Question dr refused to change code after record has been audited

deona4s

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auditing records prior to billing and dr billed 99213 and record audited 99214, dr does not want to change code to 99214. is this ok?
 

danachock

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No, absolutely not. This is simply not correct, if provider is purposely (OR - goodness a "very/well seasoned ~ possibly older provider" doing things like "back in the day" - perhaps... possibly not understanding their deficiency "undercoding" an E&M charge when documentation supports billing a higher E&M level) ...... it is your due diligence to help.
If I was in your shoes, I would reach out via email to my immediate supervisor, adding the educator trainer(s), along with compliance on this one. Let them explain the rationale/reasoning why we follow the guideline(s) for billing E&M services every single time to the provider. The provider "may need additional education" on their office visits to assist them with selecting their levels of service.
Thanks for listening,
Dana Chock (RHIT, CPC, CANPC, CHONC, CPMA, CPB)
Coding Analyst (May 2018-present), Anesthesia, Pathology, Laboratory Coder (Fall 2012-May 2018)
 

thomas7331

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Perhaps the doctor has a valid reason for not wanting to change it or disagrees with the audit finding - have you discussed it with him or her? Most audits are not final determinations and allow for a rebuttal process. With E&M coding, even two auditors may not always come up with the same code. Also keep in mind that you are looking at about a $35-$40 difference in payment between these codes. If this is an isolated instance, it is not a big deal in the scheme of things. Keep things in perspective.
 

Munzueta

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Sometimes providers feel strong about their documentation and codes. I've had instances where i would submit a query to a provider for more specificity on a diagnosis or for conflicting documentation and they won't agree with the outcome and state "i won't change it on the record"

i work in a hospital so i have to check on a lot of providers, if one doesn't one to comply, i have it on writing, and if anything happens with the record unfortunately it will fall on them. Also, yes a good approach is to request guidance from a supervisor about what to do, but just like thomas said, there might be a reason why he doesn't want to change it.
 

deona4s

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Perhaps the doctor has a valid reason for not wanting to change it or disagrees with the audit finding - have you discussed it with him or her? Most audits are not final determinations and allow for a rebuttal process. With E&M coding, even two auditors may not always come up with the same code. Also keep in mind that you are looking at about a $35-$40 difference in payment between these codes. If this is an isolated instance, it is not a big deal in the scheme of things. Keep things in perspective.
we are being asked to audit 5 charts per dr a week and seeing alot of 99213's that audit at 99214. So they are getting so many that are 'undercoded' and charting graphs are showing deviations to the national average and they want to make sure we can explain that deviation. Our physicians do not want to change to 99214 and state that they want 99213 based on medical necessity so our company has added to our compliance plan ' our policy requires 2 of the 3 Medical Decision Making be one of the 2 required components'. Do you agree this is how we should handle this or do you have any other advice?
 

thomas7331

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we are being asked to audit 5 charts per dr a week and seeing alot of 99213's that audit at 99214. So they are getting so many that are 'undercoded' and charting graphs are showing deviations to the national average and they want to make sure we can explain that deviation. Our physicians do not want to change to 99214 and state that they want 99213 based on medical necessity so our company has added to our compliance plan ' our policy requires 2 of the 3 Medical Decision Making be one of the 2 required components'. Do you agree this is how we should handle this or do you have any other advice?
I am not a fan of the making MDM level mandatory for code assignment because I have seen many cases of inappropriate under-coding result from this - cases where a presenting problem may require an in-depth history and exam, only to reach the conclusion that the patient's problem is not serious and does not require intervention. However, when applied just to high-level codes only (e.g. level 4 and 5 visits) it can be useful for preventing the up-coding that occurs due to EHR documentation and templates that artificially inflate the levels of history and exam.

Without actually looking extensively at your practice's documentation, it's not really possible to say whether or not this is going to work for you. But certainly, if the providers are saying that a 99213 is more appropriate to the nature of the patient's presenting problem than the 99214 based on their clinical judgment of medical necessity, then I'd say that is a pretty strong argument in its favor. That said, I would recommend giving it a very careful look to see what the true impact of that change would be. You may find that adding that requirement to your policy impacts a lot more than just the 99214 visits and could result in a lot of lost revenue.

One alternative to consider, which I think works well, is a 'one problem - one prescription' policy - that is, to assign no higher than a level 3 when a patient presents with a single problem and is treated with a prescription, and with no other comorbidities or complications involved - the code level should not be higher than level 3 regardless of the documentation of history and exam. I've been told that some commercial payers use this as a rule of thumb also. It's a little less invasive than capping all of your visits at the level of MDM.
 
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Pathos

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The CMS E/M guidelines clearly state that 2 of the 3 E/M components (History, Exam, and MDM) must be met in order to select a level. No-where in the current guidelines will you find where Medical Decision Making has to be one of the two E/M components. If your practice moves forward and creates a general policy which will require the MDM to be one of the two E/M components, then there is a good chance you will fail many additional audits than increasing your revenue. On a compliance viewpoint, such a dramatic policy is not sound and has nothing against a CMS audit or against other payers.
At my previous job, our company had such a MDM policy and this seemed to work well for them at the time. However, sooner or later such a policy will put your company in a predicament, and only the provider's documentation practices will save your company at the end of the day. That being said, I can totally understand the reason and simplicity behind such a MDM policy, however this is not bullet proof and adds another layer of risk to your company.

Also, to answer your original question; if the provider refuses to change the code level because he/she believes medical necessity only supports 99213, then you should probably go with that. The provider assumes full responsibility as the performing physician with all and any risks associated with that. Yes, we can be implicated as medical coders and have a Code of Ethics, which I wholeheartedly support, however ensure that if your provider goes against your recommendations, you document this and consult with your Compliance Officer and/or your practice attorney.

Finally, all things being said and done, remember that CMS is doing a major overhaul on their E/M requirements (and has already put many requirements and changes into motion starting this year [2019]), which will will providers the option to focus more on MDM rather than History and Exam. If you haven't already read up on the updates, you really should as this will directly impact your practice in terms of documentation requirements and reimbursement. Note that probably not all payers will follow suit, at least not right away, but there is a good chance that the major payers will tag along with the CMS updates and changes.



References:

CMS E/M guidelines 95/97
CMS Fact sheet for 2019-2021 changes

Hope this helps!
 
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