Orthopedic Coding Alert

Question:-What's the first step in decreasing your physician's error rate in E/M audits?

Answer:-Review all notes and records that are applicable to that service.-As obvious as the answer may sound, auditors will often omit vital pieces of information in their reviews, and that can lead to inflated error rates.

E/M services are a large part of most medical practices and can even be considered the lifeblood in some specialties. Coding accuracy and thorough documentation are critical to a practice's viability. Having a well-trained and experienced auditor is just as crucial.

When performing a documentation and coding review, what records do you collect and examine? Do you look at the dictated note or handwritten note? Patient history forms, order sheets, test results?

A new patient E/M encounter generally begins with the patient filling out a history form. The volume of information obtained from the patient will vary from office to office or specialty to specialty. The patient's medical history and social and family histories could be covered. There may be a review of systems (ROS) that is problem-oriented or greatly detailed and considered "complete."

For the physician to receive credit, she will need to indicate that she did, in fact, review the information. A co-signature and date on the form(s) would qualify, and/or a statement made within the progress note referencing the history form would suffice, too. As long as the healthcare provider creates some type of direct link to the source document, the auditor should give credit.

For subsequent or hospital visits, when your orthopedist updates a patient's history form, give him credit for the information it contains as long as he makes a notation to that effect. But updating a history form simply to inflate the documentation content for billing purposes would be inappropriate. The past medical, family and social histories, as well as the ROS, should be relevant to the nature of the presenting problem.

Electronic medical records (EMR) have changed the world of medicine over the past few years. But for those physicians still using traditional transcription or who have yet to transition to fully automated EMR, the handwritten note continues to be essential to the audit. At first glance, a handwritten note might seem scanty -- maybe just chicken scratch made by the physician as he interviews and examines the patient -- but it just might contain a missing element that could end up making a difference in code selection.

Handwritten notes can be found in obscure places in the chart, and this is especially true of an inpatient chart. The reviewer must be aware of all eligible portions of the medical record. This might include, but not be limited to, the following:

- The admission history and physical (both transcribed and handwritten)

- Daily progress notes (both transcribed and
handwritten)

- Consultation forms (both transcribed and
handwritten)

- Order forms (can be electronic or handwritten)

- Lab or x-ray results (might contain notations by the physician).

Be aware of payer-specific billing provisions such as incident-to, shared services or teaching services. Is the physician allowed to combine documentation from another professional such as a nurse practitioner, physician assistant or resident? And if combing the documentation, where might you find the additional notations? Again, is it transcribed? Is it handwritten? Just be aware of the payer's requirements for both the nonphysician and physician.

When E/M CPT code descriptions include the words "per day," this is often interpreted as "per day, per physician or physician of the same specialty within the same group." This can create another process for collecting documentation.

Example: The orthopedist sees a patient in the office and then admits the patient to the hospital later that day for a related reason.

You should use the office notes as well as the admission history and physical to select the admission code. The physician may perform a comprehensive history and exam in the office with moderate medical decision-making. If the orthopedist admits the patient later in the day because of worsening symptoms, the physician wouldn't necessarily need to repeat a comprehensive history and exam at bedside. But medical decision-making might now be considered "high" (depending on the nature of the problem, risk, etc.). In this case, combine both sets of documentation, and assign the higher admit code (99223, Initial hospital care, per day, for the evaluation and management of a patient -). Physicians should reference the hospital's medical staff bylaws for history and physical requirements.

The same could hold true for a patient seen initially in the emergency department -- or other locations -- and later admitted by the same physician. Pull both sets of records to determine the admission code.

Another area overlooked by physicians and auditors during an E/M review is the personal interpretation of radiology films, test printouts or laboratory slides. Patients are frequently instructed to "hand carry" this data to a physician's office. Under medical decision-making, you should give credit to your orthopedist for personally interpreting results. This will add to the encounter's overall complexity and can help support the medical necessity of higher-level visits.

For this scenario, advise the physician to document her personal assessment and interpretation in a clear and concise manner. But remember, reading a written report by another professional is scored lower than a personal interpretation.

If you-re outsourcing your E/M services for either coding or auditing, be sure to include all applicable documentation to avoid downcoding of your orthopedist's services. This advice also applies to releasing medical records to outside entities for whatever reason.

Physicians provide complex services that are sometimes documented in a wide variety of ways. Give them credit where credit is due, and allow them to receive the reimbursement they deserve.

-- Linda Eickmann, CPC, is a senior compliance auditor with Coding and Compliance Initiatives Inc. (CCI), located in Olathe, Kan., and focuses her practice on physician coding and reimbursement matters.