It seems like everyone wants a piece of evaluation and management coding, the most frequently billed physician service. Auditors, enforcers and whistleblowers have sunk their teeth into it, and health systems, wary of all the attention, are auditing the physician practices they plan to acquire to identify possible E/M liability.
“E/M coding seems to be getting a lot of attention at the federal level,” says Kevin Cornish, national director of the healthcare dispute, compliance and investigation practice at Navigant Consulting. Partly as a result of that, E/M coding patterns and trends may change immediately before or after an acquisition. Is it because the practice was upcoding before and it was ripe for compliance? Or was there undercoding?
“We have been spending quite a bit of time dealing with those kinds of issues,” Cornish says. Sometimes they lead to an internal compliance review with the potential for self-disclosure. For example, if a pediatric practice has a physician who is billing a lot of level four and five E/M services, which is atypical for pediatricians unless they are treating high-risk children, the practice needs to dig deeper into root causes. Or maybe an internist trends in a certain way for eight or nine years and then suddenly shifts down or up. “That is another flag someone should look at to identify what caused it,” Cornish says. It’s better to find out for yourself “before someone [external] does it for you.”
Coding spikes are rarely caused by “material changes in types of patients seen or services rendered,” Cornish contends. They may result from the use of a consultant who advises physicians to do things differently, he says. “It could be a reorientation toward more accurate coding” or away from more accurate coding—“either you are undercoding or under-evaluating services or you have been doing it too high. It can go in both directions. It depends on the impetus for why the analysis or training was done.”
Documentation May Not Support Codes
Cynthia Swanson, a senior manager at Seim Johnson in Omaha, Neb., says E/M reviews by the HHS Office of Inspector General and comprehensive error rate testing (CERT) contractors have found E/M upcoding and inadequate documentation. “We see overinflated E/M usage based on documentation, similar to the E/M information that CERT contractors publish,” she says. With the higher level of office-based E/M codes 99214 and 99215, elements are often missing. When billing counseling and/or coordination of care based on time, physicians may neglect to document time, or, if time is recorded, there is nothing written about what physicians counseled the patients on, she says. Self-audits are the best approach to identify potential documentation and begin the process of improvement.
Swanson describes examples she has identified in her reviews where documentation does not support the information on the CMS-1500 claim form or the electronic equivalent:
- Improper reporting of place of service (POS) codes (11 for office versus 22 for hospital outpatient departments, or 21 for inpatient hospital departments): The 2013 OIG Work Plan targets physician place-of-service coding errors. Physicians are required to put POS codes on Medicare claim forms to convey where services were provided. Medicare pays physicians more when a service is performed in a physician’s office than it does when services are performed in a hospital outpatient department or, with certain exceptions, an ambulatory surgical center (42 CFR Section 414.32). Also, last year CMS announced in Medicare transmittal 2407 that POS codes must be assigned based on “the setting where the beneficiary received the face-to-face encounter with the physician, nonphysician practitioner (NP) or other supplier,” although there are some exceptions (RMC 2/20/12, p. 4).
- Improper reporting of services by nurse practitioners and physician assistants: In a typical example, a physician practice bills a new patient office visit (99203) on the Medicare claim under the physician’s name and National Provider Identifier. But according to the documentation, the new patient was treated solely by the mid-level practitioner. “The new patient visit 99203 should be billed to Medicare under the mid-level practitioner’s name and NPI. Medicare has specific requirements for reporting and billing mid-level practitioner services,” Swanson says.
- E/M billing for counseling and/or coordination of care: The documentation may state that the physician had a “lengthy discussion” with the patient about CT scan findings and treatment options, but it should specify that more than half of the patient encounter—15 of the 25-minute visit—was spent on counseling the patient on CT scan findings and treatment options, Swanson says.
- Hospital discharge-day management (CPT code 99239): This code is for hospital discharge management services, and may include, if necessary, final examination of the patient, discussion of the hospital stay, prescriptions and referral forms and preparation of discharge records. This code is used when more than 30 minutes of a physician’s time is provided to the patient on the day of discharge, assuming it’s not the same as the admission date. “Any code defined by time must include time in the medical record documentation,” she says. If it takes fewer than 30 minutes, use 99238. Swanson thinks Medicare watchdogs have routine use of 99239 on their radar.
- Improper units of service on medications or incorrect medication codes: Suppose HCPCS code J1020 (methylprednisolone acetate, 40 mg) was reported and billed. Documentation supports 80 mg of the medication was given. The correct HCPCS code J1040 should have been reported and billed, Swanson says. In this case, the physician was reimbursed too little.
- Billing incorrect date of service based on the date the service was performed: Suppose an established patient office visit code (99214) was billed with the date of service 07/15/2013. Documentation supports the patient was seen on 07/16/2013. In this case, an incorrect date of service was reported on the claim. “Corresponding service dates on the claim should routinely coincide with the date(s) of service in the patient medical record,” Swanson says.
- Billing under the incorrect physician name and NPI: For example, the service was billed on the claim under the name and NPI of Timothy Black, M.D., but documentation indicates the service was performed by Robert Brown, M.D. “The performing practitioner’s information reported on the claim should routinely coincide with the performing practitioner documented in the patient medical record,” Swanson says.
- CPT code 99204: Documentation does not support the three key components—comprehensive history, comprehensive exam and moderate complexity medical decision making—required to bill this level of E/M service: A “complete” review of systems (ROS)—at least 10 organ systems—is one history element needed for E/M code 99204, Swanson says. The other two elements are history of present illness (HPI) and past, family, and/or social history (PFSH). If documentation shows that only six organ systems were reviewed, this translates to an “extended” ROS (two to nine organ systems) and alters the level of history component, which changes the overall E/M code level. Similarly, E/M code 99204 requires a “comprehensive” exam. “If less than a comprehensive exam is performed and documented, the requirements for E/M code level 99204 are not met, resulting in a lower level E/M service code,” Swanson says.