Pain Management Coding Alert

Published on Mon Dec 05, 2016 PDF

Experts: Be sure to audit ‘low-hanging’ targets annually.

Medical practices that neglect self-audits are playing with fire, experts contend. Most of those in the know about payer audits recommend that medical practices conduct coding and billing self-audits annually — at minimum.

The lowdown: “Self-audits are one of the most important tasks for practices, coders, and medical billers. They find problems that cause revenue losses, claims denials, and refund demands,” says Steven M. Verno, CMBSI, CHCSI, CMSCS, CEMCS, CPM-MCS, CHM, SSDD, a coding, billing, and practice management consultant in central Florida.

And when your PM practice decides to self-audit, you need to pay special attention to your evaluation and management (E/M) service coding. E/M codes are perhaps your most important self-audit targets, as miscoded E/M services are often what pricks an auditor’s ears up in the first place.

Check out these FAQs on the whys, hows, and whos of E/M self-audits.

FAQ 1: Why Are E/Ms So Important to Self-Audit?

E/M codes are regularly atop the list of services that medical practices most commonly miscode, says Frank Cohen, MPA, MBB, principal and senior analyst for The Frank Cohen Group in Clearwater, Fla. These codes are used across the board by virtually all practices. Additionally, there are very specific guidelines around these codes.

E/M codes “really are some low hanging fruit” for auditors, Cohen said during his recent webinar, “Is Your Practice a Government Target? Pre-Audit Risk Analysis.” This makes sense, because practices regularly use E/M codes, and getting just the right level of E/M service for each patient can get tricky.

For example, let’s say the physician is performing a level-four established patient office E/M (99214,  Office or other outpatient visitfor 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 …), but he is only documenting a level-three service (99213, … an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity …).

In this instance, a self-audit would help the practice locate the problem and provide education to the physician, says Suzan Hauptman, MPM, CPC, CEMC, CEDC, of ACE Med Group in Pittsburgh, Pa. When medically appropriate, the service should be properly documented at the 99214 level or appropriately coded at the 99213. Either way, the code selection was incorrect.

FAQ 2: How Should We Self-Audit Our E/M Services?

A self-audit for E/Ms is going to involve reviewing and vetting a lot of documentation. According to Hauptman, the encounter notes on your E/M claims “must illustrate all required elements for the [E/M] level.”

In other words: During the self-audit review of E/M charts, make sure the documentation for history, exam, and medical decision-making support the level of E/M you are coding. You can follow the 1995 or 1997 E/M documentation guidelines when reviewing claims, as long as you follow them to the letter.

(You can switch back and forth between the guidelines by encounter; the practice is not required to stick with just one guideline.)

Also, be on the lookout for “automatic” E/M coding: instances where you see an E/M coding pattern that does not line up with documentation. Programmed or “automatic” E/M coding typically involves two issues:

1. Coding at a specific level for patients with certain issues. For example, let’s say a coder reports 99213 for every established patient who reports to the practice for treatment of a sinus infection. This is bad practice, experts say, as coders need to report E/Ms based on the specifics of each encounter.
2. Reporting an E/M service each time a patient presents for a procedure. “Do not assume that just because a patient came through your door, that you can automatically [code] an office visit with a procedure,” Verno warns.

If you notice either of these patterns during your E/M self-audits, take steps to eradicate any “automatic” E/M coding at your practice.

“You want to know your bills are substantiated by the documentation found in your records,” Hauptman says. “Remember, medical necessity is the overarching criteria.”

Also: There are tools available online to help you keep your E/M coding on point. “There are the 1995 and 1997 documentation guidelines [for E/Ms], and the Marshfield audit tool to help with appropriate code selection and auditing,” explains Hauptman.

FAQ 3: Who Should Conduct Our Self-Audits?

According to experts, in-house coders are your first choice to conduct the self-audits. They know the ins and outs of your practice, as well as the payer requirements and they are stakeholders in ensuring E/M codes are accurate. In-house coders conducting self-audits might not be possible, however.

Why? Coders already have a lot on their plates, and they may not have the bandwidth to perform self-audits. If you can free up at least two senior-level coders for a few days, you might be able to use your coders as self-auditors.

There is also another potential problem with in-house self-auditing. “You don’t want to have someone audit their own work,” Hauptman warns. This means that you should, ideally, have at least two coders to shoulder the self-audit.

Alternatives: If you cannot devote two coders completely to the task, there are other self-audit options. Your practice could appoint a single self-auditor, and have another qualified coder look at the self-auditor’s work.

If using in-house personnel won’t work for your practice, you can always call in an outside auditor periodically to have them audit your E/M services, Hauptman reminds.

This helps in multiple ways. First, your coder(s) can continue coding and the outside auditor will provide an unbiased opinion on the coding as well as the documentation of the clinicians.

The report an outside auditor generates will give you a good foundation for any additional training or further education that might be needed for your practice personnel, Hauptman explains.