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Help I Need some Advice

  1. Exclamation Help I Need some Advice
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    We have an EMR system and the physicians pretty much code their own visits. They are OB/GYN's.
    Recently, I received a request from Insurance for the office notes. The visit had already been paid and it was for a preventive visit (ie; well woman exam). Upon reviewing the visit I noted that the patient actually came in for chief complaint of "infertility". The HPI was all about her infertility. The comments were all about her infertility. Although the physician did an exam, including breast, pelvic and a pap. The only mention of well woman exam was her diagnosis code and the cpt code. There was no age appropriate counseling.
    I brought this to her attention and asked her what was up.
    Her reply was that she could not do anything for the infertility and the patient was due for an annual, so she did it. I told her she should have documented this fact somewhere in the visit.
    Our new practice administrator intervened and said "the notes look fine to me" and the exam meets the preventive well woman exam, so she over rode my recommendations and told the doctor I was wrong.
    I fear a savvy auditor will take back payment and request we code this as an E/M with a diagnosis of "infertility" and of course the patient does not have coverage for this.
    I had other billers/coders blind code the chart and none of them came up with a well woman exam.
    Am I correct to be concerned?
    Thanks,
    Joni Fuller

  2. #2
    Default
    Quote Originally Posted by jfuller@cwc4women.com View Post
    We have an EMR system and the physicians pretty much code their own visits. They are OB/GYN's.
    Recently, I received a request from Insurance for the office notes. The visit had already been paid and it was for a preventive visit (ie; well woman exam). Upon reviewing the visit I noted that the patient actually came in for chief complaint of "infertility". The HPI was all about her infertility. The comments were all about her infertility. Although the physician did an exam, including breast, pelvic and a pap. The only mention of well woman exam was her diagnosis code and the cpt code. There was no age appropriate counseling.
    I brought this to her attention and asked her what was up.
    Her reply was that she could not do anything for the infertility and the patient was due for an annual, so she did it. I told her she should have documented this fact somewhere in the visit.
    Our new practice administrator intervened and said "the notes look fine to me" and the exam meets the preventive well woman exam, so she over rode my recommendations and told the doctor I was wrong.
    I fear a savvy auditor will take back payment and request we code this as an E/M with a diagnosis of "infertility" and of course the patient does not have coverage for this.
    I had other billers/coders blind code the chart and none of them came up with a well woman exam.
    Am I correct to be concerned?
    Thanks,
    Joni Fuller


    For a visit to be considered a Preventive exam, there has to be age and gender appropriate counseling/anticipatory risk factor reduction interventions documented, per CPT definition. Period. Without that, all you have is a problem-oriented E/M for infertility, which wouldn't warrant anything higher than a 99212. Now, what qualifies as "counseling" may be open to interpretation. Sometimes I see notes that just say "Counseled patient regarding current medications", or if they suggested a diet/exercise regimen, suggested that the patient quit smoking, or advised them to watch out for future heath issues (and it's documented, of course), then I'll give credit for it. I'd have to see evidence of a routine/annual exam, such as routine labs, and also an extensive history and exam. The "comprehensive" definition of preventive visits isn't equivalent to "Comprehensive" for sick visits, so it's difficult to quantify, but I would expect to see the usual elements, such as ascultation of heart and lungs, at least.

    The physician should use caution when changing visit-types halfway through, to ensure that they meet all of the documentation requirements for the exam that they're going to bill. If an auditor reviews a chart and gets the impression that the doctor was just trying to spin a non-covered service and label it a 'well check', they will downcode it to whatever it scored, at minimum. If they decide that the doctor was intentionally aiming to deceive the insurer to collect improper payment, the doctor could be inviting a fraud investigation from the OIG.

    I imagine that this doctor probably views documentation requirements as a pointless and time-consuming formality, which is unfortunate. I haven't seen the records, but I understand your position. In my experience, it's difficult to get some physicians to understand why good documentation is so important - beyond their own self-interests (re: payment). The best you can do is get the clinical coverage criteria for a routine/well woman exam from the patient's insurer (its usually on their website), and point out how your doctor's note falls short, if it eventually does. If they still want to gamble their practice over the price of an office visit, there's not much else you can do - it's their money.
    Last edited by btadlock1; 04-17-2011 at 03:32 PM.

  3. #3
    Default
    I agree with everything except the comment, "all you have is a problem-oriented E/M for infertility, which wouldn't warrant anything higher than a 99212." I don't understand how infertility automatically equals a low level visit. The work-up, including history and exam, can be quite extensive, as well as complex medical dedision making, involving ordering additional testing and discussing different courses of treatment. Even if it is a non-covered diagnosis, I would code the visit based on the services documented.
    Melanie Zinser, RMC, CPMA, CPC-I, CANPC
    Coding Educator & Quality Analyst
    OhioHealth Physician Group
    melanie.zinser@ohiohealth.com

  4. #4
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    Medical necessity is the overarching criterion when determining the level of service, in addition to the key components required by the CPT descriptor. It wouldn't be appropriate to bill a higher level of service than was medically necessary to address the nature of the presenting problem, even if the documentation requirements have been satisfied. Inferitility is not an acute illness or injury that poses significant risk to the patient's life or bodily functions if untreated. The visit described here has straightforward MDM - the doctor couldn't do anything about the infertility. Had the doctor scheduled the patient for diagnostic procedures, prescribed some sort of treatment, or done anything more than just basically having a chat with the patient about her infertility, then the visit might have qualified for a 99213. I wouldn't assign this type of minor problem a 99214 or 99215 in any situation, without further complications documented (like a co-morbidity to consider, if a prescription was given), because Trailblazer (our MAC) has explicitly said to never assign a level 4 or 5 E/M, unless the patient's condition has at least a 50/50 chance of worsening without treatment.

  5. Cool thank you
    Thank you very much for the confirmation. I agree. Always like to have more than just my professional opinion when dealing with others with billing experience. Much of what I do is automatic and judgement calls from years of experience and knowledge, and yes mistakes along the way.
    So thank you again.
    Joni

  6. Default
    Quote Originally Posted by btadlock1 View Post
    Medical necessity is the overarching criterion when determining the level of service, in addition to the key components required by the CPT descriptor. It wouldn't be appropriate to bill a higher level of service than was medically necessary to address the nature of the presenting problem, even if the documentation requirements have been satisfied. Inferitility is not an acute illness or injury that poses significant risk to the patient's life or bodily functions if untreated. The visit described here has straightforward MDM - the doctor couldn't do anything about the infertility. Had the doctor scheduled the patient for diagnostic procedures, prescribed some sort of treatment, or done anything more than just basically having a chat with the patient about her infertility, then the visit might have qualified for a 99213. I wouldn't assign this type of minor problem a 99214 or 99215 in any situation, without further complications documented (like a co-morbidity to consider, if a prescription was given), because Trailblazer (our MAC) has explicitly said to never assign a level 4 or 5 E/M, unless the patient's condition has at least a 50/50 chance of worsening without treatment.
    I got this link from my local chaper for CEUS. Heck, free CEU's.. for sure!!!!! Anyways I went to it and it was VERY informative on leveling visits. Everybody might want to look at it.. and you get free CEU's. There are two of them just on leveling and both offer 1 free CEU each. The link is: https://www.highmarkmedicareservices...isclaimer.html
    I hope this helps somebody.

    Emily

  7. #7
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    North Carolina
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    I can tell you that infertility is not straightforward. These type of visits can result in lengthy, complicated counseling sessions. We have a fertility practice and I personally audit these records. Grant it, the session does include recommendations for complicated testing and treatment. Many of these visits are coded based on time due to the length of the counseling sessions.

  8. #8
    Default I think I'm miscommunicating here...
    I'm not saying that every infertility visit is simple and straightforward...just this one, and only because the doctor didn't actually do anything to try to address it.

    Here's where I'm getting all of this:
    http://www.trailblazerhealth.com/Pub...QA09-30-09.pdf
    "Question: Referring to the “Coding Evaluation and Management Services” notice dated September 11, 2009, do we need three or four distinct medical conditions to bill the highest two codes in any family?
    Answer: Medical necessity is a requirement for Medicare payment of all Evaluation and Management (E/M) services (with few exceptions). Level of service is affected by medical necessity. Even if key component work or time/counseling and coordination (when appropriate) are documented for a higher level of service, do not report a high code if medical necessity for the higher code is not demonstrated. The nature of the patient's presenting problem and the related conditions for which the physician performed E/M work drive the medical necessity determination. Accordingly, severity of illness and number of illnesses dictate complexity of work required by the physician.

    Do not consider reporting the highest two codes of any code family (levels four and five in five-level families, or levels two and three in three-level families) when:
    The physician evaluated and managed fewer than three distinct medical conditions/complaints during the encounter and no one problem evaluated and managed, without appropriate intervention, conferred at least a 50/50 likelihood of worsening, disability or death between the time of the current encounter and the next physician encounter.

    Do not consider reporting the highest code (level five of five-level families or level three of three-level families) of any code family when:
    The physician evaluated and managed fewer than four distinct medical conditions/complaints during the encounter and no one problem evaluated and managed, without appropriate intervention, conferred at least a 50/50 likelihood of worsening, disability or death between the time of the current encounter and the next physician encounter."

    and...

    http://www.trailblazerhealth.com/Pub...ponentsEOV.pdf

    "Medically Reasonable and Necessary
    The law requires all payments (with only a few exceptions) made by Medicare to be for medically reasonable and necessary services. Medicare determines “medically reasonable and necessary” separately from determining that the work described by a reported CPT code was performed. For E/M services, the medical record documentation must demonstrate that the practitioner performed the reported E/M service as it is described in the CPT book and as required by CMS E/M Documentation Guidelines. Additionally, it must support the intensity and frequency of the E/M service met but that it did not exceed the patient's clinical needs. Information within the medical record about the patient's condition, not the diagnosis alone, determines the level of service payable by Medicare. In keeping with federal law, Medicare must deny or downcode E/M services that, in its judgment, exceed the patient's documented needs.

    Documenting Medical Necessity
    The patient's condition (severity, acuity, number of medical problems, etc.) is the key factor in determining medical necessity for Medicare payment for services. Providers who report E/M services for Medicare payment must ensure their records describe the patient's condition and reason for the visit in enough detail for a reasonable observer to understand the patient's need. Providers must also ensure the nature of the patient's presenting problem and/or status is consistent with the level of service reported. Unfortunately, practitioners often include unnecessary material while failing to record clinically pertinent information needed todetermine medical necessity of the service. The service should be coded based on the clinical needs of the patient.

    Level of Service
    The E/M code chosen must reflect both work performed and medical necessity. Though an E/M service may code to a high level based on the documentation of key component work, it is inappropriate to request Medicare payment when the patient's effective management does not require the code's work.

    Because of this unique dependence on the information contained in the MDM component, even though a medical record might contain a perfectly complete history and examination, without a correspondingly complex MDM there may be no justification for payment of a high-level E/M service. In fact, without adequate record of physician impressions and planned diagnostic/therapeutic intervention, the encounter might be rendered of no clinical benefit at all and not payable at any level."

  9. #9
    Default
    Quote Originally Posted by eadun2000 View Post
    I got this link from my local chaper for CEUS. Heck, free CEU's.. for sure!!!!! Anyways I went to it and it was VERY informative on leveling visits. Everybody might want to look at it.. and you get free CEU's. There are two of them just on leveling and both offer 1 free CEU each. The link is: https://www.highmarkmedicareservices...isclaimer.html
    I hope this helps somebody.

    Emily
    Highmark Medicare is my carrier as well but this info in the link may not be of help to other coders who are not in J12, they must follow their carriers advice. I know Trailblazer is pretty tough on their requirements for e/m.

    Although I do feel that anyone in the J12 districts would benefit from the HMS link you've provided.
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

  10. #10
    Location
    North Carolina
    Posts
    3,126
    Default
    Quote Originally Posted by btadlock1 View Post
    I'm not saying that every infertility visit is simple and straightforward...just this one, and only because the doctor didn't actually do anything to try to address it.

    Here's where I'm getting all of this:
    http://www.trailblazerhealth.com/Pub...QA09-30-09.pdf
    "Question: Referring to the “Coding Evaluation and Management Services” notice dated September 11, 2009, do we need three or four distinct medical conditions to bill the highest two codes in any family?
    Answer: Medical necessity is a requirement for Medicare payment of all Evaluation and Management (E/M) services (with few exceptions). Level of service is affected by medical necessity. Even if key component work or time/counseling and coordination (when appropriate) are documented for a higher level of service, do not report a high code if medical necessity for the higher code is not demonstrated. The nature of the patient’s presenting problem and the related conditions for which the physician performed E/M work drive the medical necessity determination. Accordingly, severity of illness and number of illnesses dictate complexity of work required by the physician.

    Do not consider reporting the highest two codes of any code family (levels four and five in five-level families, or levels two and three in three-level families) when:
    The physician evaluated and managed fewer than three distinct medical conditions/complaints during the encounter and no one problem evaluated and managed, without appropriate intervention, conferred at least a 50/50 likelihood of worsening, disability or death between the time of the current encounter and the next physician encounter.

    Do not consider reporting the highest code (level five of five-level families or level three of three-level families) of any code family when:
    The physician evaluated and managed fewer than four distinct medical conditions/complaints during the encounter and no one problem evaluated and managed, without appropriate intervention, conferred at least a 50/50 likelihood of worsening, disability or death between the time of the current encounter and the next physician encounter."

    and...

    http://www.trailblazerhealth.com/Pub...ponentsEOV.pdf

    "Medically Reasonable and Necessary
    The law requires all payments (with only a few exceptions) made by Medicare to be for medically reasonable and necessary services. Medicare determines “medically reasonable and necessary” separately from determining that the work described by a reported CPT code was performed. For E/M services, the medical record documentation must demonstrate that the practitioner performed the reported E/M service as it is described in the CPT book and as required by CMS E/M Documentation Guidelines. Additionally, it must support the intensity and frequency of the E/M service met but that it did not exceed the patient’s clinical needs. Information within the medical record about the patient’s condition, not the diagnosis alone, determines the level of service payable by Medicare. In keeping with federal law, Medicare must deny or downcode E/M services that, in its judgment, exceed the patient’s documented needs.

    Documenting Medical Necessity
    The patient’s condition (severity, acuity, number of medical problems, etc.) is the key factor in determining medical necessity for Medicare payment for services. Providers who report E/M services for Medicare payment must ensure their records describe the patient’s condition and reason for the visit in enough detail for a reasonable observer to understand the patient’s need. Providers must also ensure the nature of the patient’s presenting problem and/or status is consistent with the level of service reported. Unfortunately, practitioners often include unnecessary material while failing to record clinically pertinent information needed todetermine medical necessity of the service. The service should be coded based on the clinical needs of the patient.

    Level of Service
    The E/M code chosen must reflect both work performed and medical necessity. Though an E/M service may code to a high level based on the documentation of key component work, it is inappropriate to request Medicare payment when the patient’s effective management does not require the code’s work.

    Because of this unique dependence on the information contained in the MDM component, even though a medical record might contain a perfectly complete history and examination, without a correspondingly complex MDM there may be no justification for payment of a high-level E/M service. In fact, without adequate record of physician impressions and planned diagnostic/therapeutic intervention, the encounter might be rendered of no clinical benefit at all and not payable at any level."
    This is good information but you have to remember one thing...Infertility isn't going to be driven by Medicare's guidelines; although many carriers hold Medicare as the golden standard. Infertility is a unique specialty and the guidelines will be driven by commerical carriers; if at all since many carriers do not provide coverage for infertility beyond the first visit.
    Last edited by RebeccaWoodward*; 04-16-2011 at 08:37 AM.

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