Part B Insider (Multispecialty) Coding Alert

Published on Mon Dec 08, 2014 PDF

Physicians should strive to be more precise in E/M documentation.

The OIG and Part B MACs are coming up with new and clever ways to poke holes in your evaluation and management documentation, and Medicare is sending different types of auditors to look at your claims. These factors all indicate that you have to be more careful than ever about keeping thorough documentation for your E/M visits.

As the MACs continue to create their own audit tools for E/M visits, you should be making sure your records are as airtight as possible, say experts. And one way you could be leaving yourself open for downcoding is by including vague descriptions of body parts in your doctor’s physical exam documentation.

The problem: Many doctors will write “abdomen” instead of “gastrointestinal tract” or even just “GI.” The patient’s abdomen isn’t an organ system for purposes of the physical exam portion of the E/M visit, but the GI tract is, say experts. So your doctor may lose credit for examining the patient’s GI tract since “abdomen normal” doesn’t necessarily indicate that your doctor performed a thorough examination of the GI tract.

Also, many doctors will write “head” when they examined the patient’s eyes as well as the patient’s ear, nose and throat. Eyes count as one organ system, and so do ENT, say experts. But if the doctor merely writes “head,” he or she will receive credit for one body part instead of two organ systems--or no credit at all.

If you’re supposed to be documenting organ systems and you’re documenting body sites, then auditors could knock those claims down. Carrier auditors as well as the Comprehensive Error Rate Testing (CERT) and recovery audit (RAC) contractors will be looking for documentation that doesn’t support the level of service you claimed. 

Best practice: Talk to your physicians about the organ systems that count toward the physical exam tally so they know exactly how to document the sites. You should use a template (either on paper or electronically) to make sure your doctor documents the correct organ systems instead of body parts. Some physicians will just write a narrative in the electronic template instead of checking off specific boxes, and those are the providers that are most at risk of making this type of error.