exam Documentation Will Carry Over for Follow-Up Visits

If your EHR is producing documentation that is robust in one section (such as History) and thin in another (such as the Physical Examination), you may be trusting the device to do too much.

A subscriber recently told OrthopedicCoding Alert that an auditor down-coded most of her E/M claims due to an empty “Physical Exam” section in the documentation. However, the practice argued that the EHR vendor had told them that patients being seen for established problems already have a physical examination documentation on file, and that the EHR will carry it over from one visit to the next.

Reality: This may be true for past medical, family, and social history (PMFSH), but not for a physical examination. In addition, as the patient’s condition changes, so might physical findings. A medically indicated examination due to the patient’s complaints must be done at each separate visit

E/M guidelines state that if a patient’s PMFSH has not changed since a prior visit, your orthopedist does not need to document the information again. He does, however, need to document that he reviewed the previous information to be sure it’s up to date and also note in the present encounter’s documentation the date of acquisition and location of the initial earlier PMFSH. Some payers will give no PMFSH credit if you overlook one of these two criteria.

Good documentation: For instance, you can say, “I reviewed the past, family, social history with the patient taken from today’s patient questionnaire and our previous visit of June 1, 2012. She reports that nothing has changed since that date.”

However, there is no substitute for recording your physical exam information on each visit, Hollingshead warns. For instance, suppose the patient presented with right ankle pain in August, and your orthopedist documented a full physical examination on that day, diagnosed a sprained ankle, prescribed medications, and told her to return if the pain returns. She comes back to your practice today, and your orthopedist performs a full examination. To receive credit for a physical examination today, you must document the physical examination findings rather than trying to carry them over from the August visit. Even if you documented “patient has tenderness on right ankle” in August, and it is still tender at the current encounter, your orthopedist must document it again today.

Myth 2: EHR’s Calculation of Time Spent Qualifies You to Code Based on Time

One of the perks of electronic health records is that they typically record the date and time that you input information. In fact, many EHRs record a summary of the time spent on the record at the bottom of each visit’s documentation and give a total, such as “Total time: 26 minutes, 15 seconds.” Remember, the ICD-10 coding for time is based on time spent with the patient, not time spent with the EHR.

Several subscribers have told Orthopedic Coding Alert that they have used this time calculation to select an E/M code based on time alone. For example, if the EHR says that the time spent is 25 minutes, these practices are automatically reporting 99214 for the visits, using the rationale that CPT^® and Medicare guidelines allow you to code E/M services based on time alone.

Reality: The key to billing based on time is that counseling and/or coordination of care must dominate the visit. Therefore, you can only select an E/M code using time as the controlling factor if you meet the rules, and an EHR’s notation of time spent in the record will not meet those guidelines. Instead, to bill on time alone, your orthopedist’s documentation must contain the following three elements:

• Notation of the total time spent on the encounter,
• Notation of the total time spent on counseling and/or coordination of care or the percentage of the visit spent on counseling/care coordination
• The reason for/topic of the counseling/care
  
• coordination

For example, the following statements would allow billing based on time alone: "25 minute total office visit with 20 minutes spent on counseling about surgical options for knee care" or "Total encounter: 55 minutes with more than 50 percent spent on coordination of care and discussion in detail concerning this patient’s worsening knee pain."

In an EHR, you may not know where to put such a statement, but most of these systems will have a radio button somewhere in the software that you can press to create a comment box. As long as you enter your statement about time as indicated above anywhere in the record, you can code based on time alone, but simply stating the total time you spent — or letting the EHR calculate it for you — is not adequate.

But remember that the content of the counseling must also be in evidence in the documentation. Simply stating time in the correct format is not enough to bypass the key elements and select the E/M code based on its typical time.

Myth 3: You Should Use the EHR’s Code Selection in Every Case

Your electronic health record will most likely offer an E/M code suggestion at the end of each visit--but that doesn’t mean you should use that to justify all high-level codes.

Several practices have told Orthopedic Coding Alert that their orthopedists “thoroughly document” the History and Physical Exam elements for all conditions, leading to high-level codes, even if the medical decision-making (MDM) does not support 99214 or 99215. They justify this by pointing out that established patient office visits only require two out of three key components (History, Exam, MDM).

Reality: CMS indicates in its Carriers Manual that “Medical necessity is the overarching criterion for payment in addition to the individual requirements of a CPT^® code.” In addition, the 1995 E/M Guidelines state, “The documentation of each patient encounter should include: reason for the encounter and relevant history, physical examination findings and prior diagnostic test results.”

If your patient presents with hematuria and you’re documenting a complete neurological exam, Medicare (and most other payers) would not consider that “relevant.”

Therefore, you should use your EHR’s code selection only as a suggestion, but the final code choice should be up to the clinician, and should be based on medical necessity and the nature of the presenting problem.