Q&A: Coding just right by using clear medical decision-making documentation

Q: What is the difference between over-codingand under-documentation? 

A: This question must have come up in the context of some type of internal or compliance audit as these are terms most often heard in that area of coding and documentation.

Medicare, as the principal authority and regulatory force in this area, does not usually make this distinction. To Medicare, if you have filed a claim for a service, and the documentation does not support that service, then typically they will call this “over-coded.”

For an internal auditor the term “over-coded” is usually used to indicate that the code selected involves work in the areas of medical history (Hx), physical examination (PE) and medical decision-making (MDM) that does not appear to have happened – specifically in the MDM area. 

An encounter is typically rated “under-documented” if the decision-making area leaves significant room for doubt as to the extent of management, or if either the history or exam areas notably lack required detail. Many charts that are rated under-documented fall into the latter category. 

An auditor will distinguish between these terms because it is their job to determine what the provider needs help with. Over-coding will require that the provider receive some more in-depth coding instruction. Under-documentation will necessitate some additional education on the details required to bill specific codes.

A chart rated “under-documented” does not adequately meet federal documentation guidelines for the level of documentation of the history, exam, medical decision-making, time or procedure notes. The precise amount and type of documentation pertaining to history of present illness/review of systems (HPI/ROS) and decision-making can be variable. All federal plan administrators are expressly allowed ‘latitude’ in their ‘interpretation’ of these aspects of the federal guidelines. 

Most commercial carriers follow these guidelines in general with some variance in terms of rigidly applying the “guidance.”  All audits or reviews are somewhat subjective in that the reviewer is applying the ‘guidelines’ as best he or she can in any given case. There are three distinct sets of federal documentation definitions and rules that are intended to govern all notes and all provider specialties and types – so you can imagine that they do not fit every note well. 

In the spirit of medical necessity, a responsible auditor focuses on having providers concentrate on clarifying the decision-making area of the chart such that it is very clear how many problems, and the nature/status of those problems, were actively evaluated, managed or addressed during any given encounter.

Q: I have noticed that Medicare is not paying for the Chronic Care Management (CCM) code 99487 in January 2106. Why is this?

A: What you are seeing is the patient’s deductible now including the CCM payments that Medicare does cover, but not until the annual deductible has been met. This is not different than the payment criteria for most other Medicare services.

Some services are not affected by deductibles, such as Annual Wellness Visits and certain other preventive services, but most are. You might consider that CCM is preventive-and it is in a way-but it does deal with established chronic problems by definition and so is excluded from the deductible exempt services.

You may experience some pushback from patients on this. Chances are that when you set them up on the CCM plan, part of the appeal was that Medicare paid 80% of the monthly charge. For many, secondary insurance paid the rest.

This time of year, however, Medicare isn’t going to pay the bulk of the charge, and the secondary payers may not pay the copay because Medicare didn’t cover the principal amount. 

Your best bet is to explain to the patients that it doesn’t matter which services they receive, regular office visits or other covered services, Medicare payments don’t kick in until they have met their deductible. Their payments for CCM services will just get them to that deductible threshold sooner.

Q: I have a question regarding billing for a CPAP code. How can we use the code 94660 correctly? My understanding is that it’s for the initiation and management of CPAP. Can we use it every time we show someone how to use their mask, equipment, etc.? 

A: For the specifics of 94660 I would direct you to the October 2014 CPT Assistant published by the AMA. They have answers to frequently-asked questions as well.

This explains that CPT 94660, continuous positive airway pressure ventilation (CPAP), initiation and management, describes the initiation or subsequent management of numerous forms of PAP therapy. This includes CPAP and BPAP (Bi-level positive airway pressure) and is generally administered through a mask interface rather than the endotracheal approach.

CPT codes 95811 and 95783 are codes for encounters for PAP therapy during diagnostic testing. PAP therapy is then provided to the patient in the context of an EM code or 94660.

Code 94660 includes reviewing the medical history, performing a physical exam, and reviewing diagnostic test results, all focused on the management of PAP and the underlying disorder. Discussion with the patient may include various device and mask options. A brief chart note is required for 94660.

Q: I have a question about the Primary Care Exception modifier GE for teaching physicians. Under the Affordable Care Act (ACA), are all payers required to reimburse claims that contain CPT codes (example 99213) with the modifier GE? It has been brought to my attention that a few of our payers will not reimburse claims with this modifier and we want to continue the usage of modifier GE so that we are reporting accurately. Where does it say they have to pay this?

A: Neither the full text version of the ACA nor the Reconciliation Act contain any reference to GC or GE modifiers.

The 2011 CMS Transmittal on Teaching Guidelines  mentions the ACA in the same general paragraph as a discussion of some GE and GC issues. But these items don’t appear to be related.

When you drill down into that transmittal -  Section 100.1.8B1 is amended to read:

‘Effective January 1, 1997, services furnished by teaching physicians involving a resident in the care of their patients must be identified as such on the claim. To be payable, claims for services furnished by teaching physicians involving a resident must comply with the requirements in sections 100.1 through 100.1.6 of this chapter, as applicable. Claims for services meeting these requirements must show either the GC or GE modifier as appropriate and described below.’

These transmittals are designed to apply to CMS programs, Medicare/Medicaid and potentially other governmental programs such as Tricare.

From your question I’m uncertain who the ‘few of our payers’ are. But if they are commercial or non-governmental entities they are not bound in any way to recognize modifier GE or GC.

In fact, it seems their recognition of what these modifiers mean might be the problem. They may not want to pay for a service that was performed solely by a resident.

My question to you is why would you bill a non-governmental payer with a GE on the claim? Of course they could have Medicare primary and a secondary might not pay for this reason.