Doing It Right the First Time - E&M Auditing 101 Steven A

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Doing It Right the First Time -EM Auditing 101

• Steven A. Adams, CPC, CPC-H, COA

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Topics

• 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

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Doing 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

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2005 Coding Update

• Hide not your talents. They for use were made.
  What's a sundial in the shade.
• Ben Franklin

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2005 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.
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2005 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
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Avoiding trouble is largely a matter of knowing
the rules remembering your audience.
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CPT
What you did
Here Are The Rules
ICD-9
Why you did it
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Heres Your Audience

• Criminal Justice Field
• Accountants
• Biologists

Most individuals do not have training in the
health care field. CMS and OIG
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Payment Reform
I havent failed, Ive found 10,000 ways that
dont work. Thomas Edison
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Worthless Information?
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Rest of Georgia
Atlanta, Georgia
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Specialty Reimbursements Physicians Fee Schedule
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Recent Findings
Optimism is essential to achievement and it is
also the foundation of courage and true progress.
Nicholas Murray Butler
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CMS 2004 EM Report
20 Billion in Overpayments
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CMS 2004 EM Report
1 Billion in Under payments
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Expect 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   
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All 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 .
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Senator 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."  
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2005 OIG Workplan
He who can, does - he who cannot,
teaches. George Bernard Shaw
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2005 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

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EM Coding Auditing
There are liars, damn liars, and statistics.
Mark Twain
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First Established 1992
7 Components

• History
• Examination
• Decision-making
• Counseling
• Coordination of care
• Nature of presenting problem(s)
• Time

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Outpatient Visit
New / Consults 99201 - 99245 Requires All Three
Key Elements
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Medicare 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.
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Medicare 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.

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Remember

• 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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New - 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

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History
1

• 1. Problem Focused
• 2. Expanded Problem Focused
• 3. Detailed
• 4. Comprehensive

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Audit 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
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Just Do It

• New Patients / Consults
• Get a Comprehensive History
• Do Comprehensive Exam
• Select Code Based Upon MDM

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History Component
12,13

• Comprehensive
• Chief Complaint
• Extended HPI (4)
• Complete Review of Systems (10)
• Complete PFSH (3)

99205
60
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History Component

• Comprehensive
• Chief Complaint
• Extended HPI (4)
• Complete Review of Systems (10)
• Complete PFSH (3)

99205
60
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History Component

• Comprehensive
• Chief Complaint
• Extended HPI (4)
• Complete Review of Systems (10)
• Complete PFSH (3)

99205
60
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History Component

• Comprehensive
• Chief Complaint
• Extended HPI (4)
• Complete Review of Systems (10)
• Complete PFSH (3)

99205
60
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History Component

• Comprehensive
• Chief Complaint
• Extended HPI (4)
• Complete Review of Systems (10)
• Complete PFSH (3)

99205
60
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1995 Exam
1

• 1. Problem Focused
• 2. Expanded Problem Focused
• 3. Detailed
• 4. Comprehensive

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Audit 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
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Examination Component
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• 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
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1997 Exam
1

• Single System Examinations
• Cardiovascular
• Male GU / Female GU
• Neurological
• Eye
• Psychiatric
• ENT
• Musculoskeletal
• Hematological
• Respiratory
• Skin

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1997 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
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Based on Elements
Problem focused 1 Expanded problem focused
6 Detailed 12 Comprehensive All in a shaded
area one in each non-shaded area
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Which 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
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Medical Decision Making
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• 1. Straightforward
• 2. Low Complexity
• 3. Moderate Complexity
• 4. High Complexity

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Auditing Notes

• What you might find initially during your audits

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Note 1
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Step 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
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Step 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
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1
7/20
99204
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Step 2
Calculate Medical Decision Making
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Step 2
Calculate Medical Decision Making
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1
2
3
5
4
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Step 2
Calculate Medical Decision Making
6
1
2
3
5
4
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1
7/20
99204
99203
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Note 2
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2
8/12
99205
99203
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Step 2
Calculate Medical Decision Making
6
1
2
3
5
4
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Note 3
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3
8/17
99202
99203
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Step 2
Calculate Medical Decision Making
6
1
2
3
5
4
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Outpatient Visit
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Established Patient 99211 - 99215 Requires Two
of Three Key Elements
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99211 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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Established - 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

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Note 4
78
4
7/15
99212
99214
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Note 5
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5
11/3/04
99213
99214
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Note 6
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6
10/11
99213
99214
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Feel Like This?
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Global Periods Modifiers for Common Procedures
Not everything that can be counted counts, and
not everything that counts can be counted.
Albert Einstein
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Global Fee Policy

• Concept is that certain services are included in
  the allowance for a surgical procedure.

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Not 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

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Minor 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)

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EM MODIFIERS ONLY 21 24 25 32 52 57
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EM and Procedure

• Established office visit and removal of 12 skin
  tags.

• 99213, 11200
• 99213, 11200-25
• 99213-25, 11200
• 99203-57, 11200

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EM and Procedure

• Established office visit and removal of 12 skin
  tags.

• 99213, 11200
• 99213, 11200-25
• 99213-25, 11200
• 99203-57, 11200

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EM and Procedure

• New patient with bilateral knee arthrocentesis.

• 99204, 20610-50
• 99204-57, 20610
• 99204-25, 20620-57
• 99204-25, 20610-50

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EM and Procedure

• New patient with bilateral knee arthrocentesis.

• 99204, 20610-50
• 99204-57, 20610
• 99204-25, 20620-57
• 99204-25, 20610-50

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EM and Procedure

• Patient comes in for a 7 day f/u S/P skin biopsy
  (11100)

• 99213-24
• 99213-78
• 99213
• 99213-79

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EM and Procedure

• Patient comes in for a 7 day f/u S/P skin biopsy
  (11100)

• 99213-24
• 99213-78
• 99213
• 99213-79

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EM 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

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EM 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

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Topics

• 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

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How Do I Remember All This Stuff?
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You Cant
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Library

• Coders Desk Reference
• Principles of CPT/ICD-9
• CPT Changes
• Coding Alert Magazines
• Coders Edge - AAPC

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Resources

• 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

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Doing 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

109
Remember
If all else fails, destroy the evidence and blame
your failure on someone else. Steven Adams
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• Questions?