Keep Your Medicine Coding Audits on Task
Use this guide to prevent errors in claims for therapeutic and diagnostic services getting past you.
Therapeutic and diagnostic services, which includes injections, infusions, physical medicine, and rehabilitation, are some of the most difficult services to code. As a result, claims for these services — reported with codes from the Medicine section in CPT® — are some of the most frequently audited. Here’s what to look for when performing an audit for these services.
Injections and Infusions
Injections and infusions are often problem areas with high error rates. Therefore, it is important for an auditor to understand the fundamentals of coding injections and infusions and the documentation that is required for these services.
Use these tips for successful injection and infusion auditing:
- Pay close attention to the documentation. Ensure that you are reviewing the appropriate date of service, which corresponds with the record you are auditing. Ensure that the entire note has been read and reviewed.
- Always code the chart first. It is best practice when auditing to code the chart first without considering the codes as they were originally billed. Doing so will prevent you from leaning toward the codes chosen.
- Keep an eye out for the physician’s order. The order should provide the name of the drug, dosage, and reason for its administration.
- Keep a record of injected/infused drugs. From a best practice perspective, the documentation should also include a record that lists the drug source, lot number, and expiration date, as well as the route and the site of each administration.
- Identify the primary service, which depends on the location of the service. The primary service for professional services performed in the office setting is the reason for the encounter. The primary service for a facility service is based on the hierarchy outlined in the CPT® code book and below in the illustration.
- Ensure that the appropriate CPT® codes, ICD-10-CM codes, HCPCS Level II codes, and modifiers were billed. Make sure all services were reported and captured. Verify the correct units were billed with the appropriate HCPCS Level II code(s).
Make note of time:
Do not assume infusion time based on the physician order alone. There is always a chance that the infusion time was interrupted, and the orders won’t include IV calibration time. You should always rely on the documentation for service time.
The time that each substance was administered should also be included in the documentation to properly select the CPT® code and to sequence multiple drug administrations. CPT® and Medicare do not specifically require start and stop times for drug infusions, but it is good practice to include this information in the documentation.
Pay attention to these vital details:
- If the provider asks the patient to bring their own drug or the pharmacy has delivered the drug to the office for the patient, remember that you should not bill the drug to the payer because there has been no expense to the practice for the drug.
- Check National Correct Coding Initiative edits when more than one code is billed for the same date of service to determine if any unbundling has occurred. Also check the CPT® guidelines, which provide instructions for coding in the parenthetical notes.
- Ensure medical necessity has been met based on government and private payer policies by verifying applicable National Coverage Determinations and Local Coverage Determinations.
See the Injection/Infusion Audit Worksheet for the key areas needed to support a service.
Physical Medicine and Rehabilitation
Physical medicine and rehabilitation services, also reported with codes in the Medicine section of CPT®, are problematic. Knowledge of time guidelines is essential for an auditor to be successful with these types of services. According to the Centers for Medicare & Medicaid Services, time is based on 15-minute increments and is calculated to the nearest 15 minutes, based on the eight-minute rule. The eight-minute rule states that you may not bill for any therapy service less than eight minutes. Begin billing after the service time reaches eight minutes. See Table A for time intervals based on the eight-minute rule:
Chart the Audit Process
The audit process for physical medicine and rehabilitation will closely mirror the process for infusions and injections. There are a few details that differ for physical medicine and rehabilitation, however, according to the Medicare Benefit Policy Manual, Chapter 15, Section 220.3:
- Remember that documentation must indicate at least eight minutes of service time to bill.
- Review the plan of care documentation for physical therapy services. This documentation should include the patient’s diagnoses, the long-term treatment plan, the type of service, number of treatment sessions daily (if not indicated, Medicare will assume one treatment session per day), the duration of sessions, and the frequency.
- The initial therapy certification for physical therapy services must include the approval by the provider, a signature, and a date. In addition, the care plan must be created within 30 days of the initial service. Recertification may not be required but is used when there is a definite need to continue the therapy or to modify the therapy. This should be completed every 90 days after the initial service.
- Daily treatment notes should contain all the treatments and interventions provided; and record the time of the services to justify the billing codes reported. Documentation is required for each treatment day and all therapy services. Daily treatment notes include whether the patient presented for the appointment, what occurred during the session, amount of time spent during the session, and any observations made during the session.
- A progress report must be documented at least once every 10th visit. The documentation includes evaluation of progress, professional opinion on the need of continued care, any modifications of treatment, and termination of services.
- The discharge note should provide information regarding the patient’s care and the discharge instructions.
Always review the medical record for appropriate documentation. This goes for any medical service, not just medicine services. If you find that your provider’s documentation is not up to par, the post-audit period is a great time to start a dialogue to educate clinical personnel about what is needed to justify coding.