Podiatry Coding & Billing Alert

Avoid audit hotspots with these 3 strategies.

Even the most experienced coders struggle with proper E/M coding. E/M coding mistakes are on the top of the list of coding errors, and not to scare you, but CMS is taking aim at podiatrists’ reporting of E/M services with nail debridement in 2017.

According to the 2016 Comparative Billing Report (CBR), common codes from podiatry practices have been targeted with respect to billing: E/M codes (99211-99215) and nail debridement codes: 11720 (Debridement of nail[s] by any method[s]; 1 to 5) or 11721 (Debridement of nail[s] by any method[s]; 6 or more) will be under increased scrutiny in 2017.

The lowdown: This report also notes a claim error rate for July 2015 to December 2015 from 80 percent to 89 percent based on E/M services ineligible for reimbursement because “they were directly related to the nail debridement, and no other problems were identified in the medical record.”

CBRs are designed to inform providers of how their specialty performs in certain billing scenarios, and podiatry is lacking in the eyes of CMS. The CBR provides the tenets to “Coverage and Documentation Overview” regarding nail debridement services and how this report is generated to help the provider understand the “error of their ways.”

Below, we’ll help you correct yours with three strategies:

1. Check for Incomplete and Illegible Documentation

CMS determined billing error rates of 56 percent for CPT® 11720 and 47 percent for 11721 in its 2016 CBR. Most of the errors were related to lack of proper documentation or illegibility.

You use your provider’s notes when coding and that’s where issues may start. You can only code what is in the record, so missing or inaccurate notes will lead to coding that may not reflect what your provider actually did. Unsigned forms, lack of detail, and missing treatment orders are just a few examples of documentation errors that could wreak havoc on your coding. Look at the documentation to see if there’s room for future improvement.

“Bottom line, it is the provider’s responsibility to produce a medical record that is credible, with good documentation,” says Sharon A. Morehouse, MPA, IA, owner of Beyond Basics Medical Billing Service, LLC of Honeoye Falls, N.Y. “However, the coder does have the ability to ‘spot check’ the provider’s documentation against what she has billed out to the insurance carrier.”

You have to code from what the provider gives you. If you feel the service was more comprehensive than what was documented, certainly ask the provider. But it can’t be coded to the more comprehensive level if the documentation doesn’t substantiate. Generally the theory is that “if it wasn’t documented, it wasn’t done.”

Tips: There are things you can do to help lower the percent of payment errors blamed on insufficient documentation. You can:

• Educate yourself on when your physician’s signature is needed or when he needs to provide forms;
• Educate your physicians on documenting everything they do during an encounter to ensure you can code what they actually did;
• Spot check the physician’s documentation looking for consistent errors for which you can provide education.
• Do a pre-bill review either periodically or until you have a comfort zone for the physician’s documen­tation supporting the billed services.

2. Spot Frequent Reporting of Highest Codes in a Range

Some providers feel that they should always bill the highest level of service, such as 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity ...) or 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity ...) for the work they perform. If the notes don’t support the use of the highest level code, however, you cannot bill that code, even if your provider feels that is what he performed.

3. Consider Billing Tendencies Going Back to 2000, Because CMS is Looking Back, Too.

A June 2002 Office of Inspector General (OIG) report demonstrated the following, “Medicare allowed $51.2 million in improper payments for nail debridement services ... and since these payments were inappropriate so were the services rendered along with nail debridement, hence another $45.6 million was deemed improper as well...the total for all improper payments were $96.8 million.”

Similarly, be on the lookout for physicians who code high on a regular basis. In the May 2014 release of the OEI-04-10-00181, the OIG reported that “physicians increased their billing of higher level codes, which yield higher payment amounts, for E/M services in all visit types from 2001 to 2010.” That means OIG, CMS, and other payers are carefully scrutinizing your high-level E/M claims to see if they are really supported.

Educate docs on complexity: “Most providers need to understand the components that are in place for determining what constitutes a higher-level visit,” adds Morehouse. “It is the coder’s responsibility to bring this to the provider’s attention, particularly if there is a large volume of these services being billed on a given day.” It’s not to say that your provider doesn’t see complicated patients; perhaps it’s just that the documentation must support the high-level care code.

Pointer: If your provider’s documentation doesn’t meet the proper history, exam, or MDM levels for the high-level code he is reporting, check to see if he is trying to bill based on time alone. But be careful. You should only code an E/M service based on time alone if at least 50 percent of the visit was spent on counseling or coordination of care, and this fact must be noted in the documentation.

The 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/counseling and/or coordination of care (CoC)
• The reason for/topic of the counseling/CoC.  

Key: Be Careful With Nail Debridement and E/M codes

The CBR is a “warning shot across the bow” of podiatrists’ practices and billing habits that need to immediately change. This means that CMS is watching and will continue to do so until the abnormal percentages for the codes in question drop to the proper level or disappear completely. If not, a full-blown Medicare audit most likely will ensue. So it is imperative to fully read the CBR, and review the statistics presented as compared to your peers, and do the due diligence necessary to correct the impropriety.

To read more on the 2016 CBR, visit: http://www.cbrinfo.net/cbr201608-faqs#Report Specifics.