Urology Coding Alert
Evaluation and Management Services
Thank you very much Mandy and good morning to everybody across the country who is joining in today. I am Jim Collins and we are going to be talking about evaluation management documentation and billing, which is really a topic that anybody in the healthcare field knows has been a topic for several years now and one that is really not going to be going away. So it is an area that we are all somewhat familiar with, just because we have been forced to consider it and a lot of physicians are burdened by these regulations, everybody that bills basically any insurance company in the United States is impacted by these rules.
Clarifications From CMS Make Burden Of E/M Regulations Easier To Bear
The rules are relatively vague; they are gray, they can be interpreted in totally different ways. However, if we fail to follow these rules or if we ignore the rules, we can be heavily penalized and it makes it very important for people to understand these rules. I am going to be presenting today a really physician friendly overview of these regulations--and is not even an overview, it is a physician friendly in depth review of these rules. So, if you have got physicians in the room, they are going to get a lot of benefit from it. Also if you have people in the conference today that are auditing these services on a regular basis, a compliance officer or internal coders, this is going to be a really beneficial conference for you. And unlike other conferences that you may have attended or other people you may have talked with about these rules, I am really a strong physician advocate in everything that I do and as you will see in the content we are going to present today, there have been several key clarifications that I personally received from CMS through my advocacy efforts that make these rules much less burdensome than you might previously think they are to you.
I have gotten, directly from CMS in writing, several clarifications that take the mountain of these regulations and turn them into a molehill that, really if physicians take the time to understand these regulations and put in place the tools that I'll present to you today to help make these things less of a burden and less confusing, doctors can actually decrease the amount of time that they spend documenting services and increase the revenue and do it 100% safely and compliantly and in an audit proof fashion. So, that is really the goal today, to get you in the right ball park on these rules take a little bit of the complexity out of the rules and makes them more applicable.
E/M Services Account For 40% Of Claims Or $28 Billion Reimbursed By Medicare
I like to get you to flip to page number 2, at the top, where I present kind of an overview of why this is such a broad reaching and important regulation. The biggest reason pf course that is above 40% of what Medicare expenditures are in the part B program--40% is a very, very large dollar chunk. We are talking about 28 billion dollars this year that the government is going to be reimbursing physicians for providing evaluation and management services. This is just the population, which is probably not even half of the total patient base that is out there, so, you can imagine that the Medicare regulations are geared towards auditing services based on these evaluation and management guidelines. Other payers, whether they will be Medicare, Medicaid or just non-government-related Blue Crosses, Aetnas and Cignas and so on, they are all looking at these evaluation and management documentation guidelines and how physicians are billing for these services because they are accounting for approximately 40% of the claims that are being reimbursed. So doctors are under the spotlight on these rules and regulations and it is not something that is going to be going away.
When we look at where the government is focusing their auditing efforts, this is really where it is. And the reason is twofold; one is that it is a high dollar service, it is going to be a high dollar impact that they get back from it, and also because there is a set of rules that says, this is what it takes a bill a level 3 service, a level 4 service, a level 5 service and they can actually set it up so somebody can come in and audit any given medical record and say whether it was coded accurately or overcoded. The rules of course are flawed. You can interpret the same medical record totally different ways. So it is not a perfect standard that they are using, but is one that they feel comfortable taking to court. They have been very successful in penalizing physicians in the past.
When we look at the bottom of page number two, you can see the dollar amount that Medicare has been spending in what they call the 'Medicare integrity program,' which is just one of several different initiatives that are out there to audit physician practices, audit healthcare facilities and see if they are billing things appropriately based on documentation and claims submitted.
Audits Of Physician Practices, Healthcare Facilities Are Lucrative For The Government
You can see that approximately 720 billion dollars is being spent, and that is in 2004, how much money was spent just on auditing investigating healthcare claims, billing data. They are getting back approximately 14 dollars for every dollar for every dollar that they spent. So if they put one dollar into the Medicare integrity programs, they are going to get approximately 14 dollars back from it, whether it be refunds or penalties or savings. So, this is a program that is going to keep continuing in near future. There is guaranteed funding for it into the next several years. And because they are getting 14 dollars back for every dollar they put in there, it is really a good place to invest money from the government's perspective. They are spending billions of dollars to audit physicians and healthcare facilities and they are getting a huge return on that investment. So, they are going to keep funding these initiatives long in the future.
When you look on pages 3 and 4, what you going to actually see is, what they call the OIG work plan for the last four years and this is just an excerpt from each of them. But if you really look on pages 3 and 4 of your hand out, which consumes four different slides in the material that we sent today, the government has been looking at evaluation and management services consistently since 2002. So, if you look, you can see the OIG work plan where they specifically mention that, at the top of page of number 3, they said they are going to be examining patterns of physician coding of evaluation management services to determine whether these services were accurately coded. Medicare allowed over 29 billion dollars in ENM services on prior years. We found significant portion of certain categories of these services billed incorrectly resulting in large overpayments. So this is just their most recent position they put in 2005 work-plan. Looking at the 2004, 2003 and 2002 work plans, you are going to see that they are consistently looking at evaluation and management services and I will let you read to that material later on, on your own.
Beneficiaries Are Being Turned Into Medicare Auditors For The Benefit Of CMS
On the top and the bottom of page 5, we kind of see how this stuff impacts physicians where the rubber meets the road. The top of the page is just a screen print from the AARP's web page (American Association of Retired People), and you can see here that they are not only auditing and investigating physicians based on utilization data, like the OIG referenced in their work plan, but they are also auditing based on phone calls that they are getting from patients. There is an initiative that they have originally called the 'who pays? you pay' initiative, where they essentially told Medicare patients in a number of different formats across the country that the Medicare Trust Fund is going bankrupt and one of the main reasons why is because physicians are submitting fault claims on a regular basis. They have told these Medicare patients that if they do not ferret out the fraud and abuse and get rid of the bad apples in the bunch, what is going to happen is they are not going to have any health insurance in the future. They did this in training initiatives, in publications, on the Internet, and also on the bottom of every beneficiary statement. There in bold print they put, 'if anything on this claim form looks inappropriate, you can call this 800 number and get a reward for it.' So, we have got, essentially, every single one of our Medicare patient is being turned into a Medicare auditor for the benefit of CMS. It is never going to benefit the physician practice, but each time we submit a claim to Medicare, the patient is going to be getting a statement that says if this looks like inappropriate claim, you can call this 800 number and you might get a financial reward. So, there is this incentive that is being given to Medicare patients to really closely scrutinize claims. What happens as a result of that, is that we have patients calling an 800 number saying, I think this is inappropriate and triggering reviews left and right in a really randomized fashion. This could be even if a doctor is taking the tact of saying 'look I am going to bill nothing but level 3 services because I want to avoid the audit radar and I do not want to look like and standing up for my peer group. I will go ahead and take the $120,000 or $150,000 hit on an annual basis just to avoid the risk of audit.' Even a doctor that does that, he/she can still be audited based on the fact that any given Medicare patient might pick up the phone and say that the claim is inappropriate. They could do this just because they are confused about a government's statement. They could do this if you are employing nurse practitioners, physician assistants, and a patient comes in and spends 45 minutes with your nurse practitioner, has the best conversation she has had all month and then comes back home, a couple of weeks later, and gets a statement from Medicare saying they got a bill from the doctor that the patient does not remember meeting with over the last 6, 7 and 8 months. You know of course, the claim was billed out under the incident-to provision and was appropriately reported under the doctor's number, but the patient might pick up the phone and tell the government, 'some doctor submitted a claim for me for $160 and I have never seen him before, or I have never seen them this year,' for example. That is going to trigger an audit and then we are going to be accountable to make sure that you are following these E/M documentation guidelines.
Regulations Allow For $30,000 Penalty For A Single Count Of Upcoding
Bottom of page number five, you can just see one example of a physician who did get penalized probably close to the maximum of what a single claim can penalize you for. This doctor got convicted of a single count of upcoding. He got penalized with a prison term of 18 months, a $30,000 penalty, three years of supervised release. And this is all for a single count of upcoding. In practicality, this was probably a plea bargaining agreement, but this kind of gives you an idea what the regulations are that are out there. You know the most severe regulations out there do allow for penalties of this nature to be implemented against physicians for billing inappropriately. So it makes it important to understand these rules and to follow them.
On page number six, I gave you a quick overview of one of the initiatives that I took on year or so ago, and this is where we took on a specialty specific review of these guidelines. The reason behind the review was to identify best practices for auditing and reviewing medical records so that we could train physicians on how to best document their services. What I did was I took five evaluation and management services. all from a real cardiology practice, I cleared out any patient identifiers, any practice identifiers, doctor identifiers, and sent out the same five records to 10 certified coders that all specialized in cardiology. And the reason why we did this on a specialty-specific basis was just because the same set of rules and regulations applies to every single specialty that is practicing medicine. There are going to be variations from one specialty to another. And if you are working with a consultant that tries to cater to each difference specialty under the sun, there is going to be a certain percentage of times where they do not recognize an abbreviation that is being used or they do not understand the medical complexity associated with a specific condition and might not give you full credit for it. So this review is designed to be specialty specific so that we would have people that understand what a PTINR is, what Coumadin is, what congestive heart failure is. They understand the severity of these conditions and can apply the rules on a unified fashion.
On the bottom of page number six, you see a quick overview what the credentials of these people were and on average, I believe, we had 12 years of experience all certified coders, all working in cardiology groups. So it was really what I call the cream of the crop that reviewed these records with the thought that we are going to get back really similar audit findings because they are all looking at the same exact five medical records.
On the top and bottom of page number seven, you can see the data from this review. The top of page number seven shows, chart-by-chart basis, then it also breaks it down by the assigned levels of history, exam, complexity, the service code, the level of service that was reported, and also the service type. And you can see just looking across each of these different lines of data, you can see that there are considerable variations from one coder to the next as far as how they reviewed each of the five different claims and assign a code.
Proof That E/M Guidelines Are Inherently Flawed
At the bottom of page number seven, it kind takes all that data and puts it in to a nice understandable format for you. In a nutshell, we had a 48% degree of correlation, and 'correlation' is just saying, if we were to take any given chart and assume that the most frequently assigned code was the correct code, how many of the ten auditors actually assigned that most commonly reported code? So, we are not saying whether this was the correct code or not, we are just saying this was the popular code based on this audit. How many people pick that most popular code? And on average only 48% of the people picked the most popular code in the review, which to me is the shock because: 1) it is a specialty specific review; 2) everybody is applying the same exact standard; 3) -everybody understands every single word that was documented in the report. So, this really shows that the guidelines that were applying are flawed. There is nothing wrong with the people that reviewed these records, there is nothing wrong with the medical records themselves--they were all very clearly legible, I believe they were all transcribed out as opposed to being hand written and interpreted different ways. This really clarified for me that the guidelines are substantially flawed, when we do not even get half of the people agreeing on the code.
So, I come from the perspective that the rules are problematic, they distract physicians from patient care. However, because we can get a $30,000 penalty for a single count of upcoding it makes it so you really have to take on the effort to educate your physicians about this. You also have to be reviewing their medical records and their billing data on a regular basis, whether you do a quarterly or twice a year, even if you want to do it monthly--it is a good investment of your time and resources because if you do not take on these initiatives, you can get heavily penalized to the point that is going to shut your practice down. Also what you will find in auditing these services and taking on training initiatives, is that doctors can work less and make more money. And that is really a good goal to have because you are going to have the best the both worlds here.
How To Pick The Right Level Of Service Every Time
So with no further ado, we will dive in and start talking about what the concern, is what is the whole area that we need to focus on with assigning different service levels? And that is really the most complex element here with E/M coding-- understanding how to pick the right level of service and doing it in a consistent fashion, one that is audit proof.
On the top of page number eight, it shows you what the unadjusted allowed amounts are for Medicare patients. This is just the national average; of course your individual carriers, you are going to pay slightly more, or slightly less than this, based on local geographical adjustment factors like the cost of employment and how practice insurance rates in your area and all these other things. But this gives you a good ballpark--a level 1 service pays a little bit over $20, whereas the level 5 service pays about $100 more than that. When we see an established patient in the office, the doctor has to choose, was this a level 3 service or was this a level 5 service? If they choose the level 3, they are going to get above $53 for it. If they choose the level 5, they are going to get more than twice that amount and because the doctor is the one that is going to be receiving the check, there is this incentive to start billing higher levels of services. Just because if you put down a 5 instead of a 3 you are going to get more than double your reimbursement, which is a pretty good incentive to bill level 5 all the time. Actually, when AMA first introduced evaluation services, there were three different levels of service out there, and what we started to see on a national level was a tendency of providers to just bill all level three services; so they converted these into these five different service levels for certain service types, like consults, evaluation and management services, office-based evaluation and management services. They have got three service levels for hospital admits and hospital follow up services; but what they started seeing was as soon as they converted, doctors started leaning towards the highest levels of the service, which, to the Medicare program, spending 40% of their budget on these specific services looked like it was an abnormality. They came out with an initiative that said we are going to penalize you if you bill a level 5 when all you really provided was a level 3 service. So they are looking for doctors that are consistently billing the higher level of this service, but actually providing a lower level of service.
Guidelines For Billing A Level 3 Versus A Level 5
Based on pressure from physicians, CMS, the American Medical Association came out and developed the different sets of documentation guidelines so that physicians would have a guideline to follow that would basically prevent them from getting penalized for overbilling. Doctors said, 'we are going to be providing level 4 and level 5 services. What does the documentation need to reflect so that we cannot get penalized if we get audited?' And that is where the guidelines came from, they came at the request of physicians across the country, through specialty societies and so on, so it is really an important set of rules to understand because it is applicable, we asked for it and we got it.
Only A Very Small Percentage Of Patient Encounters Should Be Billed Based On Time
When we look at, what does it take to bill level three versus a level five, there are a couple of different pathways that you need to consider, which I have mapped out on the bottom of the page eight for you. The first thing is, you have to determine do you want to bill based on time or do you want to bill based on the documentation, elements of history, exam and medical decision making? If we bill based on time, it is really going to be a cut and dry path to follow. One sentence is going to be basically support the different service levels. However, there is only a very small percentage, for the average physician, of your patient encounters in which you are going want to follow those time guidelines. We are going to talk about that first because we can really fully address that in a relatively short period of time and then we can devote the rest of today's conference to focusing on the evaluation and management documentation guidelines for history, examination and medical decision-making.
If we are going to go down that pathway, as you can see on the bottom of page number eight, we also have to make another decision and that decision is, do we want to bill based on with they called the 1995 documentation guidelines or do we want to bill based on what they call the 1997 documentation guidelines?
In 1995 the first set of rules came out and after it was implemented, we had a lot of specialty physicians complaining 'I might not be doing a full general multisystem examination on my patient, but I am a specialist, I am providing a very intensive review of a certain single organ system, I still want to be able to bill out level 4 and level 5 when I provide them.' There was a lot of merit behind that assertion so the government came out with an initiative to kind of compensate for that specific factor. They developed another set of guidelines in 1997 that was really geared towards the specialist. And it said, 'if you provide a really extensive review of this single organ system--whether it be neurological or cardiologic or genitourinary, or whatever--if you do a very extensive head to toe review that is really just specific to this one organ system, you can still bill at these higher level of service, but here is the specific bulleted elements that you need to be documenting, pertinent to your specialty in order to bill level 4 or level 5 services.'
Why Full Conversion To The 1997 Guidelines Was Put On Hold
The 1997 guidelines when they were developed were intended to replace the 1995 guidelines that become the only standard. Of course once we reached the deadline where they were supposed to switch over from allowing the 95 guidelines to forcing us to use the 97 guidelines, there was just one of the most unanimous outpourings from every single physician specialty across the country putting pressure on the government to not make that switchover happen. The 97 guidelines are really burdensome, bulleted elements, shaded boxes. It really took it to the point that it was crippling physicians' ability to care for patients and to document things that are medically appropriate and doctors were really forced to examine things that they did not feel were appropriate if they wanted to be able to bill out even a level 4 service. So at that time, after the government felt that pressure from pretty much all the physicians across the country, they said that there are going to put the conversion to the 97 guidelines on hold. They said until they came out with a better set of rules what they would allow is either the 95 or the 97 guidelines in the event of an audit, which ever set is more beneficial to the doctors is the set that applies.
In a little bit, we will talk about the distinguishing factors between the 95 and 97 guidelines, but first I really want to talk about that first pathway on page number eight for you, which is billing based on time, because it is totally different methodology that needs to be followed--billing based on time as opposed to history, exam and medical decision making. So we will talk about time first, get it behind us and then focus on the more voluminous set of the guidelines, which are history, exam and medical decision making.
One the top of page number nine, you can see that, like I mentioned a minute ago, these time guidelines are not beneficial for most patients. The portion of your patient base that it is going to be billed based on time is going to be those patients where the doctor is spending an exorbitant amount of time counseling the patient and coordinating their care as opposed to providing a traditional history and physical for the patient.
Guidelines For Billing Time In The Office And In The Hospital
There are actually two different standards of time guidelines, one is office-based and the other is hospital-based. If we are dealing with an office-based service, what they want to see is that the majority of the face-to-face time between the patient and the physician--and it is an important distinguishing factor to make because it does not count the amount of time that the patient spends registering at the front desk, it does not count anytime that was spent with the registered nurse in the examining room (if the nurse came in to take the chief complaint from the patient, to get a brief history from the patient, talk to them about the prep work that they are doing before the doctor actually comes in and sees them) that time does not count; it is only the amount of time that the physician spends face to face with the patients that counts. Of that face to face time, if we can show that more than 50% of that face to face time was spent in counseling or coordination of care--and that is as opposed to traditional history and physical visit with the patient--if we can show that the majority of the face-to-face time was counseling and coordination of care, then what we can do as bill based on the time guidelines. If we cannot show definitively, in the medical records, that 50% or more, well, the majority of the face-to-face time was spent in counseling coordination care, we cannot use these time guidelines whatsoever. So that is an important factor to understand.
The other set of guidelines that is specific to time is hospital based. In the hospital they count that face-to-face time with the patient, but they also count what they call unit or floor time, and that is going to be the amount of time that the doctor spends in the patient's unit, where they are obtaining diagnostic test data, where they are reviewing the rounding notes of the other physicians that are also seeing the patient, that amount of time also counts towards this coordination of care time. We want to see that the majority of the face-to-face time and unit floor time was spent in counseling and coordination of care with the patient. So as you can tell, just by these two standards that have to be met before we can bill based on time, it is not going to be the majority of patients for most physicians. For some physicians they just spend a whole lot of time and that may be because of their subspecialty, it may be just because of the way that they are colloquial with patients, so they take a long time talking to the patient about treatment options, therapy response, things like that. Other doctors get in and are very efficient with the patient, they spend very little time, but when you look at the amount of work they did, they are able to bill out these level 4 level 5 services on an occasional basis just because they are doing a very extensive examinations on the patient and there is a lot of complexity associated with that. So for those patients where the majority of time was spent in counseling coordination of care, those are the ones where we want to bill based on the time guidelines. In the medical record, what has to be established are two things, one is how much time was spent with the patient and again in the office it is face to face time only, in the hospital it is face to face time plus unit or floor time. The medical record also has to establish that the majority of that total amount of time was spent in counseling or coordination of care.
How To Document Time In The Medical Record
So the bottom of page number nine shows you examples of what you want to be seeing. You want to actually see a statement in the medical record that says something like one of these three that are at the bottom: '45 minutes were spent with the patient, 30 minutes of this time was dedicated the counseling regarding treatment options.' That is going to be perfectly clear in establishing that the time guidelines apply. Other example is, one-hour face-to-face, 40 minutes equals coordination of care. That is going to be enough to establish that the time guidelines apply. Now you do not want the medical record to say this and nothing else, but this is what it is going to take to establish that the time guidelines are applicable and also to tell us how much time we want the base the level of service on. In addition to this documentation, which is like a threshold before you can bill based on time, you are also going to want to have a description of what was discussed with the patient. If we spend an hour talking to the patient about the treatment options, briefly summarize what treatment options were discussed, which ones were chosen, because that is going to accurately show what the visit consisted of and that is going to help whoever is following behind the physician in managing the patient. It is going to give them an idea of, yes this option was considered, but it was declined because of this contraindication or because the patient had an objection to it, whatever was discussed--that needs to be briefly summarized in the record in addition to this information that is just specific to billing.
The time guidelines that currently apply--if you look on the top of page number 10 you can see the actual number of minutes that we are looking at. Established patient visits are going to be the most frequent one for most doctors. You can see once you have spent 40 minutes with the patient, the majority of that time is spent in counseling and coordination of care, you are clear, you have a green light to go ahead and bill a 99215 and you are going to be audit proof. You have just got to establish those two things in the medical record: how much time was spent with the patient and that the majority of that time was spent in counseling and coordination of care and you are going to be fine. So if you see a service type that you provide frequently that is not listed on the top of the page 10, just flip to your CPT book, in the actual definition of the E/M code, they say how much time is typically spent with a patient. That is what the time guidelines are for those different service levels.
Next we are going to talk about the documentation guidelines of history, exam, medical decision making. For 90+% of your patients, it is going to be more beneficial to the physician, more profitable to the practice and more appropriate to bill based on history, exam, and medical decision making as opposed to billing just based on time.
CMS Distributed An Audit Tool Based On Official Documentation Guidelines
The bottom of the page number 10 gives you somewhat of a disclaimer in that what I am going to walk you through is based on the most commonly used auditing tool that is out there. It is one that CMS looked at and they distributed to each of their individual Medicare carriers and told them, if you need an audit tool to utilize to apply these documentation guidelines, here is one that you can use. CMS did not officially endorse the audit tool, they did not develop the audit tool, but the fact that they distributed it to all of their carriers and said, 'if you want to you can use this,' gives it the most validity of anything else that is out there. Of course it is important and understand what the documentation guidelines are, and if you want to see exactly verbatim what they are, the 95 guidelines and the 97, I put the web page on slide number 20 for you, which is at the bottom of page number 10. You might go to that and just print them out for yourself, you can read them from cover to back. They are really a quick read and it will take it so you can see the verbatim definitive guidelines as opposed to relying on my overview, because we can not just sit down and read through the guidelines for you today, I've got to give you information that is in a user friendly format so you can walk away from this teleconference and actually apply the rules in practice. Reading through the guidelines would not be providing you a good service. I am going to be presenting the information in a way that you can understand and apply it. It is based on the audit tool that CMS distributed to all of its carriers, which is based on the official good documentation guidelines, but as an additional safety net for your practice, it would be good for you to go that web page and print out the guidelines and just review them because there may be things that apply to your specialty, or your individual practice, that are not accurately reflected in this summary of a summary of the documentation guidelines. What I am going to be giving you, you can still take it to the bank, it is going to make your documentation come in line with these rules. It is going to make it so you can more accurately bill your services out, but it is still good to see the definitive rule. Whenever I find something that impacts the practices that I work with, I always like to get the official word myself as opposed to looking at what somebody else summarized about it.
The Differences And Similarities Between The 1995 And 1997 Guidelines
Top of page number 11, there are only two differences between the 1995 and 1997 guidelines. Under the 1995 and the 1997 guidelines, in the element of history, there is an element of what they call the history of present illness, and we are going to be talking exactly about what this history of present illness is briefly. Under both sets of guidelines, if you document four elements of the history of present illness, you are going to be supportive of the highest possible level of history of present illness. There are really two different levels of history of present illness; if you get four or more elements under either the 95 or the 97 guidelines, you are going to support the highest-level history of present illness. There is a finite set of elements that you get credit for, there are actually eight elements of history of present illness that you get credit for. To get to the highest level of history of present illness, you are going to have to document four of those elements under either set of rules.
Under the 97 set of rules, they also say, if you document the status of three chronic or inactive conditions, you can also get credit for the highest level of history of present illness. That is a provision that is not reflected in the 1995 guideline. It is a very small difference, but that is one of the two differences between the 95 and the 97 guidelines. Everything else in the history section--the review of systems, past and the social history, the requirements to document chief complaint--is identical from one set of rules to the other. It is just in the 97 guidelines they give you the three chronic or inactive conditions and they do not do that with the 1995 guidelines.
Exam Section Of 97 Guidelines Can Distract Doctors From Patient Care
The only other difference between the 95 and the 97 guidelines is what they call the exam section and there is a huge difference there. They are not comparable to each other. They are two totally different worlds, what it takes to support each given level of service. The 95 set of rules is much more concise with less documentation requirements, much less of distraction from the patient care. The 97 set is where we have all these boxes, bulleted elements, some are shaded, some are not shaded and there are these implied rules that you have to do a service, you have to do an examination, but you do not actually have to document it and it is really a hokey pokey, witchcraft type set of guidelines, for the 97 set is, for exams. But that is the only other distinguishing factor between the 95 and 97--one is the histories of present illness where you can document three chronic or inactive in the 97 set of rules; the only other difference is the exam section, which are two totally different worlds. I will show you what each of those looks like and allow you to make that decision yourself, as far as which set to use.
First off, we will talk about the things that are similar between both sets of guidelines. The first thing is that in each of these three different areas of documentation--which again are history, examination, medical decision making--each of these different elements of documentation can be supported at one of four different levels. When we are looking at history and exam, there are two similarities that are going to hold true. First off is that the four different levels of history and exam are both referenced the same way. They are both defined under history and exam: the lowest level is problem focused, the next lowest level is expanded problem focused, next step is detailed and the most comprehensive is what they call comprehensive. So the four different levels of history and exam, they use the same terms to describe both of them.
The Required Level Of History Always Matches The Required Level Of Documentation
Another similarity in the guidelines is that for every different type of service that is in the book, the required level for documentation for history and exam is going to be identical. So for a level 4 service, we are going to have a detailed level of history and exam. Level 5 service, we need a comprehensive history and exam. We switch over to consult, if you want to bill a level 2 consult, we are going to need an expanded problem focused history and an expanded problem focused exam. No matter what level of service, no matter what type of service we are talking about, the required level of history is always going to match the required level of documentation for exam. So that is one of the things that you might just understand that if we need a detailed level of history, we are going also need detailed level of exam.
When we flip over to the third documentation component, which is medical decision-making, you will see here that there are also four different levels of documentation and these are defined as straightforward, low, moderate or high. So it is the same concept in that there are four different levels that here they refer to these are straightforward, low, moderate, and high as opposed to a problem focused, expanded problem focused, detailed and comprehensive.
Top of page number 12, the first thing that you need to make sure is documented is that chief complaint. The chief complaint is really just something that the documentation guidelines specifically say that this is indicated at each different level of history.
Encourage Doctors To Document Chief Complaint For Every Single Visit
So, I like to think of it as, in any give note, if you are going to be trying to assign a level history, you have got to clearly show that there was chief complaint documented. One of the things you can do with your physicians is to encourage them and to monitor their compliance with documenting a chief complaint in every single visit note. Whether it would be hospital admit, a consult, a follow-up office visit, or subsequent hospital-care visit. Make sure the first thing they put in their note is chief complaint and then say why they are seeing this patient. One of the most problematic factors I found in reviewing just tons and tons of records, several thousand of it at this point in my career, is that when we look at subsequent hospital care visits, one of the things that hurts physicians the most is that they put 'the patient has no complaints.' That is going to be their chief complaint--asymptomatic. And when you look at these guidelines under the guise of what the Medicare auditor is going to look at, they are going to say, I need to pull out a chief complaint from this medical record.' What they are going to need to do is go in to the history of present illness and pull something out of that in order to establish why the doctor is seeing the patient. That is going have a detrimental impact because now, all of a sudden, where we would have had the four elements of history of present illness for the support of the service level, we just lost one or two of them because the auditor is going to be assigning that as a chief complaint. Doctors can avoid that by writing, 'chief complaint: follow-up to this specific problem, today they are asymptomatic.' That is going to eliminate the whole area of confusion.
The next element within the history is on the top of page number 13. Here we have got what they call the history of present illness. I am not going to read through and define what each of these are, but there are eight different distinguishing factors that describe the patient's condition either from the first time that the problem became a problem or from the last time that the doctor saw the patient. We are describing what is the location of the problem, what is the quality of the problem, the severity of it--and for the severity, you might think of it like on scale of one to ten, how intense is the patient pain? Duration is really just how long the problems have been present; timing--is the problem worse or better at any specific time of day? The context is really a wide target for you. If you get in an audit situation and an auditor says, 'this service was billed as a level four, but our review shows it only supports a level three and the reason why that is, is because of the history of present illness.' You can take that 'context' element and say, 'the context of the problem is the patient's whole care setting.' What is the context of the patient's condition in which this problem is present? Really make a case that the context of the problem is reflected in the patient's H&P. The context element is one that has not been really clearly been defined by anybody. So the context is one that is kind of a gray area that you can make the case for if you absolutely need to.
Modifying factors describe what can the patient do to alleviate or aggravate the pain, such as 'my symptoms get worse when I drink caffeine,' or 'if I go up a flight of stairs I become short of breath,' or 'if I move my arm I get this pain in my shoulder.' That is going to be what they call modifying factors, things that the patient can do to modify their condition.
Associated signs and symptoms are really just what other conditions, what other symptoms and signs does the patient have in relation to their chief complaint? This is something that doctors are typically going to be asking patients left and right. You are coming in with one specific condition, is there any thing else that you have that is associated to this, something that is just routine in the patient's care setting.
The HPI Elements Can Be Documented As Positive Or Negative
At the bottom of page number thirteen, you can see the areas that I have gotten clarified from CMS in recent months, and this stuff really helps us out quite a bit. The biggest thing is that the history of present illness elements can be documented as being positive or negative. This is a very, very big benefit to physicians because for some of these elements, the patients are going to be coming and they are not symptomatic. They are asymptomatic patients, they have got a condition that they were diagnosed with whether it would be weeks ago or months ago. They are coming in today and they are not having any problems. When we look and say, 'what is the severity of your problem?' Well it is not severe, it is non-existent at this point. 'I am following up with you for this chest pain because you said to follow up in six months to make sure that my problem is resolving' and all this other stuff. The other elements that are on there that can be documented positive or negative are things like the associated signs and symptoms, modifying factors, the timing of the problem, the location of the problems, you typically are going to be able to document out. But what I mean by positive or negative is if the patient responds negatively, meaning 'I do not have any associated sign or symptoms,' it is absolutely important that you tell your doctors to record those responses. A lot of doctors will be asking the patient if they have any associated signs or symptoms but they will not record in the medical record. They are only going to be recording things that are positive in nature, meaning 'yes I do have associated signs and symptoms and I noticed I have got this numb tingling feeling in my index finger that is associated with this pain that I have been having in my shoulder.' If the patient says, 'no I do not have any associated signs of symptoms,' make sure that your doctors know to document that because they will get credit for it. A lot of these HPI elements can be documented as positive or negative if doctors do not understand they get credit for that, they are not going to document it.
Four Elements Of HPI Are Necessary For Many Commonly Reported Service Levels
On the bottom of that slide, on the bottom of page 13, you can see that I have got the different levels of service that require 4 elements of history of present illness be documented. When we are dealing with the established patient visits, if you want to reach the level of history that is necessary to support a level 4 or level 5 follow up visit, you have got to have four elements of history of present illness documented. Similarly level three, level four and level five consults, whether they be inpatient or outpatient, needs to have four elements of HPI documented. If you want to support the lowest level of hospital admission, you have got to have 4 elements of history of present illness. You can have a six page H&P that is the most detailed document ever created by a doctor, but if they only have three elements of history of present illness documented that technically is not going to support a 99221, the lowest level hospital admission possible because four elements of HPI need to be documented there. And similarly if you are doing billing at a high level subsequent hospital care visit 99233, you are also going to have to have four elements of the history of present illness.
The next element of documentation on page number 14 is the review of systems. Really, there is not too much to these guidelines. They just give us a list of systems, organ systems. If the doctor reviews those elements, they are going to get credit for it. If you want to get up to those highest levels of service, which are really the same levels of service we just talked about on page number 13, you are going to need to have ten of these review of systems. There are a couple of shortcuts that you can take with review of systems that we are going to talk about on just a few of these slides, but I am going to put that on the back burner for right now so we can talk about the last element of documentation which is past family, social history. These things are relatively self-explanatory.
How To Document Past/Family/Social History
The past history is any information that you record about the patient's past medical history, you are going to get credit for under past history. So if you say something simple about a prescription that the patient has been taking, or any diagnostic test the patient has had, any operations they have had, any therapies they have been on, any conditions they have had in the past. A single little statement about something specific regarding the patient's past history will give you credit for this.
Family history has to be something specific about the patient's family history. One of the things that is problematic is that this is sometimes not documented for elderly patients that are coming in with problems that there family history really would not have an impact on, regardless. It is still important that if you are going to be relying on supporting a higher level of service, you want to document something about past family and social history, something specific. I will talk about another concern with that in the next slide here too.
The social history is really anything that is impacting the patient's healthcare status in regards to their social habits. So a lot of times we will see here if the patient smokes. The patient drinks alcohol, if the patient has a rigorous exercise regimen you could use that; caffeine intake, you could use that. It is something just specific about the patient's social habits that would impact their healthcare.
On the top of page number 15, I have got some things that are really important to understand before we move on from this history section, because these are the things that really take the glut of these documentation rules and makes it manageable for most physicians if they just take the time to understand these elements and also these areas of interest that we are going to talk about.
Medicare Will Not Give Credit If Family History Is Documented As 'Noncontributory'
Top of page 15, if the doctor says something is 'noncontributory', they do not get credit for it and when I talk about family history that's why that is really becomes important. A lot of hospital admit notes that I have reviewed would say, 'the patient is 85 years old, presented to the emergency room for chest pain. Family history is noncontributory.' What the doctors are saying is, 'look it does not matter if this patient's mother and father are still alive or not. This patient lived into their mid or high 80s and this is the first time they are coming in with a suggestion that they have some sort of coronary disease.' So family history is noncontributory. They are saying that they do no feel it is necessary to ask the patient about family history. That's what Medicare auditors have clarified as their position on it: if you document family history as noncontributory, you do not get credit because they assume the doctor felt it was not necessary to ask the patient about family history. The same could be said about review of systems, social history, past history--if they say noncontributory, they do not get a credit. They need to say something specific. So it is much better to say the patient has no family history of early coronary disease or father died at 50 of a stroke or mother is alive and well. Something specific about family history needs to be there, if you are going to rely on that.
Past family and social history is necessary for your low-level hospital admits and that is frequently missing from notes--that family history is either not mentioned or documented as noncontributory--that is going to hold you back. It is not going to allow you to officially bill low level hospital admit, which is very alarming for a lot of groups. Past family and social history is going to be necessary for your new patient visits and your consults above a level 3. One of the things about past family, social history that is beneficial is that when we are dealing with subsequent hospital care patients, which is where the doctors are rounding on patient billing 99231, 99232 and 99233. They do not have to record past family or social history. That is where their reference as an interval history in the documentation guidelines and in the E/M book. The interval history means that you do need to document past family, social history in the note.
If we take all the elements that we talked about so far and look on the bottom of page 15, you can see that these things are all kind of classified in a grid that helps put them into perspective because if you look at the top of this grid right underneath the title where it says the level, if you look underneath there the first box underneath the word level and the title of that slide number 30 is what they call the detailed column. And if you want to bill a detail level of history, if you want to support a detailed level of history, you have to essentially have everything that is in that column below the word 'detailed.' Similarly, you have got problems focused, expanded problem focused, detailed comprehensive. If you want a detailed history; you got to have 4 or more elements of the history of present illness. You have got to have between 2 and 9 review of systems documented. You got to have at least one past family, social history documented and that is to get up to a detailed level of history.
Taking Shortcuts Through Both Sets Of Guidelines
On the next page we have, where we start to see a light at the end of the tunnel--because I know I just thrown a lot of little specific documentation requirements at you--but there are really elements in both sets of guidelines that make these things less of a burden and I call these shortcuts.
At the top of the page 16 you can see the documenting all positive, pertinent negatives and stating "all others negative," as far as review of systems will give you credit for the full review of systems. When we look at documentation, a lot of times doctors will mutate this verbiage a little bit, they will say something about positive, something about negative and then they will say 'all other is noncontributory.' And that is where we go from being 100% safe to that zone where Medicare has clarified that if we take family history as noncontributory then we do not get credit for that; they have also said that if we say 'all others are negative' in regards to the review of systems, that we will get credit for that; but what if we say review of systems noncontributory? It is a kind of gray area. I would really recommend you encourage your doctors to stay away from that gray zone and instead of using that verbiage try to get them into the habit of using the verbiage that is specifically recommended and referenced in the guidelines, and that is in the review of systems put the positive and the pertinent negatives and specifically state all others are negative. Actually use those three words in their notes. That way, instead having to document out every single one of the review of systems element they can just stay those brief work and get full credit for it. It does however establish that the doctor asked the patient about all these different review of systems, so it is not as simple as just getting a rubber stamp and saying 'all others are negative' and slapping it in every visit note. It is establishing that the doctor asked the patient about all the review of systems.
Also, a comprehensive history is going to be credited if the documentation establishes that the patient's condition precludes the doctor from obtaining a history. So if we have a patient who is not responsive to verbal stimulants, the patient is intubated, the patient is not coherent--any of these things are going to establish a comprehensive history if the doctor documents that. So it is a simple statement, the patient is intubated, cannot obtain a history. They get credit for HPI elements, 10 review of systems, past family and social history. They get full credit for everything. Their documentation just needs to establish those two factors: cannot obtain a history, here is the reason why.
Pros And Cons Of Patient Forms
We can have a staff member or the patient record the review of the systems and the past family and social history before the doctor even sees the patient and still get credit for it, as long as the doctor references the he or she reviewed that documentation. The way this really works is that we can have a form that the patient and/or the nurse completes that obtains a full review of systems, past family and social history; Doctor walks in the room, reviews it, signs off that he or she reviewed it, they get credit for the whole thing. I have got an example of that on the bottom of page number 16, which I understand is in pretty fine print but it kind of gives you a full page layout of how you might design a form. This is one that I have applied in several different practices and the doctors absolutely love it. It is something that gets done before the patient even walks in the examining room. The doctors have said, this form has caught things that I would not have to ask the patient about and I really like it. Other doctors say, 'I do not want to be asking the patient about all these different conditions, because if they document that they have a specific problem that is unrelated to the reason why I am seeing them, it establishes this clinical requirement that I at least addressed the problem.' So there are good things and bad things to using a form like this. I like it because if it facilitates compliance with these regulations, it generates a nice document that is going to essentially support the higher levels of service and make us somewhat audit proof before the doctor even sees the patient in regards to these elements.
Capturing The Chief Complaint On A Preprinted Form
Couple of things to note: chief complaint and history of present illness the doctor still has to document personally. So that is not something we can address with a form like this. Also we can take a form like this on the bottom of the page 16, it is going to have all the review of systems, all the past family and social history. Next time we see the patient, we do not need to re-record that information. We do not need to fill out another form. All we have to do is reference that the doctor reviewed it, updated it with the patient, and referenced the date and the location of it in the current visit note. The way that I like doing that is actually having an encounter form that has a specific reference to the date and the location of the chart. If you look at the top of the page 17, you could see an example of how you can set up a form to do that. You can see right below the title there is a line that says 'name, ID, date of service' and so on. Chief complaint on the next line and then there is a check box. The doctor checks off here and that says the patient questionnaire was reviewed, the date on the form was February 15 and it is located in the patient's chart. Just checking off on that form and putting the date on there is going to show that the doctor reviewed it. If there is any change to it, they are going to write that out on the current visit note and they will get credit for that previously recorded review of systems, past family and social history, with just a few strokes of the pen. Doctors that I work with typically like to have that form repopulated by the patient and the nurse, at least on an annual basis, but there is no guidelines that specifically says how frequently you have to have the patient complete the paper work but most practices that I work with like to use a one year rule some of them actually use a six months rule, but it is not something that I have personally seen clarified in any regulation. That is pretty much the history element.
The Exam Element Of Documentation: 1995 Versus 1997 Guidelines
On the bottom of the page 17 you can see what essentially the 1995 documentation guidelines reference as being the exam requirements. On the left hand side of this chart you can see there are two different boxes, one is body areas, one is organ systems. And if we want to get up to say, an expanded problem focused level of the exam, what is going to be the second highest level, we are going to have to have between 2 and 4 areas of body areas or organ systems documented is being examined. Under the 95 set of rules, they do not specify how much documentation has to be there to establish that you reviewed a certain body area organ system. So, you could essentially say, 'skin negative' or 'cardiovascular within normal limits' and you will get a credit for examining that organ system.
Under the 97 guidelines that I will show you in a second, it is a lot different than that. But on the 95, they do not get specific. You still, of course, want to make sure your doctors document what is clinically pertinent to them. We do not want to change their clinical pathways, we just want to make sure that the documentation supports what they are billing and that they are billing these things out appropriately--not more than they should be, not less than they should be. The one thing about the 95 guidelines that is relatively difficult to swallow and somewhat absurd, is if you look at the difference between the detailed and the comprehensive exam you will see that under the first, second and third levels of the exam--problem focused, expanded problem focused, detailed--they give us a credit for examining both body areas and organ systems. If we want to jump from a detailed level of exam up to a comprehensive level of exam, they only give us credit for the organ system. And that is really just something that does not make any sense; you can have a document that has a whole a lot of information about examining body areas, and if they fall short of 8 organ systems it is going to limit them to billing a detailed level of exam. Not fair, not a lot of logic behind it, but it is just one of the things in the guidelines that if you are really look at the 95 guidelines, you will see that they only reference organ systems for that highest level of exam.
One of the ways we can take these 95 guidelines and put them into place in a practice with as little physician burden as possible, is to actually document or to generate a preprinted form that has the different recognized body areas and organ systems and put check boxes for normal exams and then allow the doctors to write out abnormal exam.
On the top of page 18 you can see one such example of that where we list out body areas and organ systems in order that the physician is comfortable with. If they are examining the patient's head and it is within normal limits, they can just put a check box there. They do not have to separately say, 'I examined the patient's head and the head exam was within normal limits.' They can just put a check box down and this really saves the doctors a lot of time.
Make Sure Doctors Know The Risks Of Check Box Lists
You want to be kind of wary of doctors that just see a check box list like this and instead of checking off the individual body areas or organ systems that they are examining, they might just draw a line down all the check boxes and that is really problematic because it is saying I examined each of these body areas, each of these different organ systems and every single one of them was within normal limits. If that is what they did then technically that is fine to do, but in an audit situation Medicare could ask the patient: 'This doctor said he examined your head, eye, mouth and throat, neck and chest. Did he really do that?' And the patient says: 'No. He walked in put a stethoscope to my chest, changed my medications and sent me home.' In that situation you are going to be in double jeopardy because you just submitted a false statement to the government saying we provided this type of level of exam when you really did not, you probably submitted a false claim to go with it--so you are impacting that rule and set of regulations. Then you have also got the malpractice risk that goes with saying, 'I did this' when you really did not do that. What if that patient walks out there and drops dead because he had some specific problem that the doctor should have caught if he really did examine the patient's neck. Maybe he would have realized that the patient had a very extreme carotid bruits that would have easily been caught if the doctor did examine the patient's neck. So these are forms that are beneficial but also just taken with a grain of salt or at least that caveat, that warning, that some doctors will abuse these forms and you want kind of monitor that if you implement something.
95 Guidelines Do Not Define 'Complete Examination Of A Single Organ System'
Under the 1995 set of guidelines, the guidelines also reference a single system comprehensive exam. To get up to these highest levels of service you could have what they call the general multi-system exam, which is what we just covered, or they reference a complete examination of a single organ system. They do not define anywhere in the 95 guidelines what a complete examination of a single organ system is. It is something that you could potentially go to your Medicare carrier and say, 'based on our specialty this is what we define as being a complete single system examination. Do you agree with that? If not what guideline should be followed in order to use a 95 guidelines?' In the absence of something in writing from your carrier and, from that perspective, each of your individual payers as well, I do not recommend that you use this one provision in the 95 guidelines. It is much better to go along with the general multisystem exam, which fully presented at the bottom of page number 17.
When we look at the 1997 guidelines, I have got these presented on page 19, 20 and 21 for you but we do not need to really go through these in great depth. It is just the concept that there is this general multisystem examination under the 97 guidelines and they also have individual single specialty examination. So they have these listed out for each of the different specialty exams that you might be providing, a different set of guidelines for each of these, so this makes the 97 guidelines much more voluminous than the 95 guidelines, just based on the fact that there are several different standards that you could use and apply.
The Easiest Way To Document A Comprehensive Exam
If you look on the top of page 19 you can see the four different levels of exams again--problem focused, expanded problem focused and detailed comprehensive. To get up to a comprehensive, let us use that as one example: under the 97 guidelines, they say we have to perform all of the elements identified by a bullet in at least nine organ systems or body areas. So, if you look on pages 19, 20 and 21, we have to pick nine of these boxes and perform every single bulleted element in order to be able to bill a comprehensive level of exam. We have to perform each element. Then they say we have to document at least two elements identified by a bullet from each of nine areas or systems. So there is this rule that we examine all these different bulleted elements from each of nine different boxes, but we only have to document two of those. So this is one of the reasons why the 97 guidelines are problematic, because how are we going to establish that we did examine all of the bullets in nine of these different boxes? That is the first challenge.
The second challenge is that they say we have to document two elements in nine of the different areas. So this is going to be 18 specific elements that we have to document in order to bill a comprehensive level of exam. If you really take the time to look through what these bulleted elements are, they are very specific, it is going to be time intensive to do those exams, it is going to be time intensive to record each of these specific elements. You compare that to what is required for the 1995 comprehensive level of exam, which is 8 organ systems, you can just say 'organ systems are negative' basically. You go through each of the individual organ systems, say 'negative' or 'within normal limits.' If there is a positive finding, record it out, that is all it takes to get to a comprehensive level. So for that reason I really do think 95 guidelines are much preferable to the 97 guidelines for every single physician in the United States of America. The one benefit that the 97 guidelines have is the whole thing about recording three chronic or inactive conditions as opposed to four specific elements of HPI. But now that we have got CMS to clarify that history of present illness can be documented as a positive or negative, I think that really undermines any benefits that once would have been there under the 97 set of guidelines. So it is really not that problematic to get four elements of HPI at this point.
On the bottom of page number 21, you can see what CMS' current position is. Like I said earlier, they have said that until they develop a new set of guidelines that they field test, and will work, we can use either the 95 or the 97 sets of guidelines; in the event of an audit, Medicare is going to audit under both sets of these guidelines, whichever is more beneficial to the doctor is the set of guidelines that they are going to apply in the review.
Why Practices Should Opt For The 95 Guidelines
On the top of page 22, I kind of put together my own little analysis of the decision-making process, in my mind, as far are why I recommend the 95 rules. In talking to consultants and doctors and attorneys from across the country, specific to this issue of the 97 guidelines, the only real stance people come back with as far as recommending or following the 97 guidelines, is they say that if we try to follow the 97 guidelines, try to hold the physician to a higher standard, in the event that we get audited, if they flounder under the 97 guidelines, chances are that they are going to be safe under the 95 guidelines. And that is accurate as all can be, but I think it is exposing your physicians to way more work. It is distracting them from patient care when you really do not need to. And I would like to think of it as if you are driving four hours to go to a meeting somewhere and you see that speed limit is posted as 70 miles an hour. Instead of going 70 miles an hour, you will go 70 kilometers an hour, because if you accidentally go over and hit a speed trap, you will be safe. It is the same concept, it is not just a small difference between the 95 and the 97, it is a huge difference. If you go 70 kilometers a mile on route 81, you are going to have tractor trailers rolling over you like a speed bump and the same is true in practice. If you try to follow the 97 guidelines when you only need to be following the 95 guidelines, you are not going to be able to keep up with your patient flow, you are going to be seeing several fewer patients every week than you could be seeing and the doctors are going to be focused more on little bulleted elements and shaded boxes than on taking care of patient and growing the practice. So I think the 95 guidelines are much preferable. Those practices that are using the 97 guidelines, my personal opinion is, you need to abandon all those efforts and just follow the 95 guidelines. Doctors will walk out of the room just hugging you and loving you for ushering in that change.
EMR Systems May Facilitate The 'Carry Forward' Effect
One of the things to keep in mind when we are dealing with the documentation guidelines is that a lot of practices have implemented electronic medical record systems that really are in alignment with the 97 guidelines. And the doctors, when you suggest to them that maybe we should follow the 95 guidelines, they may come back saying, 'no, we just invested several hundred thousand dollars to implement this EMR system and with the click of a button and we can generate all of the elements of comprehensive exam relatively quickly.' That is problematic. When a doctor signs off on a visit note, whether it would be electronic or handwritten, they are signing off that I did this work; this is what my objective findings were. If they are using pre-canned documentation, it is fine to do as long as it is accurate and as long as it accurately reflects what was done that day. When the doctor signs off on it, the document needs to be accurate. There is no rule that says you cannot define what your normal examination is of a patient, click a button, and it will populate your medical record with this paragraph that essentially details out what your normal examination is; and then you go back and change it to make it accurate and specific to the unique findings of this patient encounter. However, one of the things that we can never do is use what they call a carry forward. This is where we examine a patient, where we have not just a normal exam, but we have problematic things documented as well. We have findings of the exam, such as a murmur or difficulty with range of motion or the patient has visual disturbances or whatever it is. We cannot populate a record on the patient say in January, have that patient come back in March, click a button and just carry over that whole exam and just keep carrying it forward. If we check off on a record and sign off on it, it is saying this is what we did today, not last week, not last month, not last quarter. This is what we did today and it needs to be accurate. So some of the EMR systems that are out there will facilitate this carry forward of information and it is something that the doctors might get into the habit of doing and you really need to make sure that they understand that when they sign off on a record, it needs to accurately show what you did that day, this is not like the review a systems, this is not like the past family, social history where the guidelines allow you to carry it forward. These are objective findings of a physical hands-on examination. The note needs to be accurate every single time that they sign off on it.
The 'Three Ring Circus' Model For Medical Decision-Making
The last element of documentation is what they call the complexity. A lot of people call it the medical decision-making. Of the three sets of rules, this is the one that is the most farfetched, the most concocted, probably the hardest to really wrap your arms around; but once we walk through it, it will be probably one of the easiest ones for the doctors to implement and follow in practice. I'll present to you in the way that I have been able to make sense out of it in my own relatively uneducated mind.
The documentation guidelines for complexity are essentially a three-ring circus. And when we go through a medical record in an audit situation, what we need to do is consider three different rings of information, three different rings of a circus, I like to think of them as. Within each ring of the circus, we are going to assign a value from 0-4 and our level of complexity or our level of medical decision-making is going to be dictated by the two highest rings of the circus. We have to meet or exceed two out of the three rings of the circus in order to support a given level of complexity. The first ring of the circus is specific to the problems that are being addressed, the problems that are impacting the current visit. And in this ring of the circus, just like all the other ones, we are going to try to calculate a value somewhere between 1 and 4. Once we get up to a value of 4, we do not need to keep counting inside of this ring of the circus as far as the audit process goes, because once we get up to a value 4, this ring of the circus is maxed out. It will support the highest possible level of service in and of itself. Now of course, we still have to have a history in the exam there to support it and I will tie that all together for you in just a second.
In this ring of the circus you get one credit for self-limited or minor problems. They only allow you to get credit for 2 of those and that impacts several patients that might come in with 50 little things that they just want to have a chance to talk to the doctor about. None of them are really impacting the patient's healthcare. Everything is going resolve itself in 24 hours with no medical intervention whatsoever. That is a self-limited or minor problem. For the first two of those that the doctor discusses and evaluates with the patient, we will get one credit each for those. We also get one credit for each established problem--and that is established to the doctor, not the patient--for each established problem, whether it is stable or improved, meaning everything is going fine, the patient is responding to therapy, we are not going to have to significantly impact their healthcare based on today's exam. They are going to get one credit for each of those and they do not put a ceiling on that. So we can have four of those things addressed in a patient encounter for this ring of circus, we are going to one credit for each of those, that is going to give us a total value of 4 for this ring of the circus, that is a green light to bill the highest level in this one element of documentation anyway.
If we have an established problem that is worsening or not responding to therapy, we will get two credits for each of those. A new problem that does not require any work-up, we are going to get three credits for that. If we have a new problem requiring any work-up, we will get four credits for that. So for the patient that comes in, whether the patient is new or established, they come in and say, 'I have had a little bit of chest pain lately,' and we order an EKG to evaluate it. For this ring of the circus that is a new problem requiring a work-up, it is going to give us a level of 4 for that ring of the circus. So for this ring of the circus we are maxed out.
The Second Ring And The Levels of Risk
The second ring of the circus is specific to what they call the table of risk. This is, how much risk is the patient exposed to during this visit? The four different levels of service of course are minimal, low, moderate and high and these are essentially level of 1, 2, 3 and 4; and the three different columns of documentation are specific to the patient's presenting problems, the diagnostic procedures that are ordered, the management options that are selected for the patient. At the top end of this grid are the minimal risks to the patient; the bottom end of the grid is the high risks to the patient. Minimal risk, an example of that is like a insect bite; the high level risk is a transient ischemic attack or a seizure. The middle column is the diagnostic test, here we have got things like an x-ray or an EKG, minimal risk to the patient; whereas if we were to do a cardiovascular imaging study with contrast and identified risk factors, we are going to be at the high level of risk to the patient.
Management options selected: rest is the lowest level and elective major surgery is going to be the highest level of risk. It is how much risk that the patient exposed to. If we get up to a high level risk in anyone of these three columns, that is going to be the level of risk that is associated with the patient encounter. We do not have to worry about the other two columns of risk. A couple of things that are going to push a lot of visits up to that moderate level of risk are the fact that they include two stable chronic illnesses. A lot of the patients that we are going to be seeing are having 2, 3, 5, 6, 7 stable chronic illnesses or they are having one acute problem, either of these things are going to push us up to that moderate level.
Also medication management. If we are prescribing a patient's prescription, as you can see on the bottom of page 24, for writing a prescription, discontinuing one, or if the doctors are reviewing the patient's medical regimen and saying that we are going to continue medications as prescribed, we are still going to be able to support that moderate level of risk, which is a big factor, because that is sufficient for a level 4 consult essentially as far as the that ring of the circus goes.
Credits Are Assigned Based On The Different Types--Not The Volume--Of Data
The last ring of the circus is going to be the different types of data that we are evaluating and looking at, whether we are ordering it or reviewing the findings. We get a credit for the different types of data, not the volume of data. So if we have ordered or looked at one lab test we are going to get one credit. If we order 15 lab tests we are still going to get just one credit for it. So it is really not fair, but none of this stuff is really fair, it just goes with the big physician paycheck, in essence.
If we order or look at a test of radiology section that belongs in that medical section and this is the medicine section of the CPT book, the codes that begin with a 9 at the back of book as opposed to the codes that begin with a 9 in the beginning of the book. A couple of things that really help doctors out are the things that they get two credits for at the bottom, which is obtaining history from someone other than the patient or if they independently visualize an image tracing or specimen. What that is, essentially, is if the doctor looks at an x-ray image or looks at an EKG tracing as opposed to reviewing another doctor's interpretation of that.
When we look at these three different things, we have to say, in each ring of the circus we had a value 1 through 4, and that is going to define--like on the top of page 26, where we have straight forward low, moderate or high level of complexity associated with the visit. In reality it is a really complex, goofy process to go through, but once doctors take the time to understand what is inside each of the three rings of the circus, understand that they only need to meet or exceed two out of three rings of the circus, it really makes it not that complex.
Determining What Level Of Service Is Supported By The Medical Record
When we look at history, exam and complexity, knowing that we have got each of these different elements there, the next challenge is: what level of service do we have supported by the medical record? On pages 27 and 28, what I have got are some graphs for you that show your most frequently used service types as far as what levels of history exam and complexity need to be there. I'll just go through the most frequently used one, which is going to be on the bottom on page 27, this is your established patient office visit. The bars, I have tried to make these different colors so you can make sense out of them. The first set of bars are history and this is the first clump above each level of service. You can see like a level 2, 99212, requires that you get up to a level-1 history examination and complexity. If we go up to a level 3 established patient office visit, we have got to get up to the second highest level; so that is going to be the expanded problem focused history, expanded problem focused examination and we are going to have a low level of complexity associated with that visit. So as you can see, as you go from a level-1, you do not need to have any of these specific elements. Level-2, you need to get up to a level-1 in each of these areas; to get up to a level-3 you need to have a level-2 in each of these different areas, and so on. So that kind of shows you, code by code, how these guidelines apply in determining your level of service. And for any of the ones that I do not have referenced here, just look in your CPT book because they spell those all out for you.
Even The Lowest Level Hospital Admit Requires A Detailed Level Of History And Exam
One of the things that the official guidelines show that a lot of physicians do not apply is at the top of page 29. They say, essentially, in the rare circumstance when a physician or non-physician practitioner provides a service that does not reflect a CPT code description, the service must be reported as an unlisted service for CPT code 99499. So, in essence, what they are saying is if we have a document that does not have the lowest possible level of documentation for a given service type, we should bill it as an unlisted code. If you flip back one page to the hospital admission, you can see we need to have a detailed level of history and a detailed level of exam to support even the lowest level hospital admit. Those detailed levels of history and detailed levels of exam require a substantial amount of documentation. Under the detailed level of history, detailed level of exam, we are going need to show, again, for history, four elements of HPI, 2-9 review of systems, one past family and social history elements. If we do not have that information documented, we are not going to be supportive of that lowest level of hospital admit, so we have two or three elements of history of present illness documented, that is going to essentially hold us back to billing an unlisted code, and doctors nationwide hardly ever bill that code, that 99499 code. Make sure your doctors are documenting those things as opposed to just kind of glossing over those.
Assigning An E/M Code In A Case Study
The patient comes in with chest pain. We are going to count that as being our chief complaint. They have a one-week history of chest pain, that is going to give us the location of the pain, in the patient's chest. The duration of it is the fact that it has been there for one week. No associated shortness of breath. We are going to count that as negatively documenting the associated signs and symptoms, currently registering a four on a scale of 1-10. This is going to give us our severity; and it has been up to perfect 10 with moderate exercise, and that fact that the moderate exercise increases the intensity is going to be a modifying factor. As you can see we have got more than four of these HPI elements documented, just with that brief little half of a paragraph essentially. Review of systems, chest pain as above, denies headache, palpitation, shortness of breath, claudication, "all others are negative." The fact that we have got positive, pertinent negative and the fact that the doctor said 'all others are negative' is going to push us up to the highest level of review of systems. He has got past history documented, family history documented; because this is an established patient, we only have to have two of those three elements documented. So for history we have got the highest possible level.
Under the exam, you can see we have got no apparent distress, we have got vital signs measured, that can give us our constitutional, organ system examination. Head is normocephalic, atraumatic--that will give us credit under our body areas for head. The neck is supple--again under body areas for neck. Neurologic: Cranial nerves II-XII are intact, that is going to give us a neurologic exam. Lungs are clear to auscultation and percussion, that will be a respiratory. Heart: Grade I/IV systolic ejection murmur without diastolic murmur, rub or gallop, that is going to give us cardiovascular. Skin: No rashes or lesions, that of course is the skin and then we have got musculoskeletal documented as well.
When we look at this basically we have got 8 different body areas organ system documented. However, it is not going to support a comprehensive level of exam, because we only had six organ systems documented. We need to have eight organ systems documented to get a comprehensive. So that is going to hold us back to a detailed. When we look at this patient encounter and the fact that we are continuing the medications as prescribed, personally reviewed an EKG, we look at all different rings of the circus. It is going to support a moderate level of complexity. And then we apply the documentation guidelines to the different levels of service. We have got a history that is comprehensive, and this is on the bottom of page number 31. We have gotten an examination that is at the detailed level, which is the third highest level, and complexity that is a moderate level and we are going to be limited to billing a 99214 which is a level four established patient office visit for this. When we look at the documentation guidelines and the definitions of these codes, you will see for established patient visit, we are only have to have two of the three elements documented, so history exam and medical decision making, only two of those three elements need to be documented for a level four office visit. We can have a really deficient history and if our examination level complexity is still up there, we are going to be fine and safe to bill the service out at the higher level.
When we are dealing with new patient visits, consults, and admissions, in these cases, we need to have all three elements of documentation there at the level that is necessary for that given level of service.
Pros And Cons Of The Bell Curve Analysis
On page 32, I have got an excerpt for you from the Medicare web page that shows that Medicare looks at physicians' utilization of these different service levels to identify who they want to come in and audit. On the bottom of that page I showed you what they call a Bell Curve Analysis. A lot of practices are having this conducted and it is really a good thing to do on a quarterly basis, or maybe even twice a year, you can get away with doing that. It just compares your doctors to your specialty as far as how many different times they are billing each of different levels of service. As you can see in the example on the bottom of page 32, we have got a really high utilization of those 99245s. These doctors are going to stand out from the norm and Medicare is going to come in and audit them at some point. At least that is what the indications are here.
On page 32, we have got the pros and cons to this. It is beneficial because it is the same analysis that the government uses but at the same time, we are comparing your doctor to the national norm--or what I use is I actually the state specific data for each specialty--and some doctors or subspecialists within a given specialty, they might have a more acute patient base, they might have a less acute patient base. But this analysis, one of the big flaws is that it compares them to the average doctor that is registered in their specialty, which for some sub-specialists that is going to be a lower level of service that they will typically bill.
Consider Providing Auditors A Translation Of Doctor's Handwriting
The final thing that I want to talk on, at the bottom of page number 33, is legibility of documentation. The documentation guidelines say, we need to be seeing information on medical records that are fully legible or else the doctors are not going to get credit for it. This is definitely a good goal to strive for but if your doctors are writing their medical records out by hand, you are not going to get their documentation legible. I have been trying this for the last 13 years and no matter what you do, the doctors are not going to change their ways as far as how they document things. In an audit situation, what you can do is transcribe the note for the Medicare auditor or for your private payer auditor. You do not want to say, 'this is the medical record.' What you want to do is say, this is a transcript of this document. You want give them the official medical records and say look, 'we realized that some of this documentation is not legible, however, here is a transcript of what it says.' That is something that the Medicare auditory will be able to utilize in reviewing the note and give you credit for as opposed to saying, 'look I cannot read half of this note, I am just not going to give credit for any of it.' It is not something you want to do like generate a record, transcribe it out and send it and say here is the medical record. You want to recognize the hand written note is not fully legible, here is a transcript of it and it is going to help you out. And Medicare auditors that I have worked with have actually thanked me up and down for taking that extra step for them.
Question & Answer session:
At this point I am going to open the floor to questions and answers and on the last page, number 34, you have got my contact information and web page. I cater primarily to cardiology practices and the web page that we have there, will really give you an in depth view of the training, auditing services that are provided and also give you chance to earn three additional continuing education units free of charge on the page for taking a proficiency examination; so at this time I will open the floor up to Mandy and then she will allow you to buzz and ask questions before we adjourn.
Ladies and gentlemen, I would like to remind you that this portion of the teleconference is also being recorded. If you have a question at this time, please press *1 on your touchtone telephone. If your question has been answered or you wish to remove yourself from the queue, please press #. Please limit yourself to one question at a time so that everyone may have a chance to participate. If you have another question, you may reenter the queue by pressing the *1.
Our first question comes from Sonia Spence. Please state your question.
Question (SS): My question regards your examination where you have divided it from two to four to five to seven and to CMS' guideline under expanded problems focused, it says that it is a limited examination of the affected body areas and detailed is an extended examination of the affected body areas, which would be more in line with your sample examination versus the check off list according to what we have been told by a local carrier, even if you checked off 'within normal limits,' you still would not be able to classify it as a detailed exam because it is not detailed, it is just a check off 'within normal limits.'
Answer: Yes, you are right in that the documentation guidelines themselves do not say what the difference is between explained problem focused and detailed. They do not really clarified. That is something that back in 1996 or in 1997, there was a publication and it was specific to family practitioners, I cannot remember what the name of it was, but they had clarified with CMS that the expanded problem focused should be reported two to four elements examined, and then the detailed is 5-7 elements; because prior to that clarification it was really just a gray void of how much documentation is necessary to springboard from this expanded problem focused exam up to a detailed. They clearly indicated that a comprehensive exam is if we document 8 or more organ systems and they clearly indicated that a problem focused exam is going to be at least one body area organ system, but they never specifically said what are those two different middle levels? However, CMS, it was published in that family practice management magazine that an expanded problem focused is going to be the two to four elements and then the detailed is 5 to 7. And that is really the guideline that I have seen people applying across the country because it came directly from CMS. So you might want to track that down somehow and I do not know if I have it myself but I have it somewhere, I have to put my finger on it. I have not had a copy for anybody lately but it is something that CMS clarified back shortly after the 95 guidelines came about.
Comment (SS): A problem with our local carriers is they have the right to interpret CMS' guidelines and they actually do not follow some of CMS' published guidelines. We are going through a lot of pre payment audits that I am having to appeal and they are applying their own specific guidelines for their own interpretation.
Answer: Yes, and they actually have the right to do that. And that is one of the things I mentioned before. The information we are presenting is based on that audit tool that CMS distributed to each of the individual carriers. It is actually a large healthcare organization that developed that audit tool, shared it with CMS and said, is it good for us to follow? CMS liked it, they sent it out all their carriers and said that you can use this if you want, but they never said this is the mandatory audit tool to follow. You are right that the your individual carriers have that right, but I think it is one of areas that you might want to pressure them to clarify, like show them what is out there and available and say, 'why are you holding us to this different standard? There are enough regulations that we are dealing with now, and can we work with you on this?' Really approach them from a perspective of trying to reconcile the difference.
Comments (SS): Thank you.
Answer: You are welcome. You are absolutely right in that individual carriers, even non-Medicare payors have the right to over interpret these goofy rules. Thank you for the question.
Our next question comes from Susan of Hilton Head and Heart. Please state your question.
Question (D): This is not Susan this is Dennis. How you are doing today, Jim?
Answer: Good Dennis. How are you?
Question (D): Good. I have a quick question about pointing back from one document to another and what I am specifically talking about is, for instance, a patient who is seen in the office and the doctor decided to admit that patient on the same day and during the completion on a dictation of his H&P, he points back in that document saying for the complete physical exam, 'see the office note from today.' I just wanted you to speak on the appropriateness of that. Do you understand the question?
Answer: Well, certainly I do. When you are dealing with that specific scenario that you mentioned where you have two different places of service, in an audit perspective, what is going to count let's say the patient was seen in the office, you sent him to the emergency room, they ultimately were admitted to the hospital; for that doctor, for that patient encounter, regardless of the fact that they were maybe seen in two or three different areas for care, we are only able to bill one service. And what we are going to be billing is the hospital admission--the office visit, the ER visit and the admission and are all going to be included in the admission code. In an audit situation there could be three separate notes from each of those places, each of those is going to go towards contributing to supporting the high-level hospital admissions. So in that specific case, you do not necessarily have to tie the documents together. You just have to make sure if you get reviewed, that you send all three documents in. If however there was a lapse in days between the two--you saw the patient in the office on Monday, we admitted them on Friday, in that case in your hospital admit on Friday you can reference the comprehensive patient questionnaire that was completed on Monday, document that the doctor reviewed it with the patient, update it if any updates are necessary, which may be the case (the patient is now acute to the point where they are be admitted) and also reference the date and the location of it. In that case what you are doing essentially, just like in Microsoft Word, you are copying and pasting that whole review of systems, past family and social history from your Monday note into your Friday note as far as what is admissible on the event of an audit. Does that answer your question.
Question (D): Yes, It does but can I ask a follow-up to what you just stated.
Answer: Sure thing.
Question (D): All right then. Say for instance today the doctor sees the patient in office. You complete the note but then the patient was going to be admitted, but he is not going to charge for an admission but he is going to go ahead and complete an H&P for that patient today. Even though we are not billing for it, is it alright to point back from the office note to the hospital? What I am saying is, is there a limit on the direction? Is it alright to point from the hospital note to the office note and is it alright to point from office note to the hospital notes?
Answer: What you should actually be billing for is the admission. If it is on the same date of service, you do not necessarily need to link the two documents, but in an audit situation you need to put both of those notes. And you could go either away, but if you have an office visit and an admit on the same day, the admit is what is going to be billed out, so it would be good to make a reference to the office visit note just so that who was following up knows that these two visits are linked together. And in an audit situation we put both notes, but there is not that requirement there as though the patient was seen on two different days.
Comments (D): Thanks.
Answer: Okay you are welcome. Thanks Dennis.
Our next question comes from Debra Schwartz of Oxford Health Plan. Please state your question.
Question (DS): Hey Jim, I wanted to know if the E/M codes are just limited to physicians such as, would a speech therapist be prohibited from billing an E/M?
Answer: Oh Gosh, this is a good question and there are really specific rules that say who can and cannot bill these things. From my understanding, I have not worked with speech therapists before so what am I am going to give you is my general understanding of these E/M rules. A 99211, the lowest level establish patient office visit is something that can be billed by ancillary staff, which is going to include registered nurses and may be not even somebody that is a nurse. In order to bill higher than a level-1 admit or level-1 office visit, we have to have somebody that is a mid level provider quot; what they call either a mid level provider or a physician. They reference the mid level providers as primarily clinical nurse specialists, nurse practitioners, physician assistants; and if you are a speech therapist I do not believe that you are going to fall into that category. However, maybe speech therapists are also nurse practitioners. I am really not too sure but in essence, for the E/M services, in order to bill above that level-1 you either have to be a doctor or a recognized mid level provider. But then again, there could be specific other services that would apply to a speech therapist. I hate to just point you in the wrong direction because there are penalties that could apply if I try to generalize something for you.
Comments (DS): Okay, thank you.
Answer: You are welcome.
Our next question comes from Joseph Casey of Naval Hospital-Camp Pendleton. Please state your question.
Question (M): This is Melinda and this is a kind of a follow-up of the question that we just asked and I do coding for the emergency room and we have a separate little clinic off to the side of the emergency room, where there is a nurse practitioner. Now can she bill the 99282s and 99283s when she is doing x-rays and medications and full exams just like the physician does but it is just for a lower key level patient?
Answer: They certainly can. The Balanced Budget Act of 1987 established it so that nurse practitioner and physician assistants can essentially act like physicians in regards to when they are doing these E/Ms, there is no site or service restrictions on them. In certain scenarios such as the one you are mentioning, they are going to be billing that out under their own name and number. The reimbursement that they get will be 85% of what would be generated by a physician if a physician personally billed the service out. In other care settings, such as the office setting, we can bill under what they call incident-to previsions, which is probably a separate 90 minute conference in itself, which is where essentially the service gets billed out under doctor even though it is provided by the nurse practitioner. Or, in the hospital setting, they could bill under what they call a shared visit rule and that is where the doctor and the nurse practitioner both evaluate the patient, both are involved in the care plan and in that situation you can bill it out under either one of the provider's names and numbers, so yes, they can bill E/M services on their own. They can bill it out under own numbering, get a 15% reduction on reimbursement.
Question (M): We have another question, can we ask another one?
Answer: Sure thing, go ahead.
Question (M): I was asking about time guidelines when the physician spends 50% more of the visit with the patient and he is going to charge under the time guidelines. Does he need to report the time in and time of the visit?
Answer: No, they do not. They can simply put down how much time was spent with the patient and establish that the majority at that time was in counseling and coordination of care. They could say spent 40 minute with the patient, the majority of which was spent counseling' and that would be sufficient. They could go overkill and put start/stop time but they do not need to here.
Comment (M): Thank you.
Answer: You are welcome.
Due to time constraints, we must now conclude the question and answer session. I would like to turn the call over to Mr. Collin for any closing comments he may have.
Well, thank you all for joining in today and hopefully this information was of benefit to you. We covered a lot of different things and hopefully seen in this perspective it will help to make a little bit more sense and also the clarifications that we have gotten from CMS this past year will really take these guidelines and make them so they are little bit more workable. I know that we are not going to achieve full understanding of these rules in a day, but hopefully this will get you into the right ball park. And also keep in mind we had cream of the crop people reviewing five records quot; less than half of them agreed on the correct codes, so if you do get audited by Medicare or any of your private payers and they say you over-billed, 50% of the time they are going to be wrong and what you need to do is to be auditing those records yourself and standup for yourself if they say 'this is over coded' but you look at it and you know your own specialty, your own physician better than they do. Keep in mind that Medicare auditors are people that are going to be looking at medical records for every single specialty that submits claims to Medicare. They may not understand the abbreviations that your doctors are using and interpreting 'MI' as something other than a myocardial infarction is greatly going to reduce the complexity of service and you can come up with examples specific to your specialty that are just as big of an impact as that. So, if you get a lot of them saying you are over billing, you look at the note, and you do not feel you did over billed, stand up for yourself because chances are, you can educate them about your individual patient note and get them to reverse their decision. It is going to save you penalties, and it is also going to save you the follow up audit process that comes with over billing.
So, good luck with everything. Hopefully, this helped. Definitely review this information with your physicians and also make sure to fill out your evaluation forms and fax those to the Coding Institute at the number that is mentioned there. If you liked this conference, let us know and we will come back with another that is similar to it. Mandy, I will go ahead and let you close out the call. Are you available?
Thank you. This is the conclusion of "Coding For Success: Maximizing E/M revenue" national teleconference. We hope you enjoyed this session. Please complete your teleconference evaluation form and return it to the Coding Institute at the address listed on the form. Mr. Collins, the Coding Institute, and I would like to thank you for your attendance. To end this call, just simply hang up your phone. Good bye.
To review the slides please refer to this issues pdf.
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Thank you very much Mandy and good morning to everybody across the [...]
