Urology Coding Alert

Stay out of the audit crosshairs by avoiding over- and under-coding both.

Even if your urologist specializes mostly in surgical procedures, you may still have at least an occasional hospital or office visit that requires proper evaluation and management (E/M) coding. With E/M coding being at the top of every payer’s audit hot list and the Office of Inspector General’s (OIG’s) discovery of $6.7 billion in improper E/M payments, you need to ensure your claims will stand up to audit scrutiny.

According to recent E/M audit results, which the OIG published on May 29, 55 percent of E/M claims were incorrectly coded during 2010, resulting in $6.7 billion in improper payments. Review these four issues that the OIG found and learn how you can improve those areas in your practice.

1. Stress Medical Necessity 

Finding: The OIG discovered that upcoded claims comprised 26 percent of the errors.

If your urologist insists that all of his patients are complex cases and therefore deserve 99215 (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 comprehensive history; a comprehensive examination; and medical decision making of high complexity ...) coding, check the documentation again and make sure he’s right. The code that you select is typically driven by the medical necessity of the visit, but the required elements of the visit still need to be documented, or you can’t bill.

This often occurs when patients who have multiple problems, such as urinary incontinence, kidney stones, and history of prostate cancer, present only for a minor issue such as a skin tag on the penis. The urologist might report 99214 because the patient has chronic conditions, but if he doesn’t address them at that visit and only addresses the skin tag, then, the documentation will then only support 99213. This would constitute a $34 over-code.

Remember: If you don’t have the history, exam, and medical decision-making to support a particular code, you may be able to bill based on time if you meet the criteria. The doctor will need to document the total time spent, as well as the time spent counseling/coordinating care (which should make up 50 percent or more of the visit), and document what was discussed in detail.

2. Remember Under-coding Is as Bad as Over-coding

Finding: The OIG states that practices down-coded 15 percent of claims. 

Just as you don’t want to report a higher code than warranted, you also shouldn’t ever sell yourself short when reporting E/M visits. 

In the example of our patient above who has as urinary incontinence, kidney stones, and history of prostate cancer, the urologist might evaluate all three conditions but still mark 99203 for the visit, even if his documentation supports 99205. There is almost a $100 difference between the payment amounts for these two codes, so if you make this mistake 20 times a month, you just cost your practice $24,000 a year just for that simple error.

Best practice: Educate all practitioners about how to document thoroughly and select the most accurate code based on that documentation.

3. Ensure Sufficient Documentation

Finding: The OIG notes that they uncovered insufficient documentation in 12 percent of claims. 

If a payer asks for your documentation and you only send part of it, or if it’s illegible, you’ll be accused of having insufficient documentation. You can also be subject to a charge of insufficient documentation if you’re missing a crucial element. 

“For example, the level of the E/M service for one insufficiently documented claim in our sample was based on counseling and/or coordination of care,” the OIG said in its report. “However, only the length of time of the encounter was documented in the medical record. The medical record contained no description of the counseling and/or activities to coordinate care.”

Don’t miss: The OIG also noted that seven percent of claims had no documentation. You probably have some type of documentation for every patient visit, but if your payer requests it and you don’t send it, then you’ll be counted as having no documentation at all. If you’re subject to a documentation request, send the complete file immediately to ensure that you don’t fall into the “no documentation” category.

4. Avoid Relying on E/M Codes

Finding: The OIG states that two percent of the time, practices simply billed the wrong code entirely. 

Have you ever performed an injection and erroneously reported an E/M code instead of the administration code? This is an example of billing the wrong code, which the OIG found happened in two percent of cases.

“These errors included wrong codes (i.e., when the documentation in the medical record supported codes for non-E/M services) — and unbundling (i.e. the practice of inappropriately reporting each component of a service or procedure instead of reporting the single, comprehensive code),” the OIG said. “For example, one claim in our sample contained documentation that supported a procedure but not a significant, separately identifiable E/M service.”

Remember that E/M services aren’t automatically billable every time you see a patient — the documentation must support the need for the evaluation and management visit, as well as the code that you report.

Resource: To read the complete OIG report, visit http://oig.hhs.gov/oei/reports/oei-04-10-00181.pdf.