Title: Doing It Right the First Time - E&M Auditing 101 Steven A
1Doing It Right the First Time -EM Auditing 101
- Steven A. Adams, CPC, CPC-H, COA
2Topics
- Update on CPT 2005
- Payment Reform Continues
- why is it important to code what you do?
- Recent Medicare Audit Findings
- what did The Man find last year
- 2005 OIG Workplan
- what is The Man looking for this year
- Auditing new patients established patient notes
- using my tools to audit successfully
- Modifiers and global periods
3Doing It Right The First Time!Five Steps to
Proper Reimbursement
- 1. Understand the Guidelines
- 2. Perform the Service
- 3. Document What You Did (according to the
guidelines) - 4. Bill what you documented
- 5. Collect what you billed
42005 Coding Update
- Hide not your talents. They for use were made.
What's a sundial in the shade. - Ben Franklin
52005 Changes
171 new codes 61 revised codes 46 deletions 1.5
Increase in Reimbursement
The Conversion Factor (CF) for 2005 will be
37.8975 up from 37.3374 in 2004.
62005 Changes
ICD-9-CM has more than 800 changes in the tabular
section alone October 1st April 1st
http//www.instacode.com/news-2005-changes.htm
7Avoiding trouble is largely a matter of knowing
the rules remembering your audience.
8CPT
What you did
Here Are The Rules
ICD-9
Why you did it
9Heres Your Audience
- Criminal Justice Field
- Accountants
- Biologists
Most individuals do not have training in the
health care field. CMS and OIG
10Payment Reform
I havent failed, Ive found 10,000 ways that
dont work. Thomas Edison
11Worthless Information?
12Rest of Georgia
Atlanta, Georgia
13Specialty Reimbursements Physicians Fee Schedule
14Recent Findings
Optimism is essential to achievement and it is
also the foundation of courage and true progress.
Nicholas Murray Butler
15CMS 2004 EM Report
20 Billion in Overpayments
16CMS 2004 EM Report
1 Billion in Under payments
17Expect Audits...
Infectious Disease 23.7
Nephrology 23.2 Cardiac
Surgery 22.3 Pulmonary
Disease 20.2 Radiation Oncology
18.2 Endocrinology 17.8
Pediatrics 17.7
Intreventional Radiology 17.3 Plastic
Surgery 16.8 Internal
Medicine 16.2
18All Specialties
43.7 Failed to have sufficient documentation
to support the code submitted 29.7 Did
not respond to request for error rate reviews
(and deemed to have insufficient
documentation) 17.2 Prescribed medically
unnecessary services 7.7 submitted
incorrect codes. The most common coding
mistake physicians made in 2004 billing one
level of EM higher or lower than allowable .
19Senator Charles Grassley
CMS must work even more aggressively to stem the
tide of this error rate and work closely with the
Justice department and the Inspector general in
the pursuit of waste, fraud and abuse."
"Improper payments jeopardize Medicare's ability
to treat a growing population of beneficiaries.
"They have to stop."
202005 OIG Workplan
He who can, does - he who cannot,
teaches. George Bernard Shaw
212005 Watch For...
- Billing Services The preferable method for
compensating a billing company for their
services is a flat fee per month or a fee based
on the number of claims processed rather than a
percentage of collections. - Care Plan Oversight(CPO)
- Ordering Physicians Excluded by Medicare
- Physician Pathology Services
- Coding for Evaluation and Management Services
- Use of Modifier 25
- Use of Modifiers With National Correct Coding
Initiative Edits (CCI) - The complete Work Plan is available on the OIG
Web site at http//oig.hhs.gov/publications/docs/w
orkplan/2005/200520Work20Plan.pdf
221
EM Coding Auditing
There are liars, damn liars, and statistics.
Mark Twain
23First Established 1992
7 Components
- History
- Examination
- Decision-making
- Counseling
- Coordination of care
- Nature of presenting problem(s)
- Time
24Outpatient Visit
New / Consults 99201 - 99245 Requires All Three
Key Elements
25Medicare Transmittal 1644
- Consultation Versus Visit - Pay for a
consultation when criteria is met - opinion is requested by another physician
- need for consultation is documented in note
- written report is provided to referring physician
Payment may be made regardless of treatment
initiation unless a transfer of care occurs. A
transfer of care occurs when the referring
physician transfers the responsibility for the
patients complete care at the time of the
referral.
26Medicare Transmittal 1644
- Consultation for Preoperative Clearance - Pay for
the appropriate consultation code for a
pre-operative consultation for a new or
established patient performed by any physician at
the request of a surgeon, as long as all of the
requirements for billing the consultation codes
are met.
27Remember
- If you bill it as a consultation visit you must
state it is a consult. - Thank you for allowing me to see your patient in
consultation for. - Patient being seen in consultation at the request
of Dr
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29New - Consults
- Level 1
- Level 2
- Level 3
- Level 4
- Level 5
- Self limited problem
- Self limited problem
- OTC, minor surgery
- Undiagnosed problem
- Rx management
- Endoscopy surgery without risk factors
- Major surgery risk factors
- Major surgery with risk factors
- Complex problem with data review
30History
1
- 1. Problem Focused
- 2. Expanded Problem Focused
- 3. Detailed
- 4. Comprehensive
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32Audit Form
HPI location duration severity quality
context timing signs/symptoms
modifiers ROS cons eye ent resp muscle
psych cv gi gu skin neuro lymph
endo allergy
all other systems negative counts as
10 EXAM Systems cons eye ent resp
muscle psych cv gi gu skin neuro
lymph Areas head chest
abdomen neck back genitalia each
extremity
33Just Do It
- New Patients / Consults
- Get a Comprehensive History
- Do Comprehensive Exam
- Select Code Based Upon MDM
34History Component
12,13
- Comprehensive
- Chief Complaint
- Extended HPI (4)
- Complete Review of Systems (10)
- Complete PFSH (3)
99205
60
35History Component
- Comprehensive
- Chief Complaint
- Extended HPI (4)
- Complete Review of Systems (10)
- Complete PFSH (3)
99205
60
36History Component
- Comprehensive
- Chief Complaint
- Extended HPI (4)
- Complete Review of Systems (10)
- Complete PFSH (3)
99205
60
37History Component
- Comprehensive
- Chief Complaint
- Extended HPI (4)
- Complete Review of Systems (10)
- Complete PFSH (3)
99205
60
38History Component
- Comprehensive
- Chief Complaint
- Extended HPI (4)
- Complete Review of Systems (10)
- Complete PFSH (3)
99205
60
391995 Exam
1
- 1. Problem Focused
- 2. Expanded Problem Focused
- 3. Detailed
- 4. Comprehensive
40Audit Form
HPI location duration severity quality
context timing signs/symptoms
modifiers ROS cons eye ent resp muscle
psych cv gi gu skin neuro lymph
endo allergy
all other systems negative counts as
10 EXAM Systems cons eye ent resp
muscle psych cv gi gu skin neuro
lymph Areas head chest
abdomen neck back genitalia each
extremity
41Examination Component
14
- Comprehensive
- 8 System Exam
Const Well Developed Eyes PERRLA CV RRR Lungs
CTA
Abd Bowel Sounds Skin Warm, Dry Neuro
Intact Psych A O X 3
421997 Exam
1
- Single System Examinations
- Cardiovascular
- Male GU / Female GU
- Neurological
- Eye
- Psychiatric
- ENT
- Musculoskeletal
- Hematological
- Respiratory
- Skin
431997 Single System Exam
Based on Elements
Problem focused 1 Expanded problem focused
6 Detailed 12 Comprehensive All in a shaded
area one in each non-shaded area
44Based on Elements
Problem focused 1 Expanded problem focused
6 Detailed 12 Comprehensive All in a shaded
area one in each non-shaded area
45Which One Should I Use
I recommend the 1995 guidelines
However
If your doctor is doing a specialty exam it
better match the 97 guidelines
Exactly
46Medical Decision Making
6
- 1. Straightforward
- 2. Low Complexity
- 3. Moderate Complexity
- 4. High Complexity
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53Auditing Notes
- What you might find initially during your audits
54Note 1
55Step 1
Audit Your History Examination
HPI location duration severity quality
context timing signs/symptoms
modifiers ROS cons eye ent resp muscle
psych cv gi gu skin neuro lymph
endo allergy
all other systems negative counts as
10 EXAM Systems cons eye ent resp
muscle psych cv gi gu skin neuro
lymph Areas head chest
abdomen neck back genitalia each
extremity
56Step 1
Audit Your History Examination
HPI location duration severity quality
context timing signs/symptoms
modifiers ROS cons eye ent resp muscle
psych cv gi gu skin neuro lymph
endo allergy
all other systems negative counts as
10 EXAM Systems cons eye ent resp
muscle psych cv gi gu skin neuro
lymph Areas head chest
abdomen neck back genitalia each
extremity
571
7/20
99204
58Step 2
Calculate Medical Decision Making
59Step 2
Calculate Medical Decision Making
6
1
2
3
5
4
60Step 2
Calculate Medical Decision Making
6
1
2
3
5
4
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621
7/20
99204
99203
63Note 2
642
8/12
99205
99203
65Step 2
Calculate Medical Decision Making
6
1
2
3
5
4
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68Note 3
693
8/17
99202
99203
70Step 2
Calculate Medical Decision Making
6
1
2
3
5
4
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73Outpatient Visit
1
Established Patient 99211 - 99215 Requires Two
of Three Key Elements
7499211 with PT test
The disease or condition for which
anticoagulation is indicated would allow periodic
EM services. If there is a complaint or stated
reason for concern, it would be appropriate to
provide the necessary EM service to address the
problem. Physicians or qualified nonphysician
practitioners may file such claims. Services by
other office personnel would have to meet all of
the conditions of "incident to" coverage. Per
MCM 2050, to be covered incident to the services
of a physician, services and supplies must be
- An integral, although incidental, part of
the physician's professional service.
- Commonly rendered without charge or
included in the physician's bill. - Of a
type that are commonly furnished in physician's
offices or clinics. - Furnished
by the physician or by auxiliary personnel under
the physician's direct supervision.
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76Established - Subsequent
- 99211
- 99212
- 99213
- 99214
- 99215
- Nurse Code
- (1) stable / resolved problem
- (1) Unstable or
- Multiple stable problems
- Multiple conditions, something is wrong
- Counseling - 25 minutes
- Highly acute problem w / data
- Counseling - 40 minutes
77Note 4
784
7/15
99212
99214
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81Note 5
825
11/3/04
99213
99214
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85Note 6
866
10/11
99213
99214
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89Feel Like This?
90Global Periods Modifiers for Common Procedures
Not everything that can be counted counts, and
not everything that counts can be counted.
Albert Einstein
91Global Fee Policy
- Concept is that certain services are included in
the allowance for a surgical procedure.
92Not In Global Package
- Initial Consult
- Unrelated Visits
- Diagnostic Test
- Return Trips to OR
- Staged Procedures
- Treatment for the underlying condition or an
added course of treatment, which is not part of
the normal recovery from surgery
93Minor Surgery / Service
25
- 22 - Surgery Only
- 24 - EM Only
- 25 - EM Only (Minor surgery / service)
- 50 - Surgery Only (Bilateral procedure)
- 57 - EM Only (Major surgery)
- 58 - Surgery Only (Related, staged)
- 78 - Surgery Only (Related, complication)
- 79 - Surgery Only (Not Related)
94 EM MODIFIERS ONLY 21 24 25 32 52 57
95EM and Procedure
- Established office visit and removal of 12 skin
tags.
- 99213, 11200
- 99213, 11200-25
- 99213-25, 11200
- 99203-57, 11200
96EM and Procedure
- Established office visit and removal of 12 skin
tags.
- 99213, 11200
- 99213, 11200-25
- 99213-25, 11200
- 99203-57, 11200
97EM and Procedure
- New patient with bilateral knee arthrocentesis.
- 99204, 20610-50
- 99204-57, 20610
- 99204-25, 20620-57
- 99204-25, 20610-50
98EM and Procedure
- New patient with bilateral knee arthrocentesis.
- 99204, 20610-50
- 99204-57, 20610
- 99204-25, 20620-57
- 99204-25, 20610-50
99EM and Procedure
- Patient comes in for a 7 day f/u S/P skin biopsy
(11100)
- 99213-24
- 99213-78
- 99213
- 99213-79
100EM and Procedure
- Patient comes in for a 7 day f/u S/P skin biopsy
(11100)
- 99213-24
- 99213-78
- 99213
- 99213-79
101EM and Procedure
- 7 days after arthrocentesis of right knee,
patient returns with pain in left knee. Has EM
visit with arthrocentesis of left knee.
- 99213-24,25, 20610
- 99213-25, 20610-LT
- 99213-25, 20610-78
- 99213-24,25, 20610-79-LT
102EM and Procedure
- 7 days after arthrocentesis of right knee,
patient returns with pain in left knee. Has EM
visit with arthrocentesis of left knee.
- 99213-24,25, 20610
- 99213-25, 20610-LT
- 99213-25, 20610-78
- 99213-24,25, 20610-79-LT
103Topics
- Update on CPT 2005
- Payment Reform Continues
- Why is it important to code what you do?
- Recent Medicare Audit Findings
- what did The Man find last year
- 2005 OIG Workplan
- what is The Man looking for this year
- Auditing new patients established patient notes
- using my tools to audit successfully
- Modifiers and global periods
104How Do I Remember All This Stuff?
105You Cant
106Library
- Coders Desk Reference
- Principles of CPT/ICD-9
- CPT Changes
- Coding Alert Magazines
- Coders Edge - AAPC
107Resources
- cms.gov
- gamedicare.com/provider/EandM/index.htm
- oig.hhs.gov/publications/workplan.html
- cms.hhs.gov/providerupdate/whatsnew.asp
- cms.hhs.gov/physicians/cciedits/default.asp
- medville.com
- aapc.com
108Doing It Right!Five Steps to Reimbursement
- 1. Understand the Guidelines
- 2. Perform the Service
- 3. Document What You Did (according to the
guidelines) - 4. Bill what you documented
- 5. Collect what you billed
109Remember
If all else fails, destroy the evidence and blame
your failure on someone else. Steven Adams
110