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Questions resulting from recent educational audit

  1. #1
    Default Questions resulting from recent educational audit
    Medical Coding Books
    We recently completed an in-house documentation review and several questions came up which I'm hoping you folks help me with. If you would prefer to just point me in the right direction, that's fine too.



    1. Is CPT's "Decision Tree for New vs Established Patients" absolute? If a doctor saw a patient four years ago, but would still like to bill the patient as an established patient, is that okay? I found CMS' statement on it, but I'm wondering what others' perspective is. I have a physician who would like to to choose.


    2. I recently took an auditing workshop run by the AAPC during which I was given a rough guide to selecting risk from the DG's Table of Risk. It was suggested (as a starting place only) to put surgeries with a 10 day global period in the "Low" category and those with a 90 day global period in the "Moderate" category. I have one physician who has deep misgivings about this approach and feels that "Moderate" is a better starting place for all surgeries, including liquid nitrogen destructions (we are a derm practice.) Any thoughts?



    3. Although prescription drug management falls on the "Moderate" level of the Table of Risk, would it be fair to put Accutane, methotrexate, and gabapentin on the "High" level given that they are used for "one or more chronic illnesses with severe... side effects of treatment"?



    4. In determing complexity of MDM, we used the Marshfield tool. One physician wanted to know if there was anywhere he could "score" more points when he invites his partners into an exam room to discuss a challenging case. Any thoughts?



    5. In counting exam bullets, can a bullet be counted as complete if some, but not all, of the elements of that bullet are documented? (i.e. would I count "eyelids" if that is all that is documented or does it specifically have to say in the chart "eyelids and conjuctivae"?)

    Thanks in advance for any help. I do so appreciate it.
    Last edited by hkatie; 12-13-2013 at 04:17 PM.

  2. #2
    Location
    Rose City (Portland, Oregon)
    Posts
    321
    Default
    1. Wow - normally people want to bill higher, not lower, than they should. I would question why the physician wants to short change himself. And, yes, those rules are absolute. It would be considered a coding error in an audit.
    2. That's an interesting proposal but I don't think it would work for all scenarios.
    3. Accutane, methotrexate, etc could fall under drugs intensive monitoring. Use of these drugs usually requires frequent, ongoing labwork to check for toxicity.
    4. I don't know what the Marshfield tool is but he might be able to get a point under data with "discuss results with testing dr" if that is applicable. That's a tough one to get "credit" for.
    5. Funny enough, I just read in the Coding Answer book about this very question. Check out page 15316 for the answer. Basically the answer is "yes but".

    Erin

  3. #3
    Default
    Erin,

    Thanks so much for your reply. I don't have access to Coding Answer book, but I'll find something to bring to my physician. 2009 was quite a year for me, professionally speaking. I've spent a lot of time in various departments, including billing, in my derm office over the years, but I felt uncomfortable about my lack of solid knowledge when I started working with the coding sets. I went from simply requesting increased education in March 09 to certified coder by August. I've learned a lot just by reading these boards-I don't have an on-site mentor so I'm taking as many webinars, seminars, and classes as I fit in. Thanks again for your help.

    Katie

  4. #4
    Location
    Rose City (Portland, Oregon)
    Posts
    321
    Default
    Here is the passage from CAB: " For example,'examination of the spleen was unremarkable, examination of the liver was deferred" would not fulfill the requirements for the element "examination of liver and spleen," whereas "examination of the spleen was unremarkable" would fulfill the documentation requirements." Pretty tricky, eh?

  5. #5
    Location
    Swainsboro/Statesboro, GA
    Posts
    754
    Default Great discussions!
    Hey Katie,

    Isn't it funny how we can work in this field and yet still get stumped by situations on an almost daily basis?! I understand exactly how you feel!

    Regarding your specific questions:

    1. AMA states and CMS agrees that a patient can be considered new if not seen in the previous three years. That being said, if your physician doesn't want to bill an established patient as a new patient, I would not "force" him/her to do so, but what I would force would be that this be made into a written policy and that it is applied to every single patient. The physician cannot decide which patients would get the established charge and which would get the new patient charge. That would be very wrong.

    Regarding your questions on MDM, this is one area that is entirely up to the physician or physician extender. I would certainly allow a physician to make those decisions. As coders and auditors, we should not tell a physician what the MDM level is. As long as their documentation supports their decision, I would always allow this to be the MDM level.

    I would also allow for the bullet to be counted if most of the elements within the bullet are met.

    Please understand that these are my opinions!

    Good luck!!
    Freda Brinson, CPC, COC, CEMC
    AAPC Swainsboro/Statesboro Chapter
    2017/2018 Secretary/Treasurer
    2016 Education Officer
    2014/2015 President
    Past President - 2012, 2008; Past Vice President - 2013, Past Education Officer - 2009 of Savannah, GA Chapter
    Past Member AAPCCA Board of Directors (2009-2012)
    brinsonfr@sjchs.org

  6. #6
    Default Coding Answer Book?
    What is the "Coding Answer Book"? I never heard of it, but it sounds very interesting.

  7. #7
    Location
    Milwaukee WI
    Posts
    4,466
    Default I'll try to answer
    1. It's clearly a new patient ... more work is involved in taking the history and exam and in your medical decision making because you haven't been following the patient regularly. That being said, if your doc insists ... be sure to have a written policy in place that you consider "established" patients to be anyone who has received face-to-face services within the last x years (can't be LESS than what CPT says ... so at minimum 3 years) and apply that standard uniformly to all patients.

    2. The table of risk is pretty clear. "Minor surgery with no identified risk factors" is LOW. The physician must specify the risk factors (risk to the patient for surgery, not just risk OF performing surgery ... e.g. diabetes or previous problem with anesthesia or bleeding disorder).

    3. I'm usually in the minority here, but to me "intensive monitoring" is the kind provided in a hospital or office suite with continuous monitoring over a period of time. ANY drug needs to be monitored for toxicity ... even Tylenol will kill you if you overdose.

    4. Check the Data points - 2 data points awarded for "discussion of case with another health care provider" Or, on the table of risk - Moderate for "undiagnosed new problem with uncertain prognosis" might fit the scenario.

    5. That's why I like the 1995 guidelines! When 1997 guidelines use the word "and" it means everything must be done to count the bullet.

    Remember though, that the guidelines are just that - guidelines - not law. They are open to interpretation. Your practice should have a compliance plan in place that includes any specific guidelines that you follow. Any outside auditor will always ask to see that plan and your own practice protocols. Have them in writing, and follow them consistently.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  8. #8
    Location
    Springfield, MO
    Posts
    258
    Default
    See answers below:

    Quote Originally Posted by khanninen View Post
    We recently completed an in-house documentation review and several questions came up which I'm hoping you folks help me with. If you would prefer to just point me in the right direction, that's fine too.



    1. Is CPT's "Decision Tree for New vs Established Patients" absolute? If a doctor saw a patient four years ago, but would still like to bill the patient as an established patient, is that okay? I found CMS' statement on it, but I'm wondering what others' perspective is. I have a physician who would like to to choose.

    Answer: I agree with the above. It would be incorrect to report an established patient code as the criteria is not met.

    2. I recently took an auditing workshop run by the AAPC during which I was given a rough guide to selecting risk from the DG's Table of Risk. It was suggested (as a starting place only) to put surgeries with a 10 day global period in the "Low" category and those with a 90 day global period in the "Moderate" category. I have one physician who has deep misgivings about this approach and feels that "Moderate" is a better starting place for all surgeries, including liquid nitrogen destructions (we are a derm practice.) Any thoughts?

    Answer: I was always told a minor surgery is a surgery with 0 or 10 days. This is consistent with Medicare's guidelines. Now if the patient has cancer or there is some risk involved, that could definitely affect the level of risk for the presenting problem. However, for a minor surgery with no identified risk factors, that is a low level of complexity.



    3. Although prescription drug management falls on the "Moderate" level of the Table of Risk, would it be fair to put Accutane, methotrexate, and gabapentin on the "High" level given that they are used for "one or more chronic illnesses with severe... side effects of treatment"?
    Answer: If the patient has a chronic illness with severe exacerbation, then a high level of complexity is appropriate. The risks associated with taking the medications would not count though.


    4. In determing complexity of MDM, we used the Marshfield tool. One physician wanted to know if there was anywhere he could "score" more points when he invites his partners into an exam room to discuss a challenging case. Any thoughts?
    Answer: Under the data reviewed, a provider could get two points for discussing the case with another provider. Just make sure it is documented.


    5. In counting exam bullets, can a bullet be counted as complete if some, but not all, of the elements of that bullet are documented? (i.e. would I count "eyelids" if that is all that is documented or does it specifically have to say in the chart "eyelids and conjuctivae"?)
    Answer: This is a good question. I always counted it even if they only stated conjunctivae. I am thinking it could be interpreted either way. There are some aspects of E/M that are subjective and this could definitely be one of them.

    Thanks in advance for any help. I do so appreciate it.

    Katie Hanninen, CPC, CPCD

  9. #9
    Default
    regarding #3, i have always heard that only black box drugs qualified for the toxicity level in MDM....has anyone else heard that?
    Dawnelle Beall, CPC, CPMA, CPC-I
    Licensed AAPC PMCC Instructor
    AAPC ICD-10CM Certified Trainer
    Previous AAPC Local Chapter President & VP

  10. #10
    Default
    Thank you so much to everyone who took the time to reply. It's just terrific to read well thought out, logical explanations for different interpretations. You've all given me great perspectives to sift through.

    Thanks,

    Katie

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