Tuesday 10/08/2013 3:30PM - 4:30PM Room 6D

1. E&M Coding - Bridging the Gap Between Providers and Administrative Staff Tuesday 10/08/2013 3:30PM - 4:30PM Room 6D

2. My Background • Active in health care since 1998 and at Physicians’ Ally since 2007. • Masters of Health Administration in 2006 and CPC designation in 2010 • Combination of experiences influence consulting projects • Performed chart audits for hundreds of physicians. Usually present findings to only administrative staff or in tandem with physicians.

3. Objectives • E&M coding as it relates to a provider and the most common audit findings • Guidelines for presenting E&M coding with providers and staff • How to best utilize E&M coding for continued success with providers and staff NOTE: Throughout the presentation, handouts will be indicated in purple.

4. Objectives • E&M coding as it relates to a provider and the most common audit findings

5. Prominence E&M Codes • Most highly utilized codes • Numerically, E&M codes should be at the end of the CPT coding book, but they are in the front because this is where most services begin with a patient • Between 2001 and 2010, Medicare payments for E&M services increased by 48%, from more than $22 billion to more than $33 billion. Source: oig.hhs.gov

6. MedPar – Established patients* *See “How to Obtain MedPar Data” Handout on how to obtain data

7. MedPar – New patients**See “How to Obtain MedPar Data” Handout on how to obtain data

8. RAC AUDITORS The Recovery Auditor Contractor (RAC) in each region: Region A: Performant Recovery Region B: CGI Federal, Inc. Region C: Connolly, Inc. Region D: HealthDataInsights, Inc.

9. RAC AUDITORS In May 2012, OIG reported that nearly 442,000 physicians billed E&M services in 2010. Of those physicians, 1,669 were found consistently to bill higher-level E&M codes. (1) While this percentage is low, those 1,669 physicians are now (for the first time) susceptible to a RAC audit…. Physicians who practice in Region C of will be the first RAC audits to focus on claims using higher-level E&M codes (specifically, CPT codes 99214 and 99215). Auditors will review claims with dates of service as far back as Oct. 1, 2007. (1) and (2) Source: (1) http://www.amednews.com/article/20121001/government/310019952/1/ (2) http://www.aafp.org/news-now/practice-professional-issues/20120918racaudits.html

10. Motivation to Audit The RAC auditors are paid based on the recoveries they are able to find. For example, RAC auditors are paid 9 to 12.5%. Source: FY 2011 Report To Congress at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/recovery-audit-program/index.html?redirect=/rac/ Payors are motivated, too…

11. Sample Payor Letters See “Sample Payor Letters” Handout for examples. Our clients do not always share the letters with us, so this is just a small sampling. NOTE: Confidentiality does not allow for distribution of complete letter.

12. External Audit versus Internal (Self) Audit • RAC Auditor or Payor wants to recoup funds from the provider • Internal Auditor works to improve and ensure correct documentation

13. Audit Results – Sample of Findings See “Sample Audit Results” Handout for sample findings for an: • OB/Gyn • Pediatrician • Neurologist • Primary Care • Sub specialist

14. Denials for E&M Palmetto GBA reviewed claims with CPT 99214 (from July to September 2012 for California, Hawaii and Nevada) • Denial rates from the reviews of thousands of claims ranged from 43.8% to 64.6%. Most frequent reasons for denials • Documentation inadequacy • Coding too high an intensity • Illegible or missing signatures Source: “Completion of Prepayment Service Specific Complex Review for CPT Code 99214,” Palmetto GBA at http://www.palmettogba.com/palmetto/providers.nsf/docsCat/Jurisdiction%201%20Part%20B~EM%20Help%20Center~Medical%20Review

15. Objectives • Guidelines for presenting E&M coding with providers and staff

16. “Documentation Inadequacy” versus Fraud • CMS definition of fraud: an intentional deception or misrepresentation that a person knows is false or does not believe to be true, and the person aware that the deception could result in some unauthorized benefit to him/herself or some other person. • Most frequent kind of fraud: false statement or misrepresentation made that is material to entitlement or payment under the Medicare program. • Subsequent evaluations will determine the appropriateness of Medicare payments for E&M services and the extent of documentation vulnerabilities in E&M services. (OIG May 2012)

17. “If the physician does not document, it did not happen.” • Extent of examination must be documented in medical record. • See “Elements of Documentation” Handout • The provider should document what is medically necessary and code accordingly, not learn how to code and then document.

18. “Coding too high an intensity” Documentation is something that can be reviewed with a provider to document what they do… Ensuring that the documentation supports the code is more challenging to relay.

19. Audit Results – Common Themes • Providers do not want to hear about the mechanics of an E&M code • Forms or the EHR template is great for medically-necessary History and Exam, but Medical Decision Making always has an element of subjectivity: • Most importantly: How does the provider feel after they walk out of the room? • And, how does the patient?

20. Tangent – Patient Perspective CPT 99204 vs. 99203 for an ear-tube surgery specialist visit Medically necessity is always the most important!!

21. How this affects you Most often, I would present audit results to billing and/or administration. But the provider sees the patients… If billing and/or administration know how to self audit then they customize results to the provider.

22. Do a Internal Self Audit • Compare Frequency of E&M codes by provider • To Medicare (see “How to Obtain MedPar Data” Handout on how to obtain data) • To other providers in the practice • Perform a documentation audit to determine the appropriate E&M • Using legitimate sample size (generally three charts for each provider for each applicable code)

23. Remember contributory factors • Counseling • Coordination of care • Nature of presenting problem Overall, what does the documentation support? • Levels 3-5* are reserved for “sick” or injured patients • Lower levels are for patients who present with minor and/or well controlled condition/s • Level 5 is not appropriate if patient not asked to follow-up sooner than 6 months.

24. What is E&M? See “Categories of an E&M Code” Handout

25. New vs. Established New – A new patient is a patient who has not received any E&M or other face-to-face service from the provider within the previous three years. Established – • The patient is receiving services from the same provider or another provider from the “EXACT” same specialty and “subspecialty” who belongs to the same group practice within three years. • For example, if a patient follows a provider from another practice within three years, the patient is “established” for that provider. • However, for example, if a patient sees an internist on a regular basis, but then breaks his leg and sees an orthopedist in the same practice. This patient would be considered “new “ to the orthopedist because the physicians are of different specialties. CONTINUED

26. New vs. Established Established – CONTINUED • A new problem is presented and the patient has been seen within the past three years by the provider. • The patient was seen in the prior three years even for a different diagnosis than the provider had previously treated. • The provider has given a pre-operative consultation at the request of a surgeon within the past three years. • The provider furnishes a consultation in an outpatient setting different than the office (i.e. emergency department) where the patient was seen in the past three years. • Please note: A patient might still be new if the provider had interpreted test results a month earlier but has had no face-to-face services within the previous three years.

27. E&M Coding – The Three Components • Please see“Documentation Guidelines for E&M Services” Handout • (assuming on Multi-System Exam) • The following will expand • on that handout

28. Verify compliance with reporting requirementsAll Three Components Required • History component met or exceeded • Examination component met or exceeded • Medical decision making component met or exceeded FOR: • New patients • Initial care • Consultations • Emergency Department services • Comprehensive nursing facility assessments

29. Verify compliance with reporting requirementsTwo of Three Components Required • History component met or exceeded • Examination component met or exceeded • Medical decision making component met or exceeded FOR: • Established patients • Subsequent or follow-up care

30. E&M Coding – The Three Components

31. Side Note: CPT 99211 Any established patient visit in which the physician is directly involved is a 99212 at a minimum For a 99211, the following must be documented: • Date of service • Chief complaint and/or reason for the visit • Service provided and/or information conveyed to the patient • Appropriate vital signs • Signature of the nurse or other provider

32. E&M Coding – The First Component - History

33. The First Component – HistoryThe Three Elements of History

34. The First Component – HistoryThe First Element - History of Present Illness (HPI)

35. The First Component – History The First Element - History of Present Illness (HPI) Chief Complaint (CC) Must be present 100% of the time. CC is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. The CC is usually stated in the patient’s own words (i.e. patient complains of itching) CC can be recorded by ancillary staff.

36. The First Component – History The First Element - History of Present Illness (HPI) See “Review of HPI Elements” Handout Brief: documentation of 1-3 HPI elements. Extended: documentation of 4+ HPI elements Elements include: Must document: Duration (i.e. it started three days ago) Location. (i.e. pain in left leg) Quality. (i.e. aching, burning, radiating) Severity. (i.e. 10 on a scale of 1 to 10) Timing. (i.e. it is constant or it comes and goes) Context. (i.e. lifted large object at work) Modifying factors. (i.e. it is better when heat is applied) Associated signs and symptoms. (i.e. numbness)

37. The First Component – HistoryThe Second Element – Review of Systems (ROS)

38. The First Component – HistoryThe Second Element – Review of Systems (ROS) References signs and symptoms that are taken verbally or with patient intake form. Both positive and negative responses are considered, but they must be specifically referred to. Pertinent negatives must be documented. Can be documented by ancillary staff or patient but must be reviewed and documented by provider.

39. The First Component – HistoryThe Second Element – Review of Systems (ROS) • Constitutional symptoms • Eyes • Ears, Nose, Mouth, Throat • Cardiovascular • Respiratory • Genitourinary • Gastrointestinal • Musculoskeletal • Integumentary (skin and/or breast) • Neurological • Psychiatric • Endocrine • Hematologic/Lymphatic • Allergic/Immunologic If only address pertinent system, an expanded problem If 1-8 more systems addressed, a detailed visit If all systems addressed, a comprehensive visit

40. The First Component – HistoryThe Third Element - Past, Family and/or Social Hx (PFSH)

41. The First Component – HistoryThe Third Element - Past, Family and/or Social Hx (PFSH) Pertinent: 1 patient history reviewed Complete: 3+ patient history reviewed History defined as: Past History = The patient's past experiences with illnesses, operations, injuries/treatments, and medications. Social History = An age-appropriate review of past and current activities, for example occupation, smoking, alcohol use (EtOH), sexual activity, marital status. Family History = A review of medical events in the patient's family, including age at death, diseases which may be hereditary or place the patient at risk.

42. E&M Coding – The Second Component - Examination

43. The Second Component – Exam • 1992: E&M codes first introduced • 1995: First set of guidelines published • 1997: Second set of guidelines published (expanded exam guidelines) MOST PRACTICES USE THESE GUIDELINES • 2000: Third set drafted, but tabled • CMS instructs carriers and providers to use either 1995 or 1997 guidelines • WHAT DOES YOUR PRACTICE USE???

44. The Second Component – Exam See “Medicare - 1997 Documentation Guidelines for E&M Services - General Multi-System Exam” Handout • The level of service coded is based on how sick a patient is and meeting documentation requirements. • General multi-system examination or a single organ system examination may be performed by any physician regardless of specialty. • The type and content of examination are selected by the examining physician and are based upon clinical judgment, the patient’s history, and the nature of the presenting problem(s).

45. E&M Coding – The Second Component - Examination • A brief statement or notation indicating "negative" or "normal" is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s). •  Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or organ system(s) should be described. Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented.

46. E&M Coding – The Second Component - Examination

47. E&M Coding – The Second Component - Examination • Documentation of an Exam is essential to support a code. • To determine the level of an exam, look at how many elements are performed from each system • Element = Exam Element performed • Problem Focused (PF) = 1-5 Elements from 1+ systems • Expanded PF = 6+ Elements from 1+ systems • Detailed = 12+ Elementsfrom 2+ systems • Comprehensive = 2+ Elements documented from 9+ systems • NOTE: Assuming General Multi-System Exam. Varies by specialty.

48. The Second Component – Exam EXAMPLE: One Element performed for Constitutional if… THREE of the following vital signs were measured (may be measured by ancillary staff): Sitting or standing blood pressure Supine blood pressure, Pulse rate and regularity Respiration Temperature Height Weight For this example:

49. E&M Coding – The Third Component – Medical Decision Making

50. E&M Coding – The Third Component – Medical Decision Making • Medical Decision Making is the most subjective of the three Components. • We are going to show you the complicated system behind Medical Decision Making. • However… how a provider feels when walking out of a patient room always matters. • Which is why documentation is so important.