Wiki 2021 E/M Changes and coding by MDM

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lnbrock

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Since the change in 2021 where you can now code by MDM or Time I am coming across some concerning things while auditing. I know that when the provider chooses the E/M level based on MDM that time is not supposed to be a factor but I am seeing a trend of providers billing over 95% level 4 visits and seeing 30 plus patients a day at that level but is only physically in the office 5-6 hours a day plus performing procedures in-between all of these office visits. These providers are also documenting a 14 system exam on all of these patients. I don't see how there is enough time to physically see 30 patients a day, document a full History, full ROS, and 14 system exam AND the time it takes to complete the MDM in 5-6 hours a day. Is there documentation somewhere that discusses billing for more "time" than you are physically in the office in a day for me to use when I speak to these providers? I think the OIG is actually looking into this very scenario and want to educate my providers. Thank you in advance for your help and have a great day!
 
Hi there, It sounds like you're talking about the "impossible day" which the OIG and prosecutors do use but I've never heard of a case where they just used the practitioner's time and nothing else.

Before you talk to your doctors I think you should first verify that their time might look questionable to a payer/MAC (they're the ones who see first). That means taking their schedules for a given period and using the physician time file from CMS to calculate the total typical times for all of their services. https://public4.pagefreezer.com/con...chedpfs-federal-regulation-notices/cms-1751-f

Keep in mind that the times in the CMS file are averages. So your calculations will just tell you where they are compared to the average. If you decide things look really weird you should check their documentation. Is it complete? Does it support the medical necessity of their services? Is it specific to each patient? If so, that's less to worry about because an auditor can't ding them just because they're very efficient. If not, then you do have something to worry about because that's where a lot of doctors who got in trouble ... got in trouble. Their "impossible" time attracted attention but then their documentation or other information, such as schedule discrepancies, indicated that they didn't do the work.

I do wonder why they're still doing all of that documentation for the history and exam. Do they know it doesn't count toward their level?
 
jkyles@decisionhealth.com said:
Hi there, It sounds like you're talking about the "impossible day" which the OIG and prosecutors do use but I've never heard of a case where they just used the practitioner's time and nothing else.

Before you talk to your doctors I think you should first verify that their time might look questionable to a payer/MAC (they're the ones who see first). That means taking their schedules for a given period and using the physician time file from CMS to calculate the total typical times for all of their services. https://public4.pagefreezer.com/con...chedpfs-federal-regulation-notices/cms-1751-f

Keep in mind that the times in the CMS file are averages. So your calculations will just tell you where they are compared to the average. If you decide things look really weird you should check their documentation. Is it complete? Does it support the medical necessity of their services? Is it specific to each patient? If so, that's less to worry about because an auditor can't ding them just because they're very efficient. If not, then you do have something to worry about because that's where a lot of doctors who got in trouble ... got in trouble. Their "impossible" time attracted attention but then their documentation or other information, such as schedule discrepancies, indicated that they didn't do the work.

I do wonder why they're still doing all of that documentation for the history and exam. Do they know it doesn't count toward their level?
Click to expand...
Thank you for your response. I am looking at this CMS Time File and I assume I am using the Median Intra Service Time if they are billing by MDM because it is for when the provider is in the room with the patient. If I am incorrect in this assumption please let me know. If I am correct this typical time would be 40 minutes for a 99204. Based on date and time stamps in my EMR I have providers who are seeing, for example, 2 patients in 13 minutes, documenting a 14 system exam, and billing them both 99204. My theory is that they are not actually doing this exam but getting "click happy" as I like to call it in the EMR and not taking exam elements out that they are not doing (this is a whole other can of worms), however, if they are documenting that they are doing it then technically if audited they said they did it all and there is not enough time in 13 minutes to do this much exam on 2 different patients, document their notes, and provide moderate complexity medical decision making. I am seeing this all day long on multiple providers and it is very concerning. I would love to hear your thoughts on this. Thank you again and I look forward to hearing back from you soon. Have a great day!
 
It should be the total time for the service. The times in the file are not the same as the times in descriptors. When you calculate the times remember to include all of their procedures and visits and that the CMS times are averages. Individual practitioners may be faster or slower.

So far as the exam goes, it isn't used to code the visit under the new guidelines so it wouldn't be relevant during a chart audit. The auditor will (or should) only be looking at the MDM documentation. In addition, I've never heard of an auditor invoking average times to downcode or deny claims.

Where I think extensive exams might possibly be a problem is if:

a provider isn't really doing all the work indicated by the chart and
they miss something and
the patient experiences as a problem as a result.

However, you know your doctors and the patients they see and you can see their charts. If you really think there's a problem you might start by asking them to walk you through what happens during a visit. Maybe they're really fast. If you still think there's a problem that would be a time to create a little presentation and show them where they are compared to the average in terms of time. Again, being above average doesn't automatically mean they're doing anything wrong but being out of the norm does attract attention.

You might also remind them of the new guidelines for office visits (and soon to be everywhere visits) and see if that helps with the click happiness.
 
Great advice by @jkyles@decisionhealth.com! In MY personal opinion, an efficient physician with experienced, skilled staff can meet the MDM requirements in far less time than the descriptors at least 90% of the time. I have worked with physicians that used an NPP during office hours. The MD would evaluate the patient and perform the MDM components, but the NPP would do all the charting work, issue Rx, explain procedures in greater detail, answer questions, etc. Also used scribes. That physician could regularly see 50-60 complex patients per day. Not all physicians can (or even want to) practice medicine that way. But it definitely is possible.
 
This is all great advice! Impossible time is definitely something that is considered during audit. I would agree with the above though that there could be more to this and it requires more review and research before automatically assuming something is wrong. If all the notes for every patient look exactly the same with a full exam, full H&P, and an extensive amount of documentation does that match up with the presenting problem? I agree it could be concerning depending on the specialty/subspecialty you are auditing. If you're able and the providers are willing you could ask to shadow them for a day or for a half day to see the flow and what is being done. If every visit is a level 4 the payers will audit especially if they are outside the bell curve for the specialty and geographic area as compared to peers.
It definitely requires more internal research and possibly a larger sample size to determine what is going on. As Christine said, do they use scribes and NPPs to do some of the charting, etc? Does this comply with what they are allowed to do? Also, the time can be the provider's pre/post work same day, not just face to face with the patient. Are the providers counting time for services separately reportable (not allowed).

It could be a click-happy EHR situation. I think you probably need to do more review and dig deeper possibly.

You can look up "impossible time" or "impossible day" as advised above.
 
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