Internal Medicine Coding Alert

Published on Fri Jul 24, 2009 PDF

E/M codes need your attention to stay out of CMS trouble.

In the wake of the CERT's report in which newpatient, outpatient, and subsequent hospital care codes dominated a list of errors, your office should be scrambling to polish up its E/M claims.

Take a closer look at the three worst offenders, and see how you can decrease the chances of needing to issue a refund to Medicare.

New-patient office visits (99201-99205) have a 15.5 percent error tally, according to the last Improper Medicare Fee-For-Service Payments Report -- May 2008 Report. "The big thing is that the physicians usually do the work, but do not document it correctly," says Susan Vogelberger, CPC, CPC-H, CPC-I, CMBS, CCP-P, CEO of Healthcare Consulting & Coding Education LLC. In your next physician education meeting, point out the difference between 99201-99205 and 99212-99215. "Newpatient office visits' key component requirements are different from established patients' requirements," Vogelberger says. When choosing a new-patient office visit level, you need three out of three of the key components. Often, physicians overlook the "three of three" requirement. "They tend to score lower in one of the key components and that pulls the code down," Vogelberger says.

The level you report must match the level of the patient's problem. For instance, you shouldn't bill a level five for the sniffles, Vogelberger says. The work may be done for a level five, but if it wasn't medically necessary, insurers may consider the charge overcoding and request a payback. "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code," states the Medicare Claims Processing Manual, Chapter 12. Overcoding resulted in overpayments of $242 million on 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity. Counseling and/or 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 moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family). Caution your internists to consider the problem and count only medically necessary elements.

The CMS report also indicates that Medicare paid out nearly $39 million more than it should have for subsequent hospital care code 99232 (Subsequent hospital care, per day, for the evaluation and management of a  patient, which requires at least 2 of these 3 key components: an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity.

Counseling and/or 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 patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient's hospital floor or unit) in the "insufficient documentation" error category (See www.cms.hhs.gov/certfor more information.).

"It's possible that doctors in the hospital tend to peek in on the patient and don't write a lot in the chart," notes Barbara J. Cobuzzi, MBA, CPC,CPC-H, CPC-P, CENTC, CHCC, senior coder and auditor for The Coding Network and president of CRN Healthcare Solutions. "The physician may write, 'Patient stable,' or 'Patient a bit worse, order this exam,' and although they may be examining the patient, they may not document it well enough" to support a level two hospital visit, Cobuzzi adds. Therefore, what Medicare's reviewers may classify as "upcoding" may simply be your physician underdocumenting her charts.