Practice Management Alert

Researched and prepared by Suzan Berman, CPC, CEMC, CEDC

With the introduction and now continued implementation of the Electronic Medical Record (EMR), it's more important than ever to make certain that the documentation supports the individual level of service for each patient being seen. With the creation of templates, smart phrases, easy text, etc. the clinicians are able to document more compliant to the E/M documentation guidelines without taking medical necessity into account. This is troubling to the payers and should also be to the companies creating the records as well as the providers using them.

Educating everyone within the healthcare stream is vital! The technicians and programmers need to understand why the documentation is so important and how they should be incorporated into the electronic note. It is also imperative to have this understanding so that records can be created, stored, and maintained appropriately. Educating the office staff, support staff, medical personnel, and management encompasses why signatures, dates, demographics, and more are essential and how it all should be compliantly entered into the medical record. And certainly educating the physicians about why the specifics within the documentation are needed and the over-riding umbrella of medical necessity are the driving force of clinical documentation improvement plans, and more manageable electronic systems.

The Office of the Inspection General (OIG) just published a report (May, 2012) illustrating the shift in the curves of billed E/M service toward the higher levels. The report doesn't directly point to the increased use of EMRs; however, it's clear that with documentation capabilities being more robust the trend is clear and the OIG is keenly aware.

Details of the report show that between 2001 and 2010, Medicare increased the payment of E/M services, from $22.7 billion to $33.5 billion.i E/M payments can range from $19 to $213 depending on the type of patient, the type of service, and the level of care provided. With this vast difference in payment, it is clear why this code set is a constant target of fraud, scrutiny and multiple interpretations of the guidelines.

The OIG launched this review from two prospectives. One was to look at the reimbursement based on the documentation. The other focused on the documentation mechanics (dictation, EMR, templates, forms, etc.) The services they reviewed were from 2001 and 2010. Notably, the latter dates would have a larger sampling of electronically documented records. It was pointed out that although the review didn't target potential fraudulent activity, it did mention two health care organizations had to pay back over $10 million to settle allegations about fraudulent billing.ii

It was concluded that in the top three (3) categories reviewed, (Subsequent Hospital visits, Established patient visits, and Emergency Room services) that, although the middle code (level 3 for the Established and Emergency services) was still the most often billed service, the higher levels of service are being billed higher. A statistical comparison is made in the table below.iii

With regard to subsequent hospital services, the 99232 (mid-level code) is still the one submitted most often; however, you can see a direct shift between 99231 and 99233 over the years in the following table.iv

Emergency Service Evaluation and Management codes saw the biggest change between the levels of service.v

The report points out that geographic location did not factor in to the equation regarding the physicians who consistently billed the higher two (2) levels of service. In fact, only three (3) states DIDN'T have physicians consistently billing higher in 2010 and they were Montana, Nebraska, and Wyoming.

The specialties billing the higher services more often were Family Practice, Emergency Medicine, and Internal Medicine with Obstetrics/Gynecology showing the largest percentage increase of those billing only the higher levels 4.3 percent as compared to their peers who are using all billing levels consistently at 1.9 percent.

Physicians who bill higher levels of service might say that they are seeing older patients, sicker patients, or patients with several comorbid conditions; however, the results of this study don't indicate this is the case. Their patients are around the same age, with the same diagnosis codes submitted, and the patients were no sicker than those seen by their peers billing all five levels of service.

As a result of this report, The Center for Medicare and Medicaid Services (CMS) as recommended by the OIG should continue to educate the physician community on the appropriate application of the documentation guidelines. This could include letters, in-person seminars, teleconferences, etc.

The Medicare Carriers will be reviewing more evaluation and management services (E/M) billed by physicians. With regard to the physicians who consistently bill higher levels of services as indicated in this report, those names will be provided to the carriers in those jurisdictions and depending on a cost/benefit analysis, there will be more extensive reviews done for those physicians.vi

The provider community could view this report as a call to order. Documentation is becoming more robust, more transparent amongst agencies and other providers, and it must be clear, clean, and relevant. It's imperative that the provider community make certain to put in place appropriate documentation improvement plans, and not just in preparation for ICD-10, but for cleaner claims, more appropriate billing, clearer care plans that ultimately result in better outcomes for the patients.

Education to the clinicians should be continually and timely. Physicians should welcome the education and not feel overwhelmed, over-scrutinized, or threatened. Educators should be accommodating with where and when the education is done and understand the providers prospective. They should develop their training tools for various ways to deliver the information. Meeting in small spans of times, taking a short break from patients or meeting early in the morning might be appropriate alternatives to more lengthy sessions. Weekend seminars and evening meetings with colleagues might also be great settings to provide billing and coding education. Webinars and teleconferences are also very productive ways to convey this information. The more the guidelines are reviewed, the easier they are to adapt into the patient visit flow.

EMRs are an amazing tool in the healthcare environment and went built and used properly will help the office flow, patient care, and the revenue stream. The higher levels of service might be appropriate levels of service, but the documentation must be there to substantiate not just the level of service, but also the medical necessity.

About the author: Suzan Berman CPC, CEMC, CEDC, has been responsible for teaching staff/faculty, advanced practitioners, as well as management and support staff about the nuances of documentation requirements and billing practices. She is currently the Senior Director of Physician Services for Health Revenue Assurance Associates. She has overseen the auditing process for several different specialties including General Surgery, Plastic Surgery, Cardiovascular, Behavioral Health, and several others. She teaching physician around the country about documentation as well as ICD-10 implementation.

Berman serves on the Editorial Advisory Board Member for The Coding Institute. She is a former member of the AAPC National Advisory Board as well as the former secretary for the AAPC Chapter Advisory Board of Directors.

She speaks both locally and nationally for organizations such as the University of Pittsburgh, The Coding Institute, Advanced Career Solutions, Audio Educator, AAPC, MGMA, and Optum Publishing.

FootNotes:

i Medicare payment refers to total Medicare-allowed amounts, which are 100 percent of the payment made to a physician by both Medicare and the beneficiary. Medicare pays 80 percent of allowed charges, and the beneficiary is responsible for the remaining 20 percent. http://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf page 1

ii http://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf page 1

iii Office of Inspector General (OIG) analysis of 2001 and 2010 Part B Analytic Reports (PBAR) National Procedure Summary File. http://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf , Appendix c, page 21

iv Ibid

v Ibid

vi Office of Inspector General (OIG) analysis of 2001 and 2010 Part B Analytic Reports (PBAR) National Procedure Summary File. http://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf, pages-14-15