Keeping Specialists Compliant
Possible Risk Factors
By Melody W. Mulaik, MSHS, CRA, FAHRA, RCC, CPC, CPC-H
It can sometimes be difficult to select a topic for this column that will appeal to all of our readers.
My goal is to always write about something that is relevant to a billing company regardless of its coding model. This article, though, will highlight some key areas of concern that tend to impact "specialists," or medical practitioners who focus on a particular class of disease or patients.
Here is how this ties into billing. Accompanying the designation of "specialist" comes the risk of feeling either protected or above other medical specialties when it comes to coding and billing practices. (Note that I indicated that this is a risk and not a generalization about all specialists.) This article, then, will focus on three coding and compliance risks that tend to exist for specialists in today's healthcare environment: electronic medical records (EMRs), evaluation and management (E&M) coding, and billing an E&M in conjunction with a minor procedure.
The topics that follow could each be the subject of a separate column. For this article's purpose, I will simply provide highlights that will allow you to facilitate evaluation and discussion in your organization and with your clients.
Risk Number 1: EMRs
In the January/February edition of Billing, I wrote an article titled "Top 10 Coding and Compliance List for 2014." Number two on that list was the improper use of EMRs. Although we are almost halfway through 2014, this placement is still warranted.
With meaningful use incentives and the overall industry departure from the inefficiencies of paper, most physician practices have implemented EMRs. Even those groups that have not yet implemented a system are most likely in the final stages of selection. If you have a client who still refuses to implement an EMR, you may be concerned about their long-term survival in the marketplace. They may even be looking to join or be purchased by a larger healthcare entity. Either way, this could impact your contractual relationship and the need for your services, so I recommend you view the disinterest in using an EMR as a red flag (but that is a subject for a different article).
It is very important that EMRs be used as a tool to capture clinical information for all necessary purposes to provide the best care for the patient. An EMR is not a shortcut or a replacement for clinical decision making. It also is not the answer to just about any other problem that can exist in a physician practice.
As we constantly say, there are some great EMRs available, but there are some not-so-great ones as well.
EMRs should not be utilized to generate cloned notes, inappropriate templates, or other documentation that create concerns for their potential for fraud or abuse. The Office of Inspector General's (OIG) 2014 Work Plan has finally been released, and, once again, this issue is on its target list. Specifically, OIG highlights that "Medicare contractors have noted an increased frequency of medical records with identical documentation across services."1 The focus is not only on the services provided to a beneficiary for a specific encounter compared with other patients. It is also across multiple dates of services to ensure that each encounter is uniquely documented and not just pulled from a previous encounter without appropriate updating and validation.
Even though specialists may only treat a limited number of conditions or provide some of the same treatments for their patients, this does not mean that all of the clinical documentation should and would be the same for all patients. If you and I were to go to the same specialist for the same condition, wouldn't you expect our medical record documentation to be different even if we received the same treatment? It is critical you understand how your clients are utilizing their EMRs to ensure accurate and compliant billing practices.
It is not in your clients' best interest as their billing partner to reinforce the belief that just because someone is a specialist they are either exempt from certain compliance concerns or they are justified in doing whatever is easy to save time. As their partner, you want to provide support and guidance so that both of you may reap the benefits of your hard work.
Risk Number 2: E&M Billing Levels
For your reference, this issue was number four on the "Top 10 Coding and Compliance List."
Just because a physician is a specialist, it does not mean all of their patient visits will qualify for a level 4 or 5 E&M level of care. It is important that you monitor and provide feedback to your clients on their E&M distribution levels so that you can both identify and address areas of concern.
Specialists will tend to bill more high-level E&M visits than nonspecialists, and that is fine if there is appropriate documentation and medical necessity to support the selected codes. I still remember being told years ago by an ob-gyn, "We bill all new patients as a level 4 and all established patients as a level 3." The rationale behind this was simple: we do "x" number of things for the patient, therefore it warrants that level.
It is essential that your clients understand what supports the various levels of care. When Medicare ceased to pay a greater reimbursement for the E&M consultation codes, it eliminated many of the concerns around inappropriate billing practices for these codes. That said, it is important that you bill non-Medicare payors and patients appropriately for these services and not automatically assign a high-level consultation code for each new patient.
Here is the bottom line: make sure your clients use appropriate documentation to support the assigned E&M levels.
Risk Number 3: Automatically Billing an E&M with a Minor Procedure
Now for number five on the "Top 10" list. On two occasions over the last year, I have experienced working with two different specialists billing separate E&M visits in conjunction with a minor procedure when there was nothing to support a separate visit charge. There was no history, exam, medical decision making, counseling, or other modifying factor to justify a separate visit. The office staff in both instances explained that they "always bill a visit with that procedure." So, clearly they have been instructed to always add a level 2 established patient visit (99212) to a minor procedure regardless of the circumstances or documentation.
While I would never assume that every practice does this, it did make me think it is more prevalent than it should be. Just because a provider sees a patient on the day of a minor procedure does not necessarily mean it is appropriate to bill an E&M service.
E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service.
A minor procedure is one that has a zero-day or a ten-day global period. With regard to E&M services on the same day as a minor procedure, the Correct Coding Initiative (CCI) Manual states the following:
In general E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is "new" to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure.
The CCI Manual gives the example of a patient who is being seen for a head laceration. The physician who repairs the laceration should not report an E&M code if the interaction with the patient involves simply checking allergy and immunization status and obtaining informed consent. However, the physician can report an E&M code with modifier 25 if they perform a "medically reasonable and necessary full neurological examination" in addition to the wound repair.
According to the March 2012 issue of the American Medical Association's newsletter CPT Assistant, the E&M service "is generally unrelated to the procedure or service being provided but may, on occasion, be prompted by the symptom or condition for which the procedure and/or service was provided." 2
Nonsurgical procedures (those with a global indicator of "XXX") do not have a global period. A good example of a nonsurgical procedure is radiological exams performed in a specialist's office (e.g., an ultrasound performed at an ob-gyn). However, an E&M code should be reported together with a nonsurgical procedure only if there was a significant, separately identifiable E&M service in addition to the procedure. The CCI Manual states the following:
Many of these "XXX" procedures are performed by physicians and have inherent preprocedure, intraprocedure, and postprocedure work usually performed each time the procedure is completed. This work should never be reported as a separate E&M code. Other "XXX" procedures are not usually performed by a physician and have no physician work relative value units associated with them. A physician should never report a separate code with these procedures for the supervision of others performing the procedure or for the interpretation of the procedure. With most "XXX" procedures, the physician may, however, perform a significant and separately identifiable E&M service on the same date of service which may be reported by appending modifier 25 to the E&M code. This E&M service may be related to the same diagnosis necessitating performance of the "XXX" procedure but cannot include any work inherent in the "XXX" procedure, supervision of others performing the "XXX" procedure, or time for interpreting the result of the "XXX" procedure. Appending modifier 25 to a significant, separately identifiable E&M service when performed on the same date of service as an "XXX" procedure is correct coding.
As previously stated, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25.
In a 2005 audit report ("Use of Modifier 25," OEI-07-03-00470), the OIG found that 35 percent of modifier 25 claims that were allowed by Medicare in 2002 did not meet the requirements for payment, resulting in $538 million in improper payments. This finding highlights the widespread problems with documentation and coding of E&M services performed in conjunction with procedures.
Modifier 25 should be appended to the E&M service if the patient's condition requires a significant, separately identifiable E&M service on the same day as a surgical (invasive diagnostic) procedure. The E&M service must be greater than the pre- or postservice work for the procedure. The E&M note should be distinct from the procedure note. It is not necessary to generate two separate documents, but the physician should at least document the two services in separate paragraphs. Also, the E&M service must meet all the documentation criteria for a billable service. If the encounter involved the decision to perform a minor procedure, then part of the assessment and plan will include documentation of that decision.
Both the American Medical Association (AMA) and Centers for Medicare & Medicaid Services (CMS) have stated that a different diagnosis is not necessary when billing an E&M service and a procedure on the same day. However, in the same vein, it is inappropriate to bill for an E&M service every time the patient is seen for a planned procedure. Also, keep in mind that despite the AMA and CMS guidance, some third-party payors are not paying for these services unless the procedure and the E&M service are reported with different diagnoses.
This is an important area to be scrupulous about for your clients. If there is always an E&M service billed on the same day as a procedure, view this as a red flag and investigate.
Regardless of your role in the coding process, you want to serve as a valued business partner for your clients. There is a roll-down effect for coding and compliance. If your client has compliance challenges, they could potentially impact their practice, their cash flow, and their contractual relationship with you.
Melody W. Mulaik, MSHS, is the president and co-founder of Coding Strategies, Inc. and Coding Metrix, Inc. located in Atlanta, Georgia. She is a frequent speaker and author for CSI and other nationally recognized professional organizations and publications. Melody's areas of expertise include billing and collections, coding and compliance, revenue enhancement, front-end hospital operations, management engineering, medical school relations, and operations improvement.
1 http://oig.hhs.gov/reports-and-publications/archives/ workplan/2014/Work-Plan-2014.pdf - page 17