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The ease of upcoding

  1. #1
    Default The ease of upcoding
    Medical Coding Books

    With the adoption of EHR and the ease with which one can complete an item with just the click of a button, it concerns me that this might produce upcoding.

    Case-in-point...when a patient is seen in our facilities it is always protocol to ask if they have any medication allergies. This is good practice except I wonder if medically necessary for our frequently seen patients whom a medical history is already well known.

    This question will always produce one point in either the ROS or we can also use this in our PFSH calculation of the history table for E/M and this can many times change the code to a higher level.

    Is there anybody else out there with this same concern? I would love to hear your thoughts on this.

    Thank you!
    Lisa Incaudo, CPC

  2. Default Ehr
    I too had these concerns for a long time. When I first started in the medical field I was in a small office with paper charts and transcribed notes where the average visit was a 99212 or 99213. Now I am working in a large office with many physicians, PA's, and Nurse Practitioners and the average visit is a 99214. When I first started at my current office that made me very nervous. However, now I find our EHR as a very comprehensive tool. We are an Internal Medicine/ Walk-in Clinic so many of our patients come in with acute illness. For established patients a new problem with no additional work-up planned and Rx management would indicate a MDM of moderate complexity. The part where I feel that EHR really helps is the exam according to CMS 1997 guidelines a detailed exam only needs 12 points in at least 2 body areas. These points are easier to accumulate on an EHR because you have the options in front of you during the visit while when usuing transcription typically at the end of the day with limited notes the most that was recorded on a usual basis were areas with problems. This is not only beneficial to coders but if there is more unusual behavior of an illness it is nice to know the other systems were addressed and normal in previous notes. With the MDM and Ex both moderate that would make an established visit a 99214. As far as Hx I would go ahead and have the providers notate the ROS and PFSH. These are things that are commonly addressed in notes but the providers don't even think about it like when they Rx something like Cipro instead of Amoxicillin due to allergies.

    However, I must advise to still be careful and check on payers. Many payers do not accept coding over MDM so if you have a visit with a comprehensive history and exam but a low MDM the payer would want a 99213.

    I hope this is what you were looking for. The best thing is provider education. We don't want to see one note that says the abdomen was nontender then another the next week with a CC of abdomen tender for over a month (that wouldn't be pretty to an auditor trust me I've seen in doing an external audit for someone).

  3. #3
    Default MDM level
    Thank you MDuncan for your reply!

    We're also noticing a trend towards code 99214 and this concerns me very much. The PHSH example I gave previously was just one way that I see this system upcoding. Another example is in the MDM. As you mentioned in your statement about an established patient with a new condition and medication managemnet as a MDM of moderate complexity but what about if they have an established condition, well controlled and no additional workup with medication management?

    Our system allows the providers to pick the MDM based off of the Risk of Complications and/or Mortality table, however, when performing an audit I have two additional tables within the MDM section to consider when deciding the level. One of them being the Number of Diagnosis or Treatment Options and the other The Amount and/or Complexity of Data to be reviewed. When I take these into consideration the MDM level can be reduced substancially and thus reduce my overall code, which I'm finding to be a common occurence.

    Anyone else finding this to be an issue as well?
    Last edited by linc11; 03-24-2011 at 04:52 PM.
    Lisa Incaudo, CPC

  4. #4
    Default
    Quote Originally Posted by linc11 View Post
    Thank you MDuncan for your reply!

    We're also noticing a trend towards code 99214 and this concerns me very much. The PHSH example I gave previously was just one way that I see this system upcoding. Another example is in the MDM. As you mentioned in your statement about an established patient with a new condition and medication managemnet as a MDM of moderate complexity but what about if they have an established condition, well controlled and no additional workup with medication management?

    Our system allows the providers to pick the MDM based off of the Risk of Complications and/or Mortality table, however, when performing an audit I have two additional tables within the MDM section to consider when deciding the level. One of them being the Number of Diagnosis or Treatment Options and the other The Amount and/or Complexity of Data to be reviewed. When I take these into consideration the MDM level can be reduced substancially and thus reduce my overall code, which I'm finding to be a common occurence.

    Anyone else finding this to be an issue as well?
    The problem I'm running into is that providers are over-documenting for the patient's clinical need, bsaed on the nature of the presenting problem. It wouldn't be medically necessary to perform a comprehensive history and exam for something like sinusitis, but the EHR makes it very easy to document it. RAC auditors will downcode based on medical necessity, amd 99214's are a favorite target. If your provider is billing far more than others in his specialty, he could be attracting some unwanted attention. Check with the clinical examples in Appendix C to make sure that your E/M levels are meeting up with what's considered appropriate for each level of service, and don't report high level codes just because the doctor clicked a few extra buttons.

  5. #5
    Default Appendix C
    Thank you Brandi, that's a great suggestion and I'm going to do that right now. I'm still waiting eagerly to talk with our EHR development team regarding the factors that are implemented in our system to determine the overall MDM calculation as well. I'm hoping that I'm not correct and somehow our system is taking all three components within the MDM complexity into consideration and computing our level of medical decision making but if not....well let's just say I'll have a lot to deal with!
    Lisa Incaudo, CPC

  6. #6
    Default
    I feel ya'. I can't even begin to describe the things I've come across...I've got some work to do.

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