Primary Care Coding Alert

Teach physicians to create iron-clad MDM notes

You can't get inside your FP's head to know whether his MDM warrants the E/M service code that he reported -- but zooming in on key areas can help you decide whether a 99214 needed downcoding or a 99213 needed upcoding.
 
Medical necessity is the number-one thing missing from charts, says P. Lynn Sallings, CPC, compliance officer for Family Medical Center, Area Health Education Center-Northwest in Fayetteville, Ark. Whether a claim's medical decision-making (MDM) supports the level of service the physician reported is the first thing Arkansas Medicare and Medicaid auditors look for, she says.
 
But you can be your FP's front line of defense and make sure his notes withstand scrutiny, if you follow these tips.

1. Identify a Mismatch With This Strategy

In your next staff education meeting, remind your FPs that medical necessity should be the overarching factor they use to select the E/M service level (such as 99201-99215, Office visit or other outpatient visit for the evaluation and management of a new or established patient -). -Just because a physician does a comprehensive history and examination doesn't mean he should report 99215,- Sallings says. Medical necessity should drive the components that he performs, she says.
 
You can help ensure your physicians are selecting appropriate codes by occasionally pulling a sample of their charts. -Look at the patient's chief complaint and the encounter's outcome -- or it's final diagnosis,- Sallings says. If the primary ICD-9 code does not support a billed upper level of service, you should really read the chart notes, she says.
 
Example: A patient presents with a chief complaint (CC) of sinusitis, which is also the ICD-9 code that the FP reported -- 461.1 (Acute sinusitis; frontal). Although the physician could have performed and documented the elements necessary for a detailed history and detailed examination, -the CC of sinusitis probably wouldn't warrant 99214,- Sallings says.

2. Look for Potential MDM-Boosting Factors

But complicating factors could make 99214 and 461.x a match. The patient may have comorbidities or other chronic conditions, says Lori-Lynne Webb, director of coding and compliance with Saltzer Medical Group in Nampa, Idaho. And medications that the patient is already taking or adverse reactions the patient had to previous medications could increase the level of MDM.
 
Good idea: Ask your FPs to list complicating factors. Unless the chart spells these out, you have no way of knowing that a comorbidity, chronic condition or medication played a role in upping an office visit's MDM from low (99213) to moderate (99214) complexity.

3. Unveil Extra Complexity in These Places

Medication can lead to a higher-level MDM another way. Look at the tests and medications the FP ordered for clues to the extra complexity the physician may not be explaining, says Jean Keller, an auditor with Applied Medical Services in Durham, N.C. Two tips can make identifying increased complexity easier.
 
- Look in the history of present illness and review of systems to determine what the FP is trying to rule out.
 
- Encourage your FPs to state what diagnoses they hope to rule out or confirm. Be careful: Don't put such -rule-out- diagnoses on your claims. Doing so would be inappropriate coding.

4. Explain That -Labs Reviewed- Doesn't Cut It

Ask for more details if the physician writes something like -Labs reviewed,- Keller says. The patient may have had an adverse reaction to something he received in the emergency department. Likewise, if the physician followed up on the patient's blood pressure, find out what was wrong with the patient's blood pressure earlier.

5. Give Credit for Clear Management Options

Tell your physicians that they should clearly indicate when they-re taking an intermediate step that they don't believe will solve the patient's problem. For example, they may try physical therapy before resorting to surgery or antibiotics before a more aggressive treatment.
 
Explaining that they-re trying the more conservative treatment, but that the patient may require a more aggressive approach, can boost the level of MDM, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCA, coding manager for the University of Washington's physician group in Seattle. Documenting the extra step shows that the physician considered more management options (one element of MDM).

6. Emotionally Detach Yourself From Coding

Don't code a higher level of decision-making than the documentation supports. Often, coders will boost the MDM because they know the patients are in really bad shape, Bucknam says. -They get emotionally involved in the complexity of the problem and don't code what the doctor wrote down,- she says.