How to Manage Physician Billing Vulnerabilities and Code Correctly

by | Published on Jan 10, 2018 | Medical Coding

Physician Billing Vulnerabilities
Share this:

Errors in claim submission can lead to need to rework claims and loss of reimbursement for medical practices. According to a Fierce Healthcare report, a 5% denial rate is average for practices, and physicians should be concerned if their rate is above that level. Coding mistakes can result from over-reliance on electronic health records (EHRs) to assign codes. Documentation may also fall short of requirements. Outsourcing medical billing and coding can prevent these errors as experienced service providers know how to code correctly and handle various physician billing vulnerabilities.

Three services included in the Office of Inspector General’s (OIG) Work Plan for 2017 that typically come in for payer scrutiny and denials are: Evaluation and Management (E/M), Chronic Care Management (CCM) and Prolonged Services. Let’s look at these services and how to report them correctly.

  • Evaluation and Management (E/M) – bill the correct level of care: The E/M patient visit is the basis of most physician practices. However, many practitioners are not knowledgeable about selecting the right CPT code for an E/M visit, which leads to loss of revenue. Practices come under scrutiny if their E/M levels are high compared with that of their peers. Another problem is not documenting properly to support the level of care. Higher E/M levels are often the outcome of over-reliance on EHR templates even when the medical necessity might not be there:
    • Templates may pre-populate information from previous visits or require physicians to check “all others negative” when completing the review of systems. The EHR will include the information regardless of whether the physician performs the work.
    • EHR copy-and-paste functionality is another problem. Instead of confirming whether the information is relevant to the current visit, physicians may overrule the suggested code if they think that it does not accurately report the patient’s presenting problem.

    The correct code for an E/M visit generally depends on the complexity of the visit, which in turn is determined by the number of problems and the extent to which they are addressed. Anything that is not the presenting problem is past history. For instance, CPT E/M codes 99215 and 99205 are appropriate for a patient presenting with a condition that needs an immediate referral to a specialist or the hospital:

    99215 “Office or other outpatient visit for an established patient,” should be used only for a high level of complexity appointment such as patients at significant risk for loss of life or bodily function. It should be used only for a patient with an established history and attempting to bill with this code when it does not apply could attract audits.

    Similarly, 99205 “Office or other outpatient visit for the evaluation and management of a new patient” should also be reserved for the sickest patients. Medical decision making is of high complexity and the physician typically spends 60 minutes face-to-face with the patient and/or family. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. For instance, 99205 is not appropriate for ongoing treatment of stable conditions that do not pose a threat to a patient’s life or limb.

    Payers also look progression downward in the E/M levels for the same patient over time. For instance, an established patient with acute exacerbation of COPD may be billed using 99215, but payers may not expect the provider to continue to bill this code for each visit over the next few months.

  • Using Comprehensive Care Management (CCM) codes correctly: CMS and many commercial payers pay for CCM. The CCM CPT codes are:
    • 99490 (CCM services, 20 minutes)
    • 99487 (Complex CCM services, 60 minutes)
    • 99489 (Each additional 30 minutes)
    • HCPCS code G0506 (Comprehensive assessment of and care planning for patients requiring chronic care management services)

    As of January 1, 2017, an initiating visit is only required for new patients or patients who have not been seen in the practice within one year prior to the commencement of CCM.

    CCM codes come in for greater scrutiny and denials. There are two main reasons for denials:

    One reason is that a patient’s diagnosis does not support the need for CCM services. CCM is primarily meant patients with two or more chronic continuous or episodic health conditions (such as Alzheimer’s disease, arthritis, diabetes, or cancer) which are expected to last at least 12 months or for the rest of the patient’s life. To report CCM, these conditions must put the patient at significant risk of death, acute exacerbation/decompensation or functional decline. CCM denials occur when the physician bills for uncomplicated diagnoses.

    Another reason is delay in submitting claims. Both internists and specialists can bill CCM and payers pay whichever claim they receive first. So denials occur when one provider has already billed these services for the same patient during the same calendar month. To avoid this, providers must claims as soon as possible.

    Complex CCM has more stringent rules. In addition to meeting CCM criteria, the patient must require moderate- or high-complexity medical decision-making so that the physician has to spend at least 60 minutes performing CCM services per month. The physician should also establish or substantially revise a comprehensive care plan.

    HCPCS code G0506 can be billed before CCM is initiated when the physician spends additional time at a face-to-face visit performing an extensive assessment and developing a comprehensive care plan for CCM. G0506 should be billed only once per the patient for whom CCM is provided.

  • Billing Prolonged Services – have a “clear, compelling reason”: The OIG considers prolonged services (CPT codes 99354–99359) as “rare and unusual.” Therefore, physicians can bill these services only if they have a clear and compelling reason to do so. They need to provide documentation of what was done to prolong the care.
    Private payers tend to bundle prolonged services into the payment for E/M service. For instance, Oxford states that it “will separately reimburse physicians or other health care professionals for Prolonged Services when reported in conjunction with companion Evaluation & Management (E/M) codes or other services”.
    Points to note when billing prolonged services:

    • Documentation is crucial for Medicare and many private payers. CMS requires documentation in the medical record about the duration and content of the medically necessary evaluation and management service and prolonged services that are billed.
    • The provider must appropriately and sufficiently document in the medical record that they furnished the direct face-to-face time with the patient specified in the CPT code definitions
    • The start and end times of the visit, and the date of service should be included.
    • CPT codes should be reported with the appropriate modifier.
    • Prolonged services do not include care plan oversight, anticoagulant management, medical team conferences, online medical evaluations or other non-face-to-face services which require more specific CPT codes.
    • Non-face-to-face prolonged services could include extensive record reviews or communication with other providers and must be related to another E/M service that has occurred or will occur, and to ongoing patient management.
    • Medicare requires that ­non-face-to-face prolonged services are rendered on the same date of service as the E/M code or on a date of service thereafter.
    • Prolonged services begin after the typical time (as per CPT guidelines) has elapsed for the E/M service.
    • Commercial payers may have different policies from Medicare for billing prolonged services.

In these times of heightened payer scrutiny and risks of denials, physician practices would do well to partner with a medical billing and coding company that has a team of experienced AAPC-certified coders. This will ensure accurate assignment of codes and checks to ensure that documentation meets regulatory requirements. These experts are also well versed in Medicare and private payer policies.

Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

More from This Author