Evaluation and management (E/M) codes drive much of the revenue in physician practices.
Thus, these codes are often vulnerable to third-party auditor scrutiny. When auditing, auditors frequently ask this question: Does the documentation truly justify the services rendered, and are those services medical necessary for the diagnosis treated?
Data analytics play an important role in being able to target physicians for non-compliance. Payers frequently use these types of analyses to identify outliers—i.e., physicians who bill higher-than-normal levels of more intensive codes. Other auditors, such as Recovery Auditors, Medicare Administrative Contractors, and Zone Program Integrity Contractors often follow suite using this same type of data gleaned from analytics.
Given the increased scrutiny of these codes, it's important to monitor compliance frequently, says Raemarie Jimenez, CPC, CPB, CPMA, CPPM, CPC-I, CANPC, CRHC, director of product development at AAPC. This article discusses several of the most common compliance traps and provides simple tips that practices can use to perform internal audits.
Compliance risks
Jimenez says practices should be on the lookout for these E/M compliance vulnerabilities:
1. Reporting an 'established' patient as 'new' and vice versa. E/M payments for new patients are higher than those for established patients, thus it's critical to ensure correct classification, says Jimenez. Medicare provides the following definitions:
• New patient: An individual who has not received any professional services from the physician/non-physician practitioner (NPP) or another physician of the same specialty who belongs to the same group practice within the previous three years
• Established patient: An individual who has received professional services from the physician/NPP or another physician of the same specialty who belongs to the same group practice within the previous three years
2. Copy-and-paste documentation. Electronic health records (EHR) often include tools and functions designed to increase efficiency (e.g., the ability to copy and paste information from previous encounters). However, these tools and functions may also leave physicians vulnerable to compliance risk.
For example, physicians are at risk when they copy and paste a patient's family and social history or parts of the exam from a previous visit without addressing that information on the actual date of service for which services are billed, says Jimenez. When auditing, look for entirely verbatim paragraphs that carry from record to record, as this may indicate that a physician is copying and pasting information without verifying it or reviewing it thoroughly, she adds.
In addition, some EHRs pre-populate all body systems as 'normal.' Unless a physician unchecks one or more boxes to indicate that he or she did not review a particular system, it appears as though he or she reviewed all systems and deemed them normal. This could result in higher-level E/M codes that aren't justified. Jimenez says it's important for physicians to understand the implications of the copy-and-paste function. Practices should work with their EHR vendor to better understand the purpose of this functionality and how they can use it without jeopardizing compliance.
3. Lack of medical necessity. Increasingly, auditors examine not only whether a particular service is justified based on documentation but also whether the service is medically necessary given the particular diagnosis with which the patient presents, says Jimenez. She says physicians sometimes document specific elements simply to justify a higher-level code. However, if the exam and review of systems don't seem justified for the presenting problem (e.g., a comprehensive exam performed for a simple ear ache), an auditor may come along and question why those services were rendered. It all comes down whether the services were appropriate based on the patient's presenting problem, she adds.
Auditing tips
No physician ever thinks that he or she will ever be audited, yet it happens all the time, says Jimenez. That's why it's important to be proactive and catch coding and documentation mistakes before the auditors do. The goal of an E/M audit is to identify areas of compliance vulnerability as well as areas of under-reporting or even missed charges. Practices can perform audits internally, or they can hire an outside consultant.
Regardless of the method, consider these tips to make the most of the audit:
• Choose an appropriate number of charts. The OIG Compliance Program For Individual and Small Group Physician Practices suggests 5-10 records per physician. Some audit firms recommend 10-20 charts per physician, says Jimenez. Use these smaller audits to identify trends and opportunities for more targeted audits.
• Determine whether the 1995 or 1997 E/M guidelines are more beneficial. Specialty types that often perform multi-system exams (e.g., family practice or internal medicine) typically gravitate toward the 95 guidelines, says Jimenez. Specialists who typically perform a more detailed exam related to a particular system may benefit from using the 95 guidelines. Physicians can technically use either set of guidelines and often choose the set that is most beneficial for a particular patient/encounter. However, they can't switch back-and-forth between sets of guidelines for one encounter.
• Keep tabs on auditor trends. In particular, know what your Recovery Auditor and MAC are looking for. For example, some MACs won't accept documentation such as 'non-contributory' when describing the patient's family and social history. Instead, physicians must document statements such as, 'Normal, reviewed,' 'Negative, reviewed,' or 'Patient's history does not have bearing on the present condition.'
Monitor your MAC's Web site, provider manual, and frequently-asked questions. Also monitor your RAC's Web site and any new issues that are approved.
The importance of certified coders
Certified coders play an important role in compliance because they're able to verify the accuracy of any E/M codes assigned. Some coders double check the codes that physicians assign through the EHR or circle on an encounter form. Other coders read documentation and assign the E/M codes based on that documentation. Either way, certified coders know the E/M guidelines and the type of language payers are looking for, and they are an incredible asset to any practice.
Also consider these resources to ensure E/M compliance:
• How to complete a coding audit (internal medicine) (American College of Physicians)
• Trailblazer Medicare Audit Tool
• Medicare Evaluation and Management Services Guide (CMS)
• AAPC presentation on E/M auditing
• Coding Trends in Medicare Evaluation and Management Services (an OIG report)
• Are you ready for RAC Audit of your E&M Codes
By performing regular internal audits followed by education and follow-up audits, practices are much more likely to avoid large financial penalties down the road. Focus on proactive compliance to avoid auditory scrutiny.
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Alok Prasad is the President of RevenueXL Inc. which is a leading provider of healthcare solutions and EHR Software, providing ONC-ATCB Certified Electronic Health Records Software to small and mid-sized practices. RevenueXL offers 30-day free EMR Trial to all new clients.
The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.