Fall Coding Workshop

1
Fall Coding Workshop

• Evaluation and Management Services
• Documentation Guidelines
• Facilitated by
• JoAnne M. Wolf, RHIT, CPC

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2
Objectives and Agenda

• To network with colleagues
• Gain a better understanding of the E/M
  Documentation Guidelines including billing E/Ms
  based on time and consultation codes
• Understand the importance of having an effective
  compliance program
• Obtain useful tools to implement a process of
  review and education in your clinic

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Resources

• CPT 2008 and CPT Assistant
• Specialty societies
• American Academy of Family Physicians (AAFP)
  www.aafp.org
• DHS (Medical Assistance)
• www.dhs.state.mn.us
• CMS Documentation Guidelines
• www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf
• www.cms.hhs.gov/MLNProducts/downloads/eval_mgmt_se
  rv_guide.pdf
• Local Part B Medicare Carriers
• www.wpsmedicare.com

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Why is Documentation Important?

• Patient Care
• Good documentation
• Allows healthcare professionals to evaluate and
  plan the patient's immediate treatment, and
  monitor his/her healthcare over time
• Provides communication and continuity of care
  among healthcare professionals
• Supports appropriate utilization review and
  quality of care evaluation

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Why is Documentation Important?

• Billing and Coding
• Good documentation
• Allows the medical record to serve as a legal
  document to verify the care provided
• Provides payers with proof that the services
  youve provided and have been reimbursed for have
  been accurately reported
• Receipt for services paid
• Supports the level of E/M code billed
• Supports accurate and timely claims review and
  payment

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3 Basic Rules for Providers

• Do whats best for the patient
• Document everything you do
• Code and bill according to what is documented
• Golden Rule
• If it wasnt documented, it
  wasnt done

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E/M COMPONENTS
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E/M Components

• Components of an E/M service
• History
• Exam
• Medical Decision Making
• Counseling
• Coordination of Care
• Time
• Nature of the presenting problem
• Key components

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E/M Components

• E/M levels are chosen based on the three key
  components
• History (extent)
• Exam (extent)
• Medical Decision Making (complexity)
• E/M levels may be chosen based on time if more
  than 50 of the visit was spent in counseling and
  coordination of care
• The nature of the presenting problem is only used
  to assist the provider in determining the level

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History

• Chief Complaint (CC)
• A brief statement of why the patient presents to
  you
• History of Present Illness (HPI)
• Consist of elements described by the patient of
  the illness or injury (location, quality,
  severity, duration, timing, context, modifying
  factors, and associated signs and symptoms)
• Review of Systems (ROS)
• A series of questions asked of the patient
  relating to 14 body systems (constitutional,
  eyes, ENT/mouth, card/vasc, resp, GI, GU,
  musculoskeletal, skin, neuro, psych, endo,
  hem/lymph, allergy/immuno)
• Past / Family / Social History (PFSH)

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History

• Review of Systems (ROS)
• Different from the HPI in that the ROS is a
  series of questions asked of the patient or
  parent relating to body systems
• At least one system needs to be documented in
  order to report beyond a level one new patient
  visit (99201)
• The documentation must show that the provider has
  posed a question to the patient
• Words such as Denies headache or symbols such
  as - pain or cough would indicate that
  the patient responded to questions posed by the
  provider

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History Documentation Tips

• History of Present Illness (HPI)
• Must be documented by the billing provider and
  cannot be referred to
• Review of Systems (ROS)
• Preferred documentation include a separate ROS
  section in your note
• Can be documented by ancillary personnel
  (nursing)
• A complete ROS (10 or more systems) is required
  for a comprehensive history needed for 99204 or
  99205 (level 4 or 5 New pt clinic visit) and for
  99222 or 99223 (highest 2 levels of Initial Hosp
  HPs)
• Documentation requirements can be met for a
  complete ROS if all positive responses, pertinent
  negatives and then a statement that includes the
  words Complete, All, or Remainder is
  documented
• Examples Complete ROS otherwise negative, All
  systems negative other than above, Remainder of
  systems negative
• Past / Family / Social History (PFSH)
• In addition to past medical history, family and
  social history are both required for a
  comprehensive history

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Exam

• There are two sets of guidelines developed by CMS
  for use and adopted by all major carriers
• 1995 Guidelines
• 1997 Guidelines
• Difference between the guidelines primarily lies
  with the exam component
• The 1997 guidelines require more detail in the
  documentation, but allow for comprehensive levels
  for single system exams
• Either set of guidelines can be used
• Use should be consistent

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Exam

• 1995 Guidelines
• Consist of 7 Body Areas
• Head, including face Neck
• Abdomen Genitalia
• Chest, including breasts/axillae Back,
  including spine
• Each extremity
• Consist of 12 Organ Systems
• Constitutional (vitals, gen app) Eyes
• Ears, nose, mouth, throat Respiratory
• Cardiovascular Skin
• GI GU
• Musculoskeletal Neuro
• Hem/Lymph/Immuno Psych

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Exam

• The extent of the exam is determined by the
  number of body areas or organ systems that are
  documented
• Problem-focused 1 body area or organ system
• Expanded problem-focused 2-7 with brief
  descriptions
• Some clinics have adopted a definition of 2-4
  systems for expanded
• Detailed 2-7 with detailed descriptions
• Some clinics have adopted a definition of 5-7
  systems for detailed
• Comprehensive 8 or more organ systems
• A comprehensive exam (8 or more organ systems) is
  required in order to report
• A level 4 or 5 new patient clinic visit (99204 or
  99205)
• A level 2 or 3 initial hospital HP (99222 or
  99223)

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Exam Documentation Tips

• OK to use check boxes on a preprinted encounter
  form
• Be specific and dont leave out elements of the
  exam if performed
• Additional documentation is needed if a notation
  of abnormal or an abnormal box for the exam on
  a form is checked
• An abnormal notation without elaboration is
  insufficient

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Medical Decision-Making

• Coders use a point system to determine the
  complexity of the medical decision-making
• Consists of three elements
• Number of diagnoses or treatment options
• More points are given for new problems, less for
  established problems
• Amount and complexity of the data to be reviewed
• Points are given for the ordering or reviewing of
  labs, x-rays, and other diagnostic tests
• Risk of complications and/or morbidity or
  mortality
• Based on the presenting problem(s), diagnostic
  procedure(s) ordered, or management/treatment
  options

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Medical Decision-Making

• Number of diagnoses or treatment options
• More points are given for new problems, less for
  established problems
• New problems are defined as new to the treating
  provider
• New exacerbations are also defined as new
  problems (asthma)
• Work-up planned includes diagnostic testing or
  further examinations
• Amount and complexity of the data to be reviewed
• 1 point for lab or x-ray regardless of the
  quantity of testing
• Tests in the medicine section include PFTs,
  pulse ox, allergy testing
• Risk of complications and/or morbidity or
  mortality
• See Table of Risk

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Medical Decision-Making

• Table of Risk
• This table was developed for use for the Medicare
  population
• Some clinics have added to the presenting
  problems or expanded on this list for pediatric
  cases
• Example Under moderate risk for presenting
  problem, for acute complicated injury, the table
  lists head injury with brief loss of
  consciousness as an example
• Discussed with Emergency room providers who
  determined that any head injury of a child is
  considered moderate risk (these patients are not
  often able to verbalize their symptoms vertigo,
  nausea, etc.)
• Some problems can be low, moderate or high
  depending on the severity (example asthma)

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MDM Documentation Tips

• Points can be counted for the Data element if the
  documentation shows the following
• Visualization of x-ray films
• Chest x-ray film shows no infiltrates
• X-ray read normal exam
• Decision to obtain old records or records from
  another hospital/clinic
• Will get records from patients hospitalization
  at .
• Review and summarization of other records
• Discussion of case with another healthcare
  provider
• Discussed the psych testing results with Dr.
  XXX
• These are elements often performed, but rarely
  documented.

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Choosing an E/M Level

• What type of service was performed?
• What is the place of service?
• Is this a new patient or established?
• What is the extent of the history and exam and
  the complexity of the MDM?
• Any modifying factors (eg, time)?

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Choosing an E/M Level

• Review Audit Tool

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CLINIC E/M SERVICES
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Established Patient Visits

• CPT Codes 99211-99215
• Five Levels of Care
• Only 2 of 3 key components (history, exam, MDM)
  need to be met to bill at a particular level for
  established patient visits

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Established Patient Tips

• Most Often Missed Elements
• A clear chief complaint
• ROS
• Pre-ops HPI
• MDM data elements

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New Patient Visits

• CPT Codes 99201-99205
• Five Levels of Care
• All 3 key components (history, exam, MDM) need to
  be met to bill at a particular level for new
  patient visits

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New Patient Visits

• Definition A new patient is one who has not
  received any professional service (face-to-face
  service that is reported by a specific CPT code)
  from the provider or another provider of the same
  specialty who belongs to the same group practice,
  within the past 3 years

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New Patient Visits

• Example of a patient whose services would be
  reported with an established pt E/M code
• Pt has been previously seen (in the past 3 years)
  by you or another provider of your same specialty
  in your group
• Examples of patients whose services would be
  reported with a new pt E/M code
• Pt has been previously seen (in the past 3 years)
  by a provider of another specialty in your group
  and now is being seen by you
• Pt has never been seen by any of your groups
  providers
• It has more than three years since the patient
  has been seen by any provider in your group
  practice

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New Patient Tips

• Most Often Missed Elements
• ROS
• Family or social history elements
• MDM data elements
• Because all 3 key components are needed at a
  particular level in order to bill, each
  subcomponent of history becomes very important

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HOSPITAL E/M SERVICES
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Hospital E/M Services

• Initial Hospital Care
• CPT Codes 99221-99223
• Three Levels of Care
• Even the lowest level (99221) requires
• Detailed history (includes 2-9 systems in ROS)
• Detailed exam (includes detailed description of
  2-7 body areas/organ systems)
• All 3 key components (history, exam, and medical
  decision-making) need to be met to bill at that
  level
• Per day codes All E/M services (on the same
  calendar day) related to the admission (including
  other sites of service) are considered part of
  the initial HP

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Hospital E/M Services

• Initial Hospital Care
• Because all 3 key components need to met, each
  subcomponent of history becomes extremely
  important
• Only a 99221 can be billed (regardless of the
  complexity of the case) if the following are not
  documented
• A complete ROS (10 systems)
• All 3 PFSH subcomponents (past medical, family
  and social history)
• Difference in fee schedule amt between 99221 and
  99223 is about 100.00
• The ROS and either the family or social history
  are elements that are missed the most

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Hospital E/M Services

• Subsequent Hospital Care
• CPT Codes 99231-99233
• Three Levels of Care
• Only 2 out of 3 key components (history, exam,
  MDM) need to be met to bill at that level
• Only a interval history is required (CC should
  still be doc)
• PFSH is not a required subcomponent for
  99231-99233
• Per day codes only one subsequent care visit
  may be reported per calendar day regardless of
  times seen
• Biggest issue with subsequent visits
  Handwriting
• If 3 auditors are unable to read the handwriting,
  then the documentation cannot be considered

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Hospital E/M Services

• Discharge Day Management
• CPT Codes 99238 and 99239
• Services include final exam of the pt, summary of
  hospital stay and discharge orders/instructions
• Difference between 99238 and 99239 is the amount
  of time spent
• 99238 up to 30 minutes
• 99239 more than 30 minutes
• Documentation of time is required to bill this
  code
• If time is not documented, service should be
  down-coded to 99238

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Hospital E/M Services

• Initial Observation Care
• CPT Codes 99218-99220
• Pt designated as being in observation status
• Lowest level (99218) has same requirements as
  99221 (detailed history and exam)
• All 3 key components (history, exam, and medical
  decision-making) need to be met to bill at that
  level
• Per day codes All E/M services (on the same
  calendar day) related to the admission (including
  other sites of service) are considered part of
  the initial obs.care code
• Cannot be billed based on time as there is not
  time element associated with these codes

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Hospital E/M Services

• Subsequent Observation Care
• Use established patient outpatient/ clinic E/M
  visit codes (99211-99215)
• Only on the middle day of a 3 calendar day stay
• If the pt is discharged on the day following the
  admission for observation, use the observation
  discharge day code (99217) on day 2
• If the provider performs both the initial care
  and the discharge care on the same calendar day,
  then report the combo codes (99234-99236)

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Hospital E/M Services

• Discharge Observation Care
• CPT Code 99217
• Services include final exam of the pt, summary of
  hospital stay and discharge orders/instructions
• Only one level of observation discharge care
• No time element
• Use this code on the last day of a 2-day
  observation stay

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Hospital E/M Services

• Initial Discharge Same Day
  Observation Care or In-Patient
• CPT Codes 99234-99236
• Pt designated as being in observation status or
  admit and disch from the inpt setting on same
  date
• Medicare 8 hour rule
• Lowest level (99234) has same requirements as
  99221 or 99218 (detailed history and exam)
• Report these codes when both the initial obs care
  and disch. obs care is performed on the same
  date
• These codes include both the initial and
  discharge services
• Documentation of both services should be clear

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Hospital E/M Services

• 2007 RVU info
• Initial IP Care Initial Observ Care
• 99221 2.24 99218 1.64
• 99222 3.14 99219 2.71
• 99223 4.58 99220 3.82
• Subsequent IP Care Initial/Disch Observ Care
• 99231 0.94 99234 3.30
• 99232 1.68 99235 4.35
• 99233 2.40 99236 5.42
• Discharge Day Mgmt Discharge Observ
  Care
• 99238 1.73 99217 1.74
• 99239 2.50

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Hospital E/M Services

• Scenario 1
• Patient is seen in clinic on Mon. and admitted to
  the teaching service at XXXXX Hosp. Provider
  does not see pt at hosp until Tues AM and then
  does the admission HP (det hx and exam, mod
  MDM). Pt is seen daily (prob foc hx and exam,
  low MDM) and discharged on Frid.
• Coding? _________________________________________
  
• __________________________________________________
  ______________________________________________
• Scenario 2
• Patient is admitted to observation from ER at
  1130pm Mon. Provider sees pt for admission HP
  (det hx and exam, mod MDM) on Tues morning and
  later that same day at 530pm performs discharge
  management of over 30 minutes.
• Coding? _________________________________________
  
• ____________________________________________

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CONSULTATION CODING AND DOCUMENTATION
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Consultations

• CPT Definition
• A consultation is a type of service provided by
  a physician whose opinion or advice regarding
  evaluation and/or management of a specific
  problem is requested by another physician or
  other appropriate source.
• The consultant may initiate diagnostic tests
  and/or therapeutic services at that consultation
  visit
• The request for the consult and the communication
  of the consultants opinion/advice back to the
  requesting provider must be documented

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Consultations

• Consultation CPT Codes
• Office / Other Outpatient
• 99241-99245
• Initial Inpatient
• 99251-99255

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Consultations

• Additional Coding/Documentation Guidelines
• To report the consult codes, there must be
  documentation of the 3 Rs
• Request for opinion or advice
• Render the opinion
• Respond back to the requesting provider
• If the 3 Rs are not documented, then use the
  appropriate E/M based on setting and type of
  service

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Consultations

• Request for opinion or advice
• This request must be documented in the patients
  medical record and specific to the requesting
  provider
• Seen at the request of the attending is not
  sufficient
• Example Johnny is seen in consultation at the
  request of Dr. Primary Pediatrician for
  evaluation of XXXXX
• There should be documentation of the request by
  the requesting provider in the patients chart
• Shows the intent of the requesting provider

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Consultations

• Render opinion or advice
• The level of consult billed should be based on
  the 3 key components (history, exam and MDM)
• Documentation of all 3 of the 3 key components
  need to be met to report a particular level of
  service
• If more than ½ the consult was spent in
  counseling or coordination of care, then the
  level may be billed based on time
• Face-to-face time for clinic/outpatient consults
• Face-to-face and floor time for inpatient
  consults

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Consultations

• Respond back to the requesting provider
• This response often is in a letter format
• A CC at the end of the note is sufficient
  documentation that a copy of the note was sent to
  the requesting provider

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Consultations

• New patient clinic visit vs. consultation
• Use new patient visit codes if
• Consultation documentation requirements are not
  met (the 3 Rs),
• Patient is self-referred, or
• Patient is transferring care (example patient
  just moved here and is transferring care to your
  clinic)
• Use the consultation codes if
• Another provider is requesting an opinion or
  advice
• AND consultation documentation requirements are
  met (the 3 Rs)

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BILLING BASED ON TIME
50
Billing Based on Time

• The level of E/M can be chosen based on the
  amount of time spent face-to-face with the
  patient rather than how much history and exam is
  done and the complexity of the MDM
• When more than half of the time spent is in
  counseling and/or coordination of care
• Level is chosen based on the total face-to-face
  time
• When time is documented

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Billing Based on Time

• Only face-to-face time can be used when reporting
  clinic or outpatient visits (99201-99215)
• Non-face-to-face time spent before and after the
  patient encounter cannot be included in the time
  component
• Unit/Floor time can also be used for inpatient
  visits (99221-99223 and 99231-99233)
• Emergency department visits cannot be billed
  based on time

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Billing Based on Time

• Clinic/Outpatient Visits
• New Patient Visits Established Patient Visits
• 99201 10 minutes 99211 5 minutes
• 99202 20 minutes 99212 10 minutes
• 99203 30 minutes 99213 15 minutes
• 99204 45 minutes 99214 25 minutes
• 99205 60 minutes 99215 40 minutes
• Clinic Consultations
• 99241 15 minutes
• 99242 30 minutes
• 99243 40 minutes
• 99244 60 minutes
• 99245 80 minutes

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Billing Based on Time

• Hospital Inpatient Visits
• Initial Hospital Care Subsequent Hospital Care
• 99221 30 minutes 99231 15 minutes
• 99222 50 minutes 99232 25 minutes
• 99223 70 minutes 99233 35 minutes
• In Patient Consultations
• 99251 20 minutes
• 99252 40 minutes
• 99253 55 minutes
• 99254 80 minutes
• 99255 110 minutes

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Billing Based on Time

• Documentation must show the following
• Total face-to-face or unit/floor time
• That more than ½ of the visit was spent in
  counseling or coordination of care
• Does not have to be exact minutes spent
• Provider may simply state that more than ½ the
  visit was spent in counseling
• A summary of the discussion
• Any key elements of the visit performed (history,
  exam, medical decision-making)

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Billing Based on Time

• -EXAMPLE-
• Patient is accompanied by Mom and Dad. Both
  parents have numerous questions regarding the
  patients new diagnosis of XXXXXX. We discussed
  at great length the prognosis and treatment plan.
  No exam done.
  Assessment XXXXX Disease
  Plan Will plan to follow
  patient every 3 months to evaluate and change
  plan of care as needed. Parents should continue
  current meds XXXX as prescribed earlier. If
  symptoms become acute, they should present to the
  Emergency Room. More than ½ this 40 min. visit
  was spent discussing above. Signed, Dr.
  Pediatric Specialist
• Coding?
• __________________________________________________
  _
• __________________________________________________
  _

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Billing Based on Time

• Issues
• Underreporting of levels documentation
  requirements
• Possible Solutions
• Educate providers on when to bill based on time
• Providers should get into the habit of noting the
  time when they enter an exam room
• Make it easier for providers to document the time
• Provide templates for when provider is
  transcribing
• If using preprinted encounter forms or an EMR,
  include a box for providers to check and include
  the time element
• Example
• More than half of this _______ minute visit was
  spent in counseling and/or coordination of care
• Any Other Questions?

57
COMPLIANCE BASICS
58
Questions to consider?

• What are the most utilized CPT codes in your
  clinic?
• E/M codes tend to be the most utilized by primary
  care based practices and many specialties
• Do you review the utilization of E/M levels
  reported by your providers?
• If you do, how often?
• Are there providers in your clinic that tend to
  only report one level of E/M code?
• Do you provide comparisons by provider or against
  national data?

59
Questions to consider?

• When was the last time your providers received
  coding education?
• Do you employ a certified coder?
• CPC through the American Academy of Professional
  Coders (AAPC)
• CCS-P through the American Health Information
  Management Association (AHIMA)
• Do you provide opportunities for continuing
  education for the coders you employ?
• Do you know your compliance risk?
• Do you have a documented compliance plan in place
  at your clinic?

60
Compliance Plan

• Why have a compliance plan?
• Reduces your compliance risk by protecting your
  practice from potential erroneous or fraudulent
  conduct
• Promotes adherence to statutes and regulations
• Helps to streamline business operations
• Minimize billing mistakes
• Speed and optimize proper payment of claims
• Reduce the chances of an audit (CMS, OIG, MA)

61
Compliance Plan

• Preventive Medicine for Your Clinic
• OIGs Compliance Program for Individual and Small
  Group Physician Practices
• Published in the Federal Register, Volume
  65, No. 194, Thursday, Oct. 5, 2000 Pages 59434 -
  59452
• http//oig.hhs.gov/authorities/docs/physician
  .pdf

62
Compliance Plan

• 7 basic elements of an effective compliance plan
• Implementing written policies
• Designating a compliance officer or contact
• Conducting comprehensive training and education
• Developing accessible lines of communication
• Coordinating internal monitoring and auditing
• Enforcing standards through well-publicized
  guidelines
• Responding to offenses and developing a CAP

63
Compliance Plan

• Conducting internal monitoring and auditing
• Documentation review should be done for all
  providers in your practice
• Should be done on a routine basis (annually)
• Random sample or- focused audit
• Recommend 10 charts per provider
• Easy to calculate percentages
• Gives a good picture of the providers
  documentation
• New providers to your practice
• Review documentation for the first several weeks
• Let it be a surprise

64
Compliance Plan

• Conducting training and education
• Documentation guidelines education should be
  provided to all providers in your practice
• Provide comprehensive orientation for new
  providers to your practice
• Prior to their start date
• Include review of your charge ticket and billing
  process
• Assess new providers for their level of
  understanding of coding and documentation
• Provide educational opportunities for coding and
  business office staff

65
Compliance Plan

• Developing open lines of communication
• Staff meetings
• Keep employees updated on compliance activities
  and clinic policies
• Establish a day-to-day billing feedback process
  for when a coding, documentation, or billing
  mistake or concern is detected
• Develop a standard feedback form
• If using an EMR, utilize email to provide feedback

66
Effective Billing Feedback Loop
Service is provided
Code(s) entered into PMS
RESULT - Behavior is changed
Claim is sent to payer
Feedback is given
Clinic receives EOB Payment/denial
Denials are researched
67
E/M Utilization Data Review

• What is Clinic E/M Utilization Data?
• CPT codes
• 99201 99205 New Patient Visit codes
• 99211 99215 Established Pt Visit codes
• 99241 99245 Outpt Consultation codes
• Total number of each level of E/M
• Also known as bell curve data

68
E/M Utilization Data Review

• Why review E/M Utilization Data?
• E/Ms are the most highly utilized codes for most
  clinic-based practices
• Payers are reviewing this data (so you should
  too)
• E/M UR data can pinpoint potential problem areas
  
• Can identify a potential compliance risk
• Can identify potential lost revenue

69
E/M Utilization Data Review

• How should E/M utilization data be reviewed?
• Do this review routinely (recommend quarterly, or
  at least annually)
• Provide comparisons
• Compare each provider to clinic as a whole
• Compare clinic as a whole to national data
• Part B Extract Summary System (BESS) data file
• E/M codes by specialty 2006 data (excel
  spreadsheet)
• Give a visual picture (use bar graphs)

70
E/M Utilization Data Review
71
E/M Utilization Data Review

• Most common undercoding 99213 / 99214
• Average difference in reimbursement ? 34.00
• Pediatric Clinic Undercoding Impact
• 6 mo utilization of 99214 in 2005 589
• Increasing the of 99214 to 20
• 3,000 X 34.00 102,000 (204,000 annually)

72
Take Home Messages

• Documentation and coding is important and makes a
  difference
• An effective compliance plan is essential and can
  affect your clinics overall revenue
• Because E/M codes make up the bulk of the revenue
  coming into the clinic, it is essential to be
  sure your providers are billing appropriately
  through documentation review and education
• Investing in this review and education will
  result in a good return on your investment

73
JoAnne M. Wolf, RHIT, CPCCoding Manager

• Coding Consultation Services
• [phone]
• Joanne.Wolf_at_ChildrensMN.org