Orthopedic Coding Alert

The increasing scrutiny from third-party payers of coding in general, particularly with Evaluation and Management (E/M) Services, makes 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 in St. Paul, MN. Many coding consultants believe physicians often undercode rather than overcode. Regular self-audits can help you identify when you might ethically and legally be entitled to greater reimbursement. Here are some tips to help you conduct an efficient self-audit:

1. Review Productivity and Utilization Reports. Most coding and billing 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 which 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, PA, or nurse practitioner), 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 nearly all office visits by a certain physician are being coded at a level 2, but another physician has 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 orthopedics, but a consistent run of the higher levels of service may warrant a look into the charts to be sure that the documentation justifies those codes. Contrary to the assumptions of some providers, an office visit to a specialty such as orthopedics does not automatically guarantee the higher levels.

Look for the frequencies 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. Remember that for an E/M service to qualify as a consult, the documentation must reflect that there was a clear Reason, Request, and Reply.

Editors Note: An article spelling out the specifics of orthopedic consults will appear in a future issue of Orthopedic Coding Alert.

Take a note of other special E/M codes being used, such as special evaluation and management services (99455-99456) and preventive medicine codes. Typically, the orthopedic practice will not be conducting many preventive medicine exams, but you may be providing counseling and /or risk factor reduction intervention (99401-99429).

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 three to five 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 your 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 special evaluation and management 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 or comprehensive history and comprehensive examination (including a review of systems) and a moderate or high complexity of medical decision-making are 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 percent 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 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 might have been able to rightfully code for a higher level of service. For example, a 43-year-old male comes in the office and is seen for lumbar back pain and numbness and tingling in the right lower extremity. The visit was coded at 99212. The documentation for the visit shows a detailed history and problem-focused examination. You know from experience and the nature of the problem described that the patient probably received a detailed examination, but you were unable to code at the 99214 or 99215 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 the trends and individual problems, its now time to provide feedback. An audit without feedback wont improve compliance or your 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 to your caregivers in which you can demonstrate where improvements can be made.