Do Your E/M Service Levels Match Medical...
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I n May of this year, the Office of the Inspector General (OIG) published a report describing, among other things, its meth- odology for evaluating E/M code documentation during au- dits for the Centers for Medicare and Medicaid Services (CMS). In addition to the OIG’s typical review method and process, the report contained the following (italics ours): Page 7. We … contracted with three certified profes- sional coders (hereinafter, referred to as reviewers), each of whom had experience reviewing claims for E/M services. In addition, we contracted with a regis- tered nurse to assist with determinations on whether documentation supported medical necessity. The re- viewers independently reviewed a set of records and consulted with the nurse as needed. Page 8. Reviewers classified sampled claims for E/M services as insufficiently documented if the medical record (1) did not contain pertinent information to sup- port the service provided (e.g., the patient’s name and status, overall condition and diagnosis, and the extent of services performed), (2) did not support the medi- cal necessity of the service provided, and/or (3) was illegible. What This Means for Your Practice When conducting documentation audits, the OIG is now looking at more than just how many documentation ele- ments are in the note. “They’ve supplemented their team with registered nurses who are assisting certified coders by determining whether medical necessity has been met,” ex- plains Mary LeGrand, RN, MA, CCS-P, CPC a consultant and coding educator with KarenZupko & Associates, Inc. At issue is that medical necessity must be present in the note. “This has always been the rule,” LeGrand says. “ But there has been an increased use of EHRs and templates that automatically docu- ment visit elements and drive visits to a higher level of service. CMS has added more scrutiny to medical necessity reviews to verify that the higher level visits billed indeed required a higher level of history and/or exam.” According to LeGrand, the extent of the history and exam should be based on the presenting problem and patient’s con- By Cheryl Toth, MBA KZA Practice Brief for Orthopaedics September 2014 - 1 - Do Your E/M Service Levels Match Medical Necessity? Selecting the Correct Service Level Requires More Than “Documentation Elements”
Transcript of Do Your E/M Service Levels Match Medical...
In May of this year, the Office of the Inspector General (OIG) published a report describing, among other things, its meth-odology for evaluating E/M code documentation during au-
dits for the Centers for Medicare and Medicaid Services (CMS). In addition to the OIG’s typical review method and process, the report contained the following (italics ours):
Page 7. We … contracted with three certified profes-sional coders (hereinafter, referred to as reviewers), each of whom had experience reviewing claims for E/M services. In addition, we contracted with a regis-tered nurse to assist with determinations on whether documentation supported medical necessity. The re-viewers independently reviewed a set of records and consulted with the nurse as needed.
Page 8. Reviewers classified sampled claims for E/M services as insufficiently documented if the medical record (1) did not contain pertinent information to sup-port the service provided (e.g., the patient’s name and status, overall condition and diagnosis, and the extent of services performed), (2) did not support the medi-
cal necessity of the service provided, and/or (3) was illegible.
What This Means for Your Practice
When conducting documentation audits, the OIG is now looking at more than just how many documentation ele-ments are in the note. “They’ve supplemented their team with registered nurses who are assisting certified coders by determining whether medical necessity has been met,” ex-plains Mary LeGrand, RN, MA, CCS-P, CPC a consultant and coding educator with KarenZupko & Associates, Inc. At issue is that medical necessity must be present in the note. “This has always been the rule,” LeGrand says. “ But there has been an increased use of EHRs and templates that automatically docu-ment visit elements and drive visits to a higher level of service. CMS has added more scrutiny to medical necessity reviews to verify that the higher level visits billed indeed required a higher level of history and/or exam.”
According to LeGrand, the extent of the history and exam should be based on the presenting problem and patient’s con-
By Cheryl Toth, MBA
KZA Practice Brief for Orthopaedics September 2014
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Do Your E/M Service Levels Match Medical Necessity?
Selecting the Correct Service Level Requires
More Than “Documentation
Elements”
KarenZupko & Associates, Inc. • Phone: (312) 642-5616 • Fax: (312) 642-5571 • www.karenzupko.com • [email protected]
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dition. “If an ankle sprain patient re-turns two weeks after the initial eval-uation of the injury with a negative medical or surgical history, and the patient has been treated conserva-tively, it’s probably not necessary to conduct a review of systems (ROS) that includes 10 organ systems,” she says. “If your standard of care is to provide this level of service, no one will fault you for your care delivery; however, if you also choose a level of service based on this system review, without relevance to the presenting problem, and you bill a higher level of service than is supported by the nature of the presenting problem or the plan of care, the documentation probably won’t hold up in an audit where medical necessity is valued into the equation.”
On the other hand, LeGrand adds, if a patient presents to the ER af-ter an automobile accident with an open fracture and other injuries, and the surgeon performs a complete ROS, the medical necessity would most likely be supported as the surgeon prepares the patient for surgery.
Recommended Actions
1. Even if you’ve met the documentation elements, don’t bill level 4 and 5 codes if medical necessity doesn’t support it. “If the documentation includes the elements for a higher level code but the present-ing problem or diagnosis doesn’t support the need for those elements, don’t bill the higher level,” LeGrand says. “Choose the code most appropriate for the sever-ity of diagnosis.”
2. Pay attention to EHR-driven, higher level codes. The OIG Work Plan began focusing on level 4 and 5 codes this year, after analysis showed a correlation between increased EHR usage and increased use of higher-level codes. “Comparing your usage patterns before EHR and after EHR implementation, as well as comparing them to state and national norms for orthopaedics, are ef-fective risk management strategies,” LeGrand advises.
3. Choose auditors with the right skill sets. Evaluating medical necessity in the note requires a clinical back-ground. “If internal documentation reviews are current-ly conducted by the billing team, that’s fine,” LeGrand advises. “Just add a physician assistant or nurse to your internal review team. They can provide clinical
oversight and review the note when necessary for medical necessity.”
If you are contracting with external auditors or consultants, verify auditor credentials and skill set to ensure they can abstract and incorporate medial necessity into the review. “Auditors must be able to do more than just count elements,” LeGrand says. “They must have and use clinical knowl-edge too. This knowledge should be used to verify that medical necessity is present in every note.” LeGrand is quick to point out that not every note will be at risk, based on the amount of work performed and documented and the level of service billed. “But medical necessity must always be present.”
The addition of nurses to CMS’s audit team is a big change and will fine-tune the auditing process. Be prepared by ensur-ing your documentation meets medical necessity as well as E/M documentation elements. Conduct internal reviews quar-terly and make sure you’ve got clinical
eyes and ears on your review team.
For additional detail on this topic, read LeGrand’s article, “Medi-cal Necessity Does Not Equal Medical Decision-Making,” in the September 2014 issue of AAOSNow. The article has been re-viewed and agreed to by the Academy’s physician CPT committee.
Cheryl Toth, MBA is a Leadership & Implementation Coach with KarenZupko & Associates, Inc. She is passionate about leveraging technology to work smarter, improving the patient experience, and coaching practice leaders to thrive in the midst of chaos and change. Cheryl brings 20 years of consult-ing, training, technology product management, and marketing to her projects. Reach her at: [email protected].
Mary LeGrand, RN, MA, CCS-P, CPC, is a nationally recognized cod-ing and reimbursement expert with KarenZupko & Associates, Inc. Her expertise and focus on coding and reimbursement puts her in high demand for coding education and reimbursement analysis. Mary also develops the coding workshop material that is used in her role as an instructor for AAOS national coding workshops pre-sented by KZA. Reach her at: [email protected].
About KarenZupko & Associates, Inc.KarenZupko & Associates, Inc. (www.karenzupko.com) is a Chicago-based practice management consulting and training firm that has helped physicians save time, save money, reduce risk, and improve the patient experience since 1985. KZA consultants have advised more than 800 orthopaedic practices, hospital-employed, academic and private. The firm has developed and deliv-ered coding and management courses for the American Academy of Orthopae-dic Surgeons (AAOS) since 1991. For more about KZA’s coding and documen-tation education and review services, call: (312) 642-5616.
KZA Practice Brief for Orthopaedics September 2014
E/M Profile AnalyzerBrings Coding Patterns to Life
The E/M Profile Analyzer is an Excel spreadsheet product that compares your practice’s E/M code usage against state and national data for orthopaedics. Simply generate a CPT frequency report from your practice management system, and enter the E/M data into the E/M Profile Analyzer. Line graphs are automatically generated, making trends and patterns easy to see.
The E/M Profile Analyzer is $150 and can be purchased at www.karenzupko.com. Or, it is included with the purchase of a new Code-X subscription, and available for a fee to current Code-X subscribers. Contact AAOS for details.
