Part B E/M in a Part A Setting

Five common mistakes can hobble physician coding in a facility.

By Jules Enatsky, RT, BSN, CPC-H
The grading of hospitals and physicians is a new industry, and one the public is taking a keen interest in when deciding from whom to get care and where to go. Complete documentation and proper coding not only ensure proper reimbursement; they reflect quality of care in an increasingly consumer-driven market. With this in mind, providers and facilities alike should be on the lookout for these top five coding mistakes when reporting Medicare Part B services in the Part A setting.

1. Undercoding

Medical schools provide little formal curricula in evaluation and management (E/M) coding, and providers often have limited knowledge of the topic. In a primary care clinic setting, family practice, or internal medicine, residents may learn they can bill lower-level services (such as 99201-99203 inpatient, or 99211-99213 outpatient) without seeking a teaching physician’s supervision. They’re never taught to apply higher-level codes (for example, 99204-99205 inpatient and 99214-99215 outpatient), or the specific requirements of the 1995 or 1997 E/M documentation guidelines.
It’s no wonder so many internal medicine and family practice physicians bill inordinate numbers of low-to-mid-level E/M services, robbing themselves of revenue.
Historically, payers have contacted providers whose claims have fallen out of line with expected coding patterns. Providers receive letters informing them that they are billing too many codes of a particular level (as compared to their peers), but the letter provides no information on correct coding principles. The provider might become alarmed, and begin to downcode to avoid questions. This “solution” promotes a false sense of security, has a negative effect on coding patterns and reimbursement, and tempts compliance problems down the line.
When providers undercode, they paint a picture of decreased patient care. Payers judge the level of care according to the codes they receive. For instance, if a provider bills 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family for every patient, even if a patient has five co-morbidities, the payer may believe the patients are receiving inadequate attention.
CMS stated in the 2008 Inpatient Prospective Payment System (IPPS) Final Rule (Federal Register, Vol. 73, No. 161, Aug. 19, 2008, “Rules & Regulations,” p.48448). “We do not believe there is anything inappropriate, unethical or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment as long as the coding is fully and properly supported by documentation in the medical record.”
For instance, don’t just settle for 250.00 Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled when there is a more accurate and specific code choice, such as 250.21 Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled or 250.23 Diabetes with hyperosmolarity, type I [juvenile type], uncontrolled.
Do not be intimidated: If your patient population is sick enough and your documentation and coding reflects the level of services you provide, don’t be afraid to bill correctly.
Providers should be certain they are documenting and coding based on one of the two accepted E/M guidelines, American Medical Association (AMA) 1995 or the Centers for Medicare & Medicaid Services (CMS) 1997. They also may consider an independent audit of their documentation and coding practices.

2. Illegible Documentation

As the old saying in medicine goes, “If you cannot read it, you didn’t do it.”
In the inpatient setting, many hospitals are requesting providers with less-than-stellar penmanship to re-document or amend notes so they are legible. This became especially important when, in October 2008, Medicare changed to medical severity diagnostic related groups (MS-DRGs), allowing hospitals reimbursement for severity and complexity of care as reflected by documented ICD-9-CM codes.
Many institutions have put special programs in place, where medical records are concurrently reviewed by a clinical documentation specialist (usually a registered nurse) to assist providers in identifying the most relevant illnesses based on physician documentation. This process potentially leads to increased reimbursement for the hospital and providers.
Institutions initiating such programs have seen phenomenal increases in their case mix index (CMI). Individual providers also have enjoyed the benefit of improved communication with hospital utilization and coding staff, and their own coding staff.

3. EHR Reluctance

The use of electronic health records (EHRs) in the inpatient setting has brought a new level of sophistication to providers’ documentation. More and more groups and single practice providers are moving to EHR; comparatively speaking most providers still do not use EHR. And in those institutions that have switched from paper to EHR, many of the providers do not use an EHR in their offices. Unless an institution mandates in-house EHR adoption, many physicians are delaying it for as long as possible due to cost, difficulty of transition, and time taken away from patients.
EHR implementation is inevitable, however. Providers have only until 2015 to have EHRs in their practices. To assist physicians with EHR adoption, the government is providing incentives up to $44,000. Providers should also consider piggy-backing on a hospital EHR, possibly obtaining a reduced fair-market purchase price, and easing communication between provider and hospital.
Recommendation: For practices with three or more providers, have the office staff learn the EHR system first, so they can become proficient and assist the physicians down the road.

4. The Missing Chief Complaint

One common problem with provider documentation may be corrected with the adoption of EHR: The missing chief complaint.
Providers often begin their subsequent notes with symptoms the patient may not have, or a comment pertaining to the patient’s status in relation to a procedure or medication, without mentioning why the patient is being treated.
This shortcoming is especially pressing when multiple providers of different specialties treat the same patient. For example, if an admitting physician and one or two consulting providers all bill subsequent inpatient care using the same principal diagnosis, only the provider who gets his claim to the payer first will be paid. The others most likely will be denied as duplicate services.
Multiple treating providers should bill services with the principle diagnosis of their specialty. For example, a patient is admitted with an acute myocardial infarction (AMI), a history of diabetes mellitus Type II (DM II), chronic obstructive pulmonary disease (COPD), and gastro esophageal reflux disease (GERD), with a cardiologist as the physician of record. The patient also is followed by the primary care provider (PCP), who manages the patient’s DM II and GERD. A pulmonologist manages the COPD. In this case, the admitting cardiologist would bill using the AMI as the principal diagnosis.
On subsequent visits, the cardiologist would continue to code the AMI as the principal diagnosis (along with any newly-diagnosed cardiac illness), the PCP would continue to code the DM II and GERD, and the pulmonologist would continue to code the COPD.
Providers must carve out the patient treatment pie according to their specialty. This can become tricky, especially when hospitalists are involved in treating the patient, or when the PCP is still involved and has not yet relinquished care of the patient.

5. Not Reporting a Provisional Diagnosis

Most physicians do not realize CMS pays hospitals and providers for working up patients’ illnesses in the Part A setting. Physicians-in-training learn to pick all the diagnosis that may apply to a patient, and then work through them one by one until finding the right one(s). This is not the case in the office or outpatient setting: Provisional or “rule out” (R/O) diagnoses are not permitted for coding purposes in outpatient records.
The problem for hospitals is that they must depend on physician documentation to support the degree of care provided. As previously mentioned, many hospitals have developed Clinical Documentation Improvement Programs (CDIPs) to review records concurrently, and to capture the acute severity of care data. This method reduces the number of queries hospital information management (HIM) coders must produce to get to the heart of patient diagnosis coding.
Jules Enatsky, RT, BSN, CPC-H, is senior consultant with JA Thomas & Associates. He has over 30 years of combined experience in radiology technology, acute care nursing, and consulting for Part B hospitals and physicians.

Evaluation and Management – CEMC

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