Payer requests, denials, the influence of ICD-10 codes, and audit risks are some of the issues that physician practices have to deal with while providing value based care. Physicians should focus on ensuring proper documentation in the medical record to prevent denials. While medical coding outsourcing to an expert can prevent denials, physicians need to be aware about these medical coding pearls that can optimize practice revenue:
- Document Evaluation and Management (E/M) to support medical necessity: Experts point out that there is the risk of several E/M pitfalls when using electronic health records (EHRs). A recent article in Medical Economics stresses that when physicians create their own templates, they should not assume that specific diagnoses automatically support a certain level of E/M service. The problem arises because EHRs automate the process of determining the E/M code for an office visit. The templates make it easier to report higher levels even in the absence of medical necessity, attracting the scrutiny of auditors. When documenting E/M services, physicians should take care not to forgo the SOAP (subjective, objective, assessment, and plan) documentation method. Rather than simply documenting a level of service, they should focus on documenting elements that support medical necessity.
- Be vigilant about EHR templates that pre-populate information: When documenting care in EHRs, physicians need to be wary about fields being improperly populated as well as of templates that require marking all others negative when completing review of systems. For instance, pre-populated fields in EHRs can imply tests had been performed that actually had not.
- Be alert when using the EHR copy-and-paste functionality: This can cause problems if the physician does not check whether information is relevant to the current visit. The suggested code may not correctly describe the patient’s presenting problem. Accidentally pasting in the wrong code without proper verification could lead to false claims being submitted inadvertently for services that were never provided.
- Use the right E/M codes: E/M codes used should reflect the nature of the presenting problem, and anything that does not impact the current visit should be treated as history. CPT codes 99215 and 99205 should be reserved for the sickest patients. For instance, to report Level 5, new patient evaluation and management (E/M) code 99205 appropriately, the service must necessitate a documented, medically necessary, comprehensive history, comprehensive exam, and medical decision-making of high complexity, based on the presenting problem for that particular date of service and the management options available to the physician for the established diagnosis. Coding experts say it is also important for physicians to E/M levels for the same patient over time. For instance, a patient who presents with an acute condition may improve over time, and the codes used should change to reflect that.
- Billing and coding prolonged services (99354-99359): Physicians billing prolonged services should document what was done to prolong that care. Prolonged services begin once the typical time (as per CPT guidelines) has elapsed for the E/M service. Medicare guidelines clearly state that prolonged service of less than 30 minutes total duration on a given date should not be reported since the work involved is included in the total work of the E&M codes. However, Medicare and some payers will reimburse these claims if the documentation provides proof of the time spent rendering the service and what tasks the physician performed during that time. For instance, the Medical Economics article recommends that the right way to bill for CPT code 99354(office or outpatient place of service codes) for the first hour of prolonged services, is as follows:
- Submit the documentation for the prolonged service separately from the rest of the visit with a note
- Report CPT code 99354 and the appropriate E/M code with modifier -25
- Include the start and stop time for the prolonged service on the CMS-1500 claim form
When such complete documentation is provided, the payer may not ask for more information.
Medicare provides a guide on determining the threshold time for billing CPT codes 99354 and 99355 with an outpatient visit code. However, some commercial payers have different rules and practices should check with the payer before billing prolonged services.
In the case of payment for non-face-to-face prolonged services, Medicare requires that these services are provided on the same date of service as the E/M code or on a date of service thereafter.
One of the best ways to see if your practice is documenting, coding and billing correctly is to check its claim denial rate. Practices that see rising denial rates should check how their teams are capturing data and conduct a billing analysis with the help of an experienced medical billing company. In fact, partnering with a reliable company is the best way to adhere to best practices in medical coding and billing.
Julie Clements, OSI’s Vice President of Operations, brings a diverse background in healthcare staffing and a robust six-year tenure as the Director of Sales and Marketing at a prestigious 4-star resort.
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