Internal Medicine Coding Alert

Published on Fri Sep 24, 2004 PDF

Why modifier -25 could be costing you deserved payment

If your office has been receiving many denials lately, it's probably time for an internal chart review. Here are expert solutions to what are most likely the top-four most error-prone areas in your practice: E/M and procedure code accuracy, consultations, and modifiers.

1. Support Your E/M Codes

When reporting office visits, make sure the documentation supports the level of E/M service you've billed or you could end up returning money to the insurer.
 
"Most practices are overcoding, and their documentation is lacking in the history component," says Trish Bukauskas-Vollmer, CPC, owner of TB Consulting in Myrtle Beach, S.C.
 
For instance, the appropriate history documentation for a detailed E/M service should include "extended history of present illness" and "pertinent past, family, and/or social history directly related to the patient's problems."
 
Also, the level of medical necessity is critical when you're determining the appropriate E/M code. "Many codes get downcoded because of medical necessity," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center.
 
Why: "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code," the Medicare Carriers Manual (MCM) states. "It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted." 
 
Scenario: The physician bills a level-four established patient visit for treating intrinsic asthma (ICD-9-CM 493.10) and diabetes mellitus without mention of complication, type I (ICD-9-CM 250.01). You code the visit as a 99214 (Office or other outpatient visit ... established patient). To justify billing 99214, the documentation should support the medical necessity (medical decision-making of moderate complexity) and at least a detailed history and/or a detailed examination, he adds. Also, the office visit should consist of 25 minutes of face-to-face contact with the patient and/or family, according to CPT guidelines.
 If an auditor reviewed the above 99214 charge, would your documentation support the E/M level? A "No" answer could cost you the $85 that most carriers pay for 99214.
 
2. Double-Check Coverage for Procedures

Another source of denials may be inaccurate procedural coding, Bukauskas-Vollmer says. If you're inaccurately unbundling procedures or submitting codes that your carrier doesn't pay for, you can expect denials.
 
Example: A patient's insurance information and other forms take an unusual amount of time for your doctor and biller to complete, so you assign 99080 (Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form).
 
Problem: Nearly all private and government insurers will deny this code, because Medicare has not assigned 99080 any RVUs.
 
Solution: You should check the Medicare insurer or the commercial carrier's guidelines to determine which codes the payer will accept. Say you want to report 11400 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere] trunk, arms or legs; excised diameter 0.5 cm or less) for the physician's removal of a benign lesion for cosmetic reasons to Medicare's Blue Cross Blue Shield of Arkansas. Checking that carrier's Local Medical Review Policy (LMRP) would inform you that Medicare never pays for cosmetic lesion removals.

3. Get the Three R's You Need for Consults

You should report consultation codes (99241-99275) when another physician requests a "medical opinion" from your internist, Bukauskas-Vollmer says.
 
Otherwise, if a physician asks your doctor to "evaluate and treat" a patient, then you should consider this a "referral" and assign new patient E/M codes (99201-99205), she says.
 
Coding challenge: When you're reviewing the consultation you've coded, check your physician's consult documentation to ensure it contains these three key elements: