An absence of documentation to support the codes assigned, not knowing what codes must be reported separately and an over-reliance on the electronic health record (EHR) to assign the right code. These are just a few of the reasons why physicians see denials. What’s ultimately at stake? Revenue and profitability at a time when payer scrutiny has reached epic proportions.
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Payers’ ability to analyze large volumes of claims data means they’re able to easily identify any and all reasons to initiate an audit as well as delay or deny payment, says Kathleen Mueller, RN, CPC, president of AskMueller Consulting LLC, a healthcare consulting company.
Mueller worked recently with an internal medicine practice that had been notified by UnitedHealthcare that its evaluation and management (E/M) levels were high compared with peers. One week later, the practice received a 150-record request from the payer so it could look more closely at documentation.
This anecdote demonstrates why physicians need to pay attention to coding and documentation compliance—and not assume their EHR will take care of it, says Mueller.
Here are some of the services that payers frequently deny, along with expert advice on how to avoid payer scrutiny by using Current Procedural Terminology (CPT) codes correctly. Three of these services are also included in the Office of Inspector General’s (OIG) Work Plan for 2017, an annual report that summarizes the OIG’s new and ongoing reviews and activities to reduce fraud, waste, and abuse related to various U.S. Department of Health and Human Services programs and operations.
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Payers often use this document to identify and target areas of physician billing vulnerabilities, so it’s important for physicians to know how to code properly so as to collect what they are entitled to and avoid falling under the payer microscope.
HIGH-LEVEL EVALUATION AND MANAGEMENT
When documented and coded appropriately, high-level E/M codes translate into greater reimbursement than their lower-level counterparts. However, these codes can also be a source of financial frustration when payers refuse to pay them—a trend that seems to be emerging as physicians rely more on electronic health records (EHRs), says Mike Strong, MBA, CPC, bill review technical specialist at SFM, a workers’ compensation insurer.
“The templates make it easier to get higher levels when the medical necessity might not be there,” says Strong, who provides E/M education to physicians. Physicians end up foregoing SOAP (subjective, objective, assessment, and plan) documentation methods in favor of simply answering questions prompted by the template that may be completely unrelated to the patient's presenting problem, he adds.
Strong cites the example of an established patient with asymptomatic diabetes who presents for a blood sugar recheck and prescription refill. A general diabetes template in the EHR may prompt the physician to complete a full review of systems and an eight-organ system exam when medical necessity doesn’t justify these services, says Strong.
If physicians create their own templates, they shouldn’t assume that specific diagnoses automatically justify a certain level of E/M service, says Raemarie Jimenez, CPC, CPC-I, vice president of membership and certification solutions at AAPC, an organization representing professional coders, billers, auditors, compliance professionals and documentation specialists.
For example, some physicians believe that every new patient with abdominal pain justifies reporting CPT code 99204, so they develop an abdominal pain template that supports a level four E/M code. Physicians shouldn’t be prompted to document a level of service, says Jimenez. Instead, they should document elements that support medical necessity, she adds.