Level of care coding tips to boost revenue, mitigate risk

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The clock is ticking, and you’re trying to select the right E/M level from a drop-down menu in the EHR. Choose a level that’s too high, and you run the risk of post-payment audits and recoupments. Choose one that’s too low, and you may lose revenue to which you’re entitled. You decide just to trust your instincts and go with a code that feels right so you can move on to the next patient. 

Choosing an E/M code based on a gut feeling is one of the biggest mistakes a physician can make, says Sonal Patel, CPMA, CPC, a healthcare coder and compliance consultant with Nexsen Pruet LLC, a business law firm in Charleston, S.C. Payers and auditors use a quantitative scoring process that requires specific elements (i.e., history, exam, and medical decision-making [MDM]-or time spent counseling and coordinating care) for each E/M level. 

If physicians don’t document these elements adequately-or the elements they document don’t make sense given the patient’s presenting problem (e.g., performing a comprehensive exam for a patient with a sinus infection)-payers and auditors may down-code the service or even conduct a more in-depth audit that could expose additional documentation vulnerabilities, she adds.

It’s equally risky to report the same E/M level for all patients with the same diagnoses (e.g., diabetes or congestive heart failure) without first considering medical necessity-a trap into which many physicians fall because they assume all patients with the same diagnoses generally require the same work, says Toni Elhoms, CCS, CPC, director of coding and compliance at RT Welter & Associates Inc., a healthcare consulting company in Arvada, Colo. “In reality, every single visit could be a different level based on the documentation and circumstances of the encounter,” she says.

Focus on quality E/M documentation-and the dollars will follow

Knowing what documentation is required for each E/M level is paramount. For example, the history, exam, and MDM must meet or exceed certain requirements for all new patients. The only exception is when the physician selects the E/M level using time as the controlling factor. In this case, documentation must indicate that the physician spent more than 50 percent of the encounter face-to-face with the patient and/or family providing counseling and/or coordination of care. The physician must also explain the specific services rendered and the reasons for them. 

Only two of three key components must meet or exceed certain requirements for established patients unless the physician bills based on time. Elhoms provides an E/M scoring guide that includes a visual depiction of documentation requirements for each specific E/M level based on whether the patient is new or established. 

Sound confusing? Experts agree that even the most experienced medical coders have difficulty translating physician documentation into an accurate E/M code. They cite several reasons why E/M coding is so difficult for physicians-lack of formal training on E/M guidelines, complex documentation requirements that don’t align with clinical practices, and the subjective nature of the MDM component. 

We’ve asked our experts to share their best documentation tips to ensure accurate E/M reporting. Here’s what they said. 

History

When billing a level 4 or 5 new patient E/M code (i.e., 99204 or 99205), remember to document one specific item from the past medical history (i.e., illness, operations, injuries, treatments, medications, or allergies), one specific item from the family history (i.e., medical events or hereditary diseases that place the patient at risk), and one item from the social history (e.g., use of tobacco, drugs, or alcohol). 

Also document a review of systems that relates directly to the problem identified in the history of the present illness (HPI) in addition to a review of all additional body systems, says Elhoms. Physicians frequently forget to include all of these elements, often leading payers to down-code these services to a level 2 or 3 on post-payment review, she adds. That means physicians could lose as much as $133 per encounter.

Similarly, when billing a level 3 new patient E/M code (i.e., 99203), don’t forget to document one specific item from either the past, family, and/or social history that’s directly related to the problem in the HPI. Omitting one or more of these details usually prompts payers and auditors to down-code the service to a level 1 or 2 on post-payment review, says Patel. Revenue loss in this case could be as much as $64 per encounter. 

Be as descriptive as possible when documenting the HPI. Specify the location, quality, severity, timing, context, modifying factors, and associated signs and symptoms that are significantly related to the presenting problem, says Patel. These descriptors help physicians gain points when choosing an E/M level, she adds.

Don’t repeat the same HPI for every visit. This is true even for follow-up appointments related to chronic conditions. Payers want to see what’s new with the patient-for example, new pain, new flare-ups, new concerns, or new lab results-or some acknowledgement that the patient has been stable and symptoms are controlled, says Patel. The same repetitive HPI could be a red flag that a physician is cloning their documentation, she adds.

Exam

Only review body areas or organ systems that affect MDM for the current encounter, says Michael Miscoe, JD, CPC, founding partner of Miscoe Health Law LLC in Central City, Pa. Most subsequent visits, for example, don’t require a multi-system exam even though it’s very easy in an EHR to pull this information forward from the initial visit. Doing so inflates the E/M level and could expose a physician to audit risk, says Miscoe. “More isn’t necessarily better,” he adds. “Because many docs either don’t understand this or let their EHR system flood the record with irrelevant content, we see skewed E/M profiles that lead to post-payment liability.”

Explain negative findings. Miscoe says documentation should reflect the following: For example, what did the physician specifically ask the patient about each body system, and how did they respond? How did this contribute to the physician’s overall assessment and evaluation? In the examination, what element of the organ system did the physician evaluate, and why? 

Physicians who don’t explain their analysis in the context of the patient’s complaints often end up with what Miscoe terms “healthy sick people records” (i.e., level 4s and 5s with mostly negative findings and no explanation of why the physician performed certain services) that tend to raise a red flag with payers and auditors.

Know whether your Medicare Administrative Contractor uses the 1995 or 97 E/M guidelines. These guidelines differ in their options for the exam component of the E/M level, says Patel. More specifically, the 97 guidelines provide additional options for single organ system exams, allowing providers to report higher-level services for intensive, problem-specific examinations. Once you know which of the guidelines your MAC uses, ensure your EHR vendor incorporates them into any templates you use, she adds. 

MDM

Know how payers calculate the MDM. “MDM is all about the cognitive labor a physician puts into the encounter,” says Elhoms. This includes the number of diagnoses and management options considered, the amount and/or complexity of data reviewed (e.g., urinalysis, EKG, lab results, or additional workup planned), and the risk of complications, morbidity, or mortality. Therefore, documenting each of these elements is critical because it can help justify a higher-level E/M code, she adds.

Know how your Medicare Administrative Contractor interprets MDM. Contractors publish frequently-asked questions and other guidance describing what they look for in terms of all E/M documentation, including MDM. For example, some MACs define ‘additional workup’ as any service that’s performed outside of the current encounter while others state it’s any work that goes beyond the E/M service-even when the physician performs it during the current encounter, says Shannon O. Deconda, CPC, CPMA, founder and president of the National Alliance of Medical Auditing Specialists in Knoxville, Tenn. 

Time

Document the total time (in minutes) spent face-to-face with the patient and/or family during the visit, and specify how much time (in minutes) was spent counseling the patient and/or family or coordinating care, says Miscoe.

Summarize specific details of the conversation with the patient and/or family (i.e., what was discussed with patient and/or family and why), says Elhoms.

Watch out for underpayments Experts agree that with all the buzz about upcoding, it’s easy to forget that under-coding is also a problem because it results in lost revenue. Though less common, under-coding happens when physicians report a lower-than-necessary E/M level out of fear they will be targeted by a payer for an audit. It can also happen when physicians don’t document all of the services they render or the complexity of their MDM. 

Most physicians become aware of a trend of underpayments after hiring a consultant to perform an internal audit, says Elhoms. The good news is that physicians can submit corrected claims to try and recoup some of the revenue to which they’re entitled.

Medicare allows providers to submit corrected claims up to a year from the date of service, while many other payers require resubmissions within 120 days or sooner. 

Is it worth the time and effort of resubmitting a claim? Elhoms provides this hypothetical example: A provider sees 100 patients per month, 50 of whom receive level 4 E/M services based on the documentation. However, the provider bills a level 3 for these 50 patients out of fear of being audited or because they don’t understand documentation requirements for each E/M code. The difference in payment between a level 3 and level 4 established patient is $35, equating to a $21,000 revenue loss over the course of a year. 

Five E/M best practices

• Invest in training. This includes annual E/M refresher training for all physicians and staff.

• Hire an outside consultant. Ask this individual to audit E/M documentation and ensure it supports the level of codes assigned.

• Be mindful of time-saving functionality. The Office of Inspector General (OIG) monitors copy-paste functionality (often referred to as cloned documentation) as well as auto-populated fields within E/M templates. Experts suggest turning off this functionality to avoid inappropriately upcoding E/M services. They also suggest turning off the automatic E/M calculator. This calculator is often based on a vendor-proprietary algorithm that may not accurately correlate with E/M scoring guidelines. The calculator also isn’t able to consider the medical decision-making or complexity of care that’s provided.

• Always consider medical necessity. Is it medically necessary to bill a higher-level E/M code when a lower level of service is warranted? For example, even though CPT guidelines permit physicians to report a level 5 E/M code when performing a comprehensive history and comprehensive exam, it may be appropriate to report a level 3 if the medical decision-making is straightforward (i.e., minimal risk of complications, morbidity, or mortality; minimal or no data reviewed; and minimal number of diagnoses or management options considered). Per the Medicare Claims Processing Manual, CMS considers medical necessity the overarching criterion in selecting an E/M code.

• Partner with a certified coder to validate codes prior to claim submission. Certified coders are well-versed in E/M guidelines and documentation requirements and can help increase compliance and minimize post-payment audit risk.