Part B Insider (Multispecialty) Coding Alert

Published on Thu Sep 08, 2005 PDF

Learn the new rules before an auditor uses them on your claims

Part B carrier TrailBlazer Health Enterprises has come up with new audit guidelines for evaluation and management--and other carriers may follow suit. Will you be ready?

Unfortunately the new system is so complicated it’ll make your head spin, say experts. PBI has summarized the two key changes you need to know to begin complying with the new rules.

First: TrailBlazer won’t give credit for a complete review of systems (ROS) if the physician lists all relevant positives and negatives followed by “all other systems negative.” Your physician must document each system individually, with specifics or negatives, or miss out on ROS credit. This contradicts the 1995 and 1997 E/M documentation guidelines , say experts.

Second: According to consultants, TrailBlazer now has a “points system” for medical decision-making (MDM). TrailBlazer will give no points for a new or established condition if you don’t document any evaluation or management, unless it’s clearly a co-morbid condition.

If there is some evaluation or management, or if the problem is a co-morbid condition, then you receive one point. You also receive one point each for:

• notations such as “continue same therapy” or “no change in therapy”--but only as long as the record clearly documents what the current therapy plan is and shows that the physician reviewed it; or if the physician schedules monitoring without any change in therapy, you also receive a point;

• new prescriptions or changes in dosage for the current medications;

• open or percutaneous cardiac, surgical or radiological procedures;

• physical, occupational or speech therapy, or other manipulation;

• closed treatment for fracture, dislocation;

• IV fluids;

• ordering “conservative measures,” such as rest, ice, bandages or dietary changes;

• radiation therapy;

• IM injection/aspiration, or other pain management procedure;

• educating the patient on self-care or home care;

• hospital admission; and

• referral to another physician for a consultation.

Your physician can receive two points each for:

• complex drug management, involving new prescriptions or dosing changes for more than three medications;

• complex prescriptions for insulin, hyperalmentation, or other complex IV solutions; and

• a hospital admission where the physician has to contact other physicians.

Score your MDM by adding up all of these points. Two points or fewer equals minimal MDM. Three to four points equals multiple (low) MDM. Five to six points equals multiple (moderate) MDM. And seven or more points gives you extensive MDM.