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Special Fall/Winter 2016 Presentation
Medical Necessity Crash Course for E/M Coders
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Medical Necessity Crash Course for E/M Coders
Written By: Stephanie Cecchini, CPC, CEMC, CHISP, AHIMA Approved ICD‐10 Trainer
DISCLAIMER
This course was current at the time it was published. This course was prepared as a tool to assist the participant in understanding the concepts of Medical Necessity in Evaluation and Management (E/M) coding and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.
AAPC agents, writers, contributors, contractors, employees and staff make no representation, warranty, or guarantee that this compilation of information is error‐free and will bear no responsibility or liability for the results or consequences of the use of this course. This guide is a general summary that explains commonly accepted aspects of selecting E/M codes, but it is not a legal document.
Viewpoints are discussed from the standpoint of the 1995 and 1997 Centers for Medicare and Medicaid Services (CMS) Evaluation and Management Documentation Guidelines with Medical Necessity and the nature of the presenting problem as the primary criterion of code selection (Medicare Claims Processing Manual Chapter 12 ‐ Physicians/Nonphysician Practitioners, 30.6.1 ‐ Selection of Level of Evaluation and Management Service, A. Use of CPT Codes.)
For the purpose of objective consistency, specific logics are primarily based on the same used by the E/M Documentation Auditors’ Worksheet, Marshfield Clinic, available through the Medical Group Management Association (MGMA). Specific payers, including Medicare Carriers, may use different and sometimes varied audit tools logics to gain objective consistency around the 1995 and 1997 Documentation Guidelines. Official provisions are contained in the relevant laws, regulations, rulings and contractual agreements of providers.
NOTICES
Current Procedural Terminology (CPT®) is copyright © 2015 American Medical Association. All Rights Reserved. CPT® is a registered trademark of the American Medical Association (AMA).
It is recommended that the participant of this course will familiar with:
CMS 1995 Documentation Guidelines for Evaluation and Management Services
CMS 1997 Documentation Guidelines for Evaluation and Management Services
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Contents
Objectives ..................................................................................................................................................... 5
BACKGROUND ............................................................................................................................................... 7
Laws, Mixed Messages, and E/M documentation .................................................................................... 8
EMRs ..................................................................................................................................................... 8
Malpractice ............................................................................................................................................... 9
Value Based Medicine ........................................................................................................................... 9
The Truth in SOAPY Coding ..................................................................................................................... 10
Subjective: Opinions........................................................................................................................... 10
Objective: Facts ................................................................................................................................... 10
Assessment: Judgements .................................................................................................................... 10
Plan: Strategies ................................................................................................................................... 10
Understanding the Medical Necessity Problem ......................................................................................... 10
Understanding the Mindset of the Physician ............................................................................................. 12
Section 1: Coding the Key Components ...................................................................................................... 13
History (Hx) ............................................................................................................................................. 15
HISTORY OF PRESENT ILLNESS (HPI) ................................................................................................... 15
REVIEW OF SYSTEMS (ROS) ................................................................................................................. 16
PAST, FAMILY & SOCIAL HISTORY (PFS) .............................................................................................. 18
Examination (PE) ..................................................................................................................................... 20
Medical Decision Making (MDM) ........................................................................................................... 21
THE NUMBER OF DIAGNOSES AND MANAGEMENT OPTIONS ........................................................... 21
AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWED ............................................................. 22
RISK SIGNIFICANT COMPLICATIONS, MORBIDITY, AND/OR MORTALITY ........................................... 22
Putting it together ................................................................................................................................... 23
Section 2: Medical Necessity...................................................................................................................... 23
Section 3: Evidence Based Guidelines......................................................................................................... 24
Nature of the Presenting Problem and Medical Necessity ..................................................................... 25
MDM and Medical Necessity .................................................................................................................. 26
Section 4: Five Most Deadly E/M Coder Mistakes ..................................................................................... 29
Mistake Number 1 .................................................................................................................................. 29
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Mistake Number 2 .................................................................................................................................. 29
Mistake Number 3 .................................................................................................................................. 30
Mistake Number 4 .................................................................................................................................. 33
Mistake Number 5 .................................................................................................................................. 36
About the Author: ....................................................................................................................................... 37
Appendix A: E& M Code Selection (Reference Sheet) ................................................................................ 38
Appendix B: Medical Necessity Flow Chart ................................................................................................. 39
Appendix C: Acronyms Used in this Webinar ............................................................................................ 40
Appendix D: CDI Communication Tool ....................................................................................................... 41
SLIDES .......................................................................................................................................................... 43
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Objectives
Have you ever wondered if a level 4 or 5 office visit was really medically necessary—or if a service was actually more appropriately a level 3 versus a 4? Only providers are qualified to make Medical Necessity determinations ‐‐‐ yet the medical need for services, not the provision of services, is the authoritative and winning factor to proper code selection. This virtual webinar provider 3 simple steps to ensure you’ve got the right level of service.
• Learn how to confidently code the correct E/M level ‐‐‐every time
• Discover when documentation becomes a compliance problem
• Stop over‐coding or under‐coding claims based on Medical Necessity
• Avoid the 5 most deadly mistakes in E/M coding
Plus: This webinar highlights frequent (but problematic) methods used in code selection, such as utilizing the Evaluation and Management Documentation Guideline’s Medical Decision Making component to determine Medical Necessity. This and other myths can lead to coder confusion that may artificially inflate (or deflate) coding. This webinar also provides you with alternate solutions that really work.
This webinar answers these questions (and more):
“I can use the level of the MDM to validate the Medical Necessity of the service.”
“My EMR suggested the code, which validates that the level of service is correct.”
“When an established patient has three chronic conditions, the code is always a 99214.”
“An ‘unobtainable history’ is automatically equal to a comprehensive history.”
“I document the total time and counseling at 50%‐‐‐therefore the service level is always correct.”
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If you work with physicians or providers, this webinar will provide you with valuable insights to communicate more effectively with them and other stakeholders about E/M coding and Medical Necessity issues.
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Medical Necessity Crash Course for E/M Coders
BY: Stephanie Cecchini, CPC, CEMC, CHISP, AHIMA Approved ICD‐10 Trainer
BACKGROUND
There are overlapping laws in the United States that impact a coder’s ability to correctly code physician visits. The Social Security Act1 stipulates that Medical Necessity determines the correct code by the reasonable and necessary nature of the clinical services provided to a patient. Although each payer might have its own definition of “Medical Necessity”, most follow Medicare’s example of using Medical Necessity as the “overarching criterion for payment in addition to the individual requirements of a CPT code”2.
Adhering to documentation guidelines is secondarily required to support correct code use. Medicare and other payers hold a physician responsible for correct billing and medical documentation. On the surface, this seems reasonable but the complexity of rules are not simple, or easy to remember.3 For example, physicians are not allowed to simply document what is wrong with a patient and what they want to do for them. They are required to document their patient visits according to a minimum of 50 possible service variances; all are generic hypotheticals with no bearing on necessity or quality of patient care4. Physicians fail audits
1 42 U.S.C. § 1395(A)(1)(A) 2 Pub. 100‐04 Medicare Claims Processing 30.6.1/Selection of Level of Evaluation and Management Service 3 The bulk of the rules that must be memorized are covered in: Publication # 100‐04 Medicare Claims Processing Manual Chapter 12 ‐ Physicians/Nonphysician Practitioners. This publication contains 230 pages of detailed, and heavily exception based, instructions for the correct payment and documentation of services. 4 1995 and 1997 Documentation Guidelines for Evaluation and Management Services
Medical Necessity Laws
&
Malpractice
&
Clinical Work
HITECH Act
&
Documentation Guidelines
&
Non Clinical Work
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without this arbitrary documentation ‐‐regardless of the services they actually provided or the patient’s outcome. In some cases, due to one or two missing words.
Laws, Mixed Messages, and E/M documentation
EMRs
Compounding the problem of complex documentation rules is the unrelated and well‐meaning intent of the Health Information Technology for Economic and Clinical Health (HITECH) Act, which was to reduce medical errors such as duplication of services (patients having the same tests by different providers), prescribing medications with contraindications, and avoid missing documentation that can resulted in errors. The law requires providers to use computers “meaningfully”, which means they collect and share specific patient information in an electronic format and they use technology to double check defined aspects of their clinical care. Early adopters of Electronic Medical Records (EMR) received an incentive payment and non‐adopters were told they would be penalized by a Medicare pay cut.
We know it is the necessity of the work versus the actual volume of work and documentation that should be coded and billed. But, in today’s world of EMR, more documentation is produced than ever before. Many EMRs have the ability to carry forward old clinical information into the latest note, which is could be seen as “cloning”. Cloning is the billing for services not provided on the actual date of service billed, but rather provides on a previous already billed date. The problem lies in copying forward old information, such as patient complaints from an earlier visit that have resolved themselves. It can create confusion about what the patient is presenting for on the actual date of service. A coder is not able to state what is and what is not appropriate for the needs of an individual patient.
Therefore, while the intention of the HITECH Act may be good, the reality has been EMR systems are largely cited as cumbersome, time consuming, and error prone. The point and click, auto‐populate, cut‐paste, and drop‐down menu capabilities of most EMR systems make human mistakes frighteningly possible. The programming and templates used in many EMRs can produce “over documentation.”5 The ease of added detail bloats a level of service by meeting documentation rules requirements but overlooks the Medical Necessity and appropriateness of the diagnostic and/or therapeutic services provided.
5 http://www.nytimes.com/interactive/2012/09/25/business/25medicare‐doc.html?_r=0
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Malpractice
Further, fear of malpractice leads many physicians to do medically unnecessary services‐‐‐which effects the volume of documentation in E/M coding and can cause a false positive higher level. Studies reveal that $45.6 billion is spent annually on unneeded services ordered by physicians who are protecting themselves against the patient as a plaintiff.6
Value Based Medicine
Medicare and private insurers are increasingly transitioning from paying physicians for discrete services to global payment for “value”. Value is defined by a set of statistical metrics calculated across the range of services physicians could provide, whether or not it is specifically relevant to the reason for the visit or the service of the physician. Currently, “quality” reporting (cost reporting) programs include Physician Quality Reporting System (PQRS), Value Based Modifier program, and Meaningful Use7 which will be combined in 2019 under a single Merit‐Based Payment Incentive System (MIPS).
Medical need is tightly wound with notions of “quality” –making the concepts difficult to compartmentalize. However, it is important to make the distinction because quality measures are largely preventive in nature and should not be considered in E/M levels for separate payment by way of that code. CMS Quality Measures are reported by physicians and documented with the E/M service. They are meant to ensure steps are taken to minimize preventable problems and earlier detect problems before they become more costly. They focus heavily on conditions such as heart attacks, strokes, cancer, mental illness, and problems that primarily affect the elderly such as dementia and falls. In some cases they report on the status of controlling chronic conditions, such as hypertension and diabetes.
All of this cumulates to coding that can be largely “subjective”‐‐‐ to the point of E/M coding not being reproducible by multiple. This has left coding administrators scrambling to find counter measures to ensure consistency, correctness, and accuracy. The quest for correct levels of service has led many practices to adopt logics hoping they would work. Many do not.
In the spirt of the S.O.A.P. note, this webinar addresses the most common questions in E/M coding and offers winning strategies as a better solution.
6 Harvard School of Public Health study published September 2010 Health Affairs 7 Under the HITECH Act ‐ clinical quality measure (CQM) components of Meaningful Use Part I and II
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The Truth in SOAPY Coding
Subjective: Opinions
Medical Necessity is a clinically required action – it is the reason for a service and validates the provision of service. It is open for interpretation by all parties involved.
Objective: Facts
Medical Decision Making is a measurement of work. It is defined by the 1995 and 1997 Documentation Guidelines and the Marshfield Clinic audit tool. Due to these guidelines, a coder (or an EMR computer programmer for that matter) is able to calculate a technical level of service. Medical Decision Making is the mathematically formulated result of all documented components of the physician’s service, whether medically needed or not. It is the data driven outcome of a patient visit and not a substitute for determining the appropriateness of the services rendered or the Medical Necessity.
Assessment: Judgements
The best way to stay compliant with Medical Necessity related laws is to think of each element of the patient’s history and physical exam as a separate procedure that should be performed only if there is a clear medical reason to do so. This requires making a clinical judgement. A coder, while better educated than most non‐clinicians, is not able to make that judgment with the certainty of a medical peer.
Plan: Strategies
In an effort to bridge the gap between the clinical savvy of a documenting provider and a clinically untrained coder some coding administrators have exchanged the definition of Medical Necessity with the MDM component of E/M services. This mistake can leave money on the table or result in overpayments.
Understanding the Medical Necessity Problem
CMS 1995 and 1997 Documentation Guidelines are not statutes, and they are therefore interpretive and arguable based on Medical Necessity. From the aspect of Medical Necessity,
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the correct Level of service is determined simply by how sick a patient is. Conditions that pose an immediate threat to life or bodily function qualify for the highest code Level, whereas patients with minor or well controlled problems are at the lowest.
A coder may review a document and establish that a comprehensive service was rendered; however, a medical review may find the same service lacking in necessity. A comprehensive service may be a physician's personal art and style of practice but may not be considered necessary and billable by a majority of his or her peers. For example, a comprehensive history and physical may not be necessary to repeat ten days later to provide an antibiotic for a patient who is now coughing up green phlegm.
This is a problem that only asserts itself in the healthcare industry, but it is rather like pulling in for an oil change… and then also being charged for new wiper blades, fans, and a transmission flush – all before manufacturer recommendation‐‐‐ and without being asked first. Although the services were rendered, and might even be superior to the services by the mechanic down the street…but they were unnecessary per industry standards. Therefore, the customer might complain and feel cheated. In the world of healthcare, payers are required to guard against medically unnecessary services.
Accurate E/M coding requires interpretation of documented medical records‐‐‐followed by code look up and knowledge of coding rules. Certified coders are well equipped to define clinical documentation insufficiency errors and to educate our physicians to improve. However, Medical Necessity issues are a different story. A coder might code correctly per the rules of documentation guidelines ….however, still miscode the service if they incorrectly interpret the severity of the patient’s problem as compared to proper payment.
In its annual financial report, the Department of Health and Human Services disclosed Medicare fee‐for‐service improper payments with E/M codes is a growing problem. Incorrect E/M coding resulted in $1,480,294,722 in overpayments in 2014.8 Problem code 99233 had a 58% error rate in 2014, up from 50% in 2013. Problem code 99214 had a 14.5% error rate in 2014, up from 12% in 2013. Problem code 99232 had a 16.5% error rate in 2014, up from 14.7% in 2013. 20% of initial hospital visits and 13.6% of new office patient visits were incorrectly coded in 2014. This same report found that Medical Necessity errors are twice as common as are coding errors in producing inappropriate payments.
Coders who suspect concerns often stay silent out of fear in questioning a provider’s judgement. These unvoiced concerns may lead to over‐payments and the risk of negative payer audits, which are anticipated to rise due to a projected improper payment rate in 2016 of $45.6B, which is 11.5% of total Medicare Fee‐for‐Service (FFS). While physicians can be intimidating to some coders, the most successful outcomes occur when physicians and coders communicate in a
8 http://www.cms.gov/Research‐Statistics‐Data‐and‐Systems/Monitoring‐Programs/Medicare‐FFS‐Compliance‐Programs/CERT/CERT‐Reports‐Items/Downloads/AppendicesMedicareFee‐for‐Service2014ImproperPaymentsReport.pdf?agree=yes&next=Accept
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concise manner that physicians see as time well spent. To be confident and effective in this type of communication, a coder must first understand the mindset of the physician.
Understanding the Mindset of the Physician
In the pursuit of their career, physicians are taught to assume responsibility for people’s lives and to make decisions with the goal of best patient outcomes. The mind of a physician is constantly prioritizing and classifying patient information in an effort to make the best decision ‐‐ often under extreme intellectual pressure. Physicians invest the majority of their young adult life in learning their craft.
The tenacity needed to stay the course is sometimes associated with a true “calling” to practice medicine, a profound love and respect for humanity and healing. Think shaman, medicine men, or even the patient focused doctors depicted by Norman Rockwell. However, many physicians are startled by an unexpected problem: To comply with the law, they must move their attention away from the patient.
Like elite military forces, physicians are trained to do what most of us cannot. People drawn to careers in medicine have unique personality traits and aptitudes that include high intelligence, compassion, inquisitiveness, and sensitivity to others. But, they are also extremely competitive, driven, and sometimes even obsessive‐compulsive. It is this relentless drive for perfection that hones a physician’s craft. They may not always be likable, but they know how to make life and death decisions independently, often instantaneously, and under immense pressure.
However, nine out of ten doctors discourage others from joining the profession. More than 300 commit suicide each year –making them twice as likely as the general population. A nationwide survey of physicians who practice medicine full time, found 5 in 10 have considered quitting medicine. This is cumulating to a 90,000‐doctor shortage in the United States by 2025.
These findings are difficult to accept when you look at the time and cost associated with becoming a physician. They have to want it very badly. Yet, these same highly motivated physicians are questioning if it is worth it. So why?
Physicians have become the collateral damage of a flawed system. They are being held increasingly accountable for the rising nationwide costs of medical care. Between lawsuits and new regulations, there is a growing social assault on the practice of good medicine, which includes a certain amount of risk‐taking, innovation, and professional autonomy. The problem lies in the unrealistic desire to have it both ways—meaning no possibility of a bad outcome, along with low cost. That these two needs are largely at odds has been ignored for decades. There is no financial incentive for a physician to provide elective services to a high‐risk patient—even if that physician is the best in the world at performing it.
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A recent New England Journal of Medicine study 9 found most physicians will be sued for malpractice during their career. By age 65, more than 75% of physicians in low‐risk specialties such as family medicine and 99% of physicians in high‐risk specialties such as surgery will have been sued. One study reveals that the cost of medical malpractice in the United States is running at about $55.6 billion a year with most of it spent on defensive medicine practiced by physicians seeking to stay clear of lawsuits.10
The problems associated with malpractice are known to include physician health issues. Medical Malpractice Stress Syndrome (MMSS)11 is closely related to traumatic stress disorders, and includes feelings of intense shame, depression, anger, panic, and fatigue.
Physicians are on the front lines of care and are eager to collaborate with others who are interested in helping them tackle the problems that affect them. Effective communication comes from a coder who knows how to quickly discuss issues in a clinically meaningful way the physicians can relate to. This keeps them in the patient‐centric world that is the art of medicine.
Section 1: Coding the Key Components
This webinar will first review the documentation guidelines to ensure that the documentation guidelines are well understood. If you are an E/M documentation guidelines expert, skip to Section 2: Medical Necessity. Viewpoints here are discussed from the standpoint of the 1995 and 1997 Centers for Medicare and Medicaid Services (CMS) Evaluation and Management Documentation Guidelines and, for the purpose of objective consistency, specific logics are primarily based on the same used by the E/M Documentation Auditors’ Worksheet, Marshfield Clinic, available through the Medical Group Management Association (MGMA). Specific payers, including Medicare Carriers, may use different and sometimes varied audit tools logics to gain objective consistency around the 1995 and 1997 Documentation Guidelines. Official provisions are contained in the relevant laws, regulations, rulings and contractual agreements of providers. The CMS 1995 and 1997 Documentation Guidelines are defined methods to determine the correct code for a patient visit. If all work that is documented is Medically Necessary, these guidelines serve to select a correct level of service. In most cases, the E/M code is calculated by following relational rules from 3 parent tables (together called the “Key Components”). Each of 9 Malpractice Risk According to Physician Specialty Anupam B. Jena, M.D., Ph.D., Seth Seabury, Ph.D., Darius Lakdawalla, Ph.D., and Amitabh Chandra, Ph.D. N Engl J Med 2011; 365:629‐636August 18, 2011 10 Harvard School of Public Health study published September 2010 Health Affairs 11 MMSS has been documented since 1998
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these 3 tables has child variables that are considered by themselves and then together before selecting the final E/M code. Evaluation and Management (E/M) Coding Components:
1. History ‐ Hx
A. History of Present Illness (HPI) B. Review of Systems (ROS) C. Past, Family and Social History (PFS)
2. Examination ‐ PE 3. Medical Decision Making ‐ MDM
A. Number of Diagnoses and Treatment Options B. Amount and Complexity of Data C. Overall Risk
Other E/M service components that are considered:
counseling; coordination of care; nature of presenting problem; and time
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History (Hx)
There are history sub components used to measuring the amount of physician’s work in taking a patient’s medical history. These are: History of Present Illness (HPI), Review of Systems (ROS), and Past, Family, Social History (PFS).
HISTORY OF PRESENT ILLNESS (HPI)
The patient’s EXPLANATION of what brought them to the PHYSICIAN
LOCATION: For example “chest” pain, sore “knee”, etc.
SEVERITY: A statement of degree or measurement regarding how “bad” it is… that it is improved, it is extreme pain, “Blood Sugar is 200,” feeling “better,” pain is bad enough “that the patient can’t sleep” etc.
TIMING: A measurement of when or at what frequency; i.e. “intermittent,” “constant,” in the “morning,” lasted “5 minutes,” “occasional,” “on and off,” etc.
ASSOCIATED SIGNS AND SYMPTOMS: Any associated or secondary complaints.
MODIFYING FACTORS: Anything that makes the problem better or worse, a factor that changes, improves, or alters the problem. For example, improved “with Tylenol,” worse “when standing,” better “when resting,” “calms down when mother feeds her”
CONTEXT: What the patient was doing, the environmental factors/circumstances surrounding the complaint, for example, “while sleeping,” “MVA,” “slipped and fell,” after “eating peanuts,” “while dusting,” “when arguing with his wife,” etc.
DURATION: A measurement of time regarding when the complaint first occurred. For example, began “in childhood,” “since 1995,” first noticed “2 weeks” ago, “symptoms x 3d,” etc.
QUALITY: Any characteristic about the problem and/or expresses an attribute. For example: how it looks or feels; for example. “green” phlegm, “popping” knee, “dull” ache, “sharp” pain, “metallic” taste, etc.
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REVIEW OF SYSTEMS (ROS)
The ROS is an account of body systems obtained through a series of questions seeking to spot signs and/or symptoms that the patient may be experiencing or has experienced. This query is made by the physician and/or the staff (verbally or via patient intake forms) in order to best define the patient’s total problem. It includes defining the need for expanded examination, testing, possible affected management options, etc. The review may be about the system(s) directly related to the problem(s) identified in the HPI and/or additional body systems.
CONSTITUTIONAL: Patient answers about general constitutional signs or symptoms: Examples ‐ fatigue, general appearance, exercise tolerance, fever, weakness, impaired ability to carry out functions of daily living, etc.
RESPIRATORY: Patient answers about signs or symptoms of the respiratory system: Examples ‐ cough, phlegm, wheeze, SOB, rapid or difficult breathing, chest pain on deep inhalation, etc.
INTEGUMENTARY: Patient answers about signs or symptoms of the skin or breast: Examples ‐ skin reactions to hot or cold, itching, rash, changes in scars, moles, sores, lesions, nail color or texture, changes in the color of the skin, bruising, breast pain, tenderness, swelling, lumps, nipple discharge or changes, etc.
PSYCHIATRIC: Patient answers about signs or symptoms of the psychiatric condition: Examples ‐ depression, stress, excessive worrying, suicidal thoughts, persistent sadness, anxiety, lost pleasure from usual activities, energy loss, physical problems not responding to treatment, restlessness, irritability, excessive mood swings, etc.
EYES: Patient answers about signs or symptoms of the eye: Examples ‐ use of glasses, discharge, itching, tearing or pain, spots or floaters, blurred or double vision, twitching, light sensitivity, visual disturbances, swelling around eyes or lids, etc.
GASTROINTESTINAL: Patient answers about signs or symptoms of the GI system: Examples – heart burn, indigestion or pain with eating, burning sensation in the esophagus, frequent nausea and/or vomiting, changes in bowel habits or stool characteristics, abdominal swelling, diarrhea or constipation, use of digestive aids or laxatives, etc.
NEUROLOGICAL: Patient answers about signs or symptoms of the neurologic system: Examples ‐ numbness, tingling, dizziness, syncope or unconsciousness, seizures, convulsions, attention difficulties, memory gaps, hallucinations, disorientation, speech or language dysfunction, tremor or paralysis, inability to concentrate, sensory disturbances, motor disturbances including gait, balance, coordination, etc.
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ALLERGIC/IMMUNOLOGIC: Patient answers about signs or symptoms of the allergic/immunologic system: Examples ‐ allergies to medicine, foods, environmental or other substances, frequent sneezing, hives and/or itching, chronic clear PND, conjunctivitis, chronic infections, etc.
ENT: Patient answers about signs or symptoms of the ears, nose of throat: Examples ‐ Ears: sensitivity to noise, ear pain, vertigo, ringing in the ears, “fullness” in the ears, ear wax abnormalities, etc. Nose: nosebleeds, post nasal drip, nasal drainage, impaired ability to smell, sinus pain, snoring, difficulty breathing, sinus infections, etc. Throat/Mouth: sore throats, mouth lesions, teeth sensitivity, bleeding gums, hoarseness, change in voice, difficulties swallowing, changed ability to taste, etc.
GENITOURINARY: Patient answers about signs or symptoms of the GU system: Examples ‐ painful urination, urine color, urinary patterns, hesitance, flank pain, decreased or increased output, dribbling, incontinence, frequency at night, genital sores, erectile dysfunction, irregular menses, toilet training or bed‐wetting, etc.
ENDOCRINE: Patient answers about signs or symptoms of the endocrine system: Examples – Blood Sugar readings at home, changes in height and/or weight, increased appetite or thirst, intolerance to heat or cold, etc.
CARDIOVASCULAR: Patient answers about signs or symptoms of the cardiovascular system: Examples – heart rate, chest pain, tightness, numbness, palpitations, heart murmurs, irregular pulse, color changes in fingers or toes, edema, leg pain when walking, etc.
MUSCULOSKELETAL: Patient answers about signs or symptoms of the MS system: Examples ‐ cramps, twitching or pain, difficulty walking, running or participation in sports, joint swelling, redness or pain, joint deformities, stiffness, noise with joint movement, etc.
HEMATOLOGIC/LYMPHATIC: Patient answers about signs or symptoms of the hematologic/lymphatic systems: Examples ‐ easy bruising, fevers which can come and go, swollen glands, night sweats, itching without rash, excessive bleeding, unusual bleeding, etc.
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PAST, FAMILY & SOCIAL HISTORY (PFS)
PAST HISTORY: The patient's past experiences with illnesses, operations, injuries and treatments, and medications. If a patient presents for follow‐up on a chronic condition both HPI and Past History would be considered. Positive findings of past diagnoses and current medication discovered on ROS would be considered.
FAMILY HISTORY: A review of medical events in the patient's family, including age at death, diseases which may be hereditary or place the patient at risk.
SOCIAL HISTORY: An age‐appropriate review of past and current activities, for example occupation, smoking, alcohol use (EtOH), sexual activity, marital status, etc.
Common Myths related to the History Component:
Myth: There must be a Chief Complaint (CC) separately documented Fact: The reason for the encounter must be clearly stated. The CC, ROS and PFSH may be listed as separate elements of history, or they may be included in the description of the history of the present illness. Myth: An ‘unobtainable history’ is automatically equal to a comprehensive history. Fact: If documentation shows that the provider is unable to obtain a history from the patient or other source (for example, “patient has difficulty with speaking English and presents today without a translator”, patient is “not conscious”, etc.). The overall level of Medical Necessity and the work of the provider are not penalized by the fact that the physician could not obtain a history from the patient. A physician must document the attempted history and/or the reason for not obtaining one. If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history. Myth: When an established patient has three chronic conditions, the code is always a 99214. Fact: First, for billing Medicare, a provider may choose either version of the documentation guidelines, not a combination of the two, to document a patient encounter. However, beginning for services performed on or after September 10, 2013
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physicians may use the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 guidelines to document an evaluation and management service.12 Second, the documentation guidelines must be followed for all of the E/M components (including HPI, ROS and PFSH, Exam, and Medical Decision Making) Lastly, services must be medically necessary, and related to the treatment of the provider. Myth: The same documentation can “count” twice under HPI and ROS. Fact: HPI is a patient accounting of why they are seeking medical care, while ROS is a query of symptoms so that a provider might better understand the patient’s problems. There is a fine line between the signs and symptoms that patient shares in the HPI and those obtained via the ROS. The ROS is a distinct review of a system. For example: If the documentation reads: “Patient states that her hip has been painful” credit is not given to both the HPI “location” and to the musculoskeletal (MS) review of system. If, on the other hand, the documentation reads: “Patient states that her hip has been painful. She denies any other MS complaint,” there is a distinct component of both the HPI and also a separate MS review of system. Myth: The History component, with three well defined subcomponents, is objective and easily reproducible by varied coders and auditors. Fact: The History component is riddled with subjective terms. There are times when two separate audits of the same service may produce different results and neither party can be proven technically or medically wrong. Reviewer A may argue with Reviewer B that an element of (HPI) is a “quality” versus an “associated sign or symptom”, or other element. Reviewer B may state that the documented “NKDA” constitutes an element of ROS or conversely an element of Past history. Any free‐form text is to some degree interpretive. This holds true with physicians’ notes. Since coding relies on counting general elements, the reproducible interpretation requires consistency, citable references, a logical argument and ‐ ultimately ‐ Medical Necessity.
Myth: My patient history form is updated at every visit, so my history is always comprehensive. Fact: ROS and PFS History taken from an earlier encounter can be and updated without complete re‐documentation. It is necessary for the provider to indicate the new status of the history and to leave an audit trail regarding where the original documentation is stored. Physicians should be cautioned that, although a comprehensive service may be performed, a comprehensive service is not always medically necessary or billable. Unless the encounter is for a preventive medical history and physical, it is important to ensure that physicians understand that the Chief Complaint (CC) must be readily identifiable. This is the first step in establishing Medical Necessity.
12 http://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/PhysicianFeeSched/Downloads/EM‐FAQ‐1995‐1997.pdf
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Examination (PE)
There are sub components to measuring the amount of physician’s work in performing a patient exam. These are defined by two different rule tables: The 1995 Documentation Guidelines and the 1997 Documentation Guidelines. Physicians are allowed to choose which set of rule tables to use. THE CMS 1995 DOCUMENTATION GUIDELINES13
Body Areas:
Head/Face Neck back abdomen genitalia chest/axillae/breast
Systems:
Constitutional Eyes Ears, nose, mouth and throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic, lymphatic immunologic
THE CMS 1997 DOCUMENTATION GUIDELINES The guidelines use the same body areas and systems but expand them for specialty specific use. Please review the official guidelines for details. 14
13 https://www.cms.gov/Outreach‐and‐Education/Medicare‐Learning‐Network‐MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf 14 https://www.cms.gov/Outreach‐and‐Education/Medicare‐Learning‐Network‐MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf
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A Common Myth related to the Examination Component: Myth: Documentation in EMRs must support the 1997 guidelines. Fact: Many EMR use the 1997 documentation guidelines but these are not required. Effective documentation is clinically relevant, easy to navigate, and provides a solid record of the patient problem and their care. The best defense for correct coding is to provide the physician with insight on the clinical relationships in proper code selection. The silver bullet to proper code selection is to empower the physician with the knowledge of that medical need is supported by each Level of service. And, to document what is relevant only to support the patient care and the subsequent coding. No more. No less. Most payers will allow the 1995 or 1997 Documentation Guidelines (DGs) to be used in code selection and a physician should be familiar with both. Strictly from a coding perspective, the examination component is the least subjective aspect of the documentation guidelines with only two readily identifiable grey areas associated with the ’95 DGs. These two subjective areas are: 1. The difference between an Expanded Problem Focused exam and a Detailed exam: The ‘95 DGs distinguish between the two levels only in that they both require at least 2 body areas and/or systems and that one is a “limited exam” and the other is “extended”. 2. The definition of a Comprehensive single system exam by the ‘95 DGs are distinguished only that the single system exam is “complete” (without definition). Payer rules sometimes vary. For example, Novitas Solutions uses the 4x4 method. This method requires 4 elements examined in 4 body areas or 4 organ systems to satisfy a detailed examination; however, less than such can be a detailed exam based on the reviewer’s clinical judgment.
Medical Decision Making (MDM)
THE NUMBER OF DIAGNOSES AND MANAGEMENT OPTIONS
The Number of Diagnoses and Management Options is based on the relative Level of difficulty in making a diagnosis and by the status of the problem (controlled versus worsening.) Usual indicators include the following:
Problems that are new to the patient or that the physician is seeing in this patient for the first time
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Seeking additional work‐up such as a consultant’s opinion Ordering additional work‐up such as diagnostic tests to confirm or to rule out the
suspected diagnoses and/or differential diagnoses for the patient
AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWED
The Amount and Complexity of Data to Be Reviewed is measured by the need to order and review tests and the need to gather information and data. Planning, scheduling, and performing clinical Labs and tests from the CPT® Medicine and Radiology sections are indicators. The need to request old records or to obtain additional history from someone other than the patient (for example, family member, care giver, teacher, etc.) is credited in this section. Also documented are discussions with the performing physician about unusual or unexpected patient results. If a physician needs to make an independent visualization and interpretation (for example, MRI film, gram stain, etc.) and he or she is not billing separately for this service, it too is credited to this component of code selection.
RISK SIGNIFICANT COMPLICATIONS, MORBIDITY, AND/OR MORTALITY
Risk is measured based on the physician’s determination of the patient’s probability of becoming ill or diseased, having complications, or dying between this encounter and the next planned encounter. The nature of the presenting problem and the urgency of the visit, comorbid conditions, as well as the need for diagnostic tests or surgery, are indicators of risk.
A Common Myth related to the MDM Component: Myth: I can use the level of the MDM to validate the Medical Necessity of the service. Fact: Using the MDM to validate the medical need for a service is not appropriate and will often result in false positives or under‐coding. This will be discussed in detail later in this webinar.
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Putting it together
View the form in Appendix A to visualize typical code selection for Outpatient visits (based on combining each of the key components).
A Common Myth related to E/M Coding: Myth: My EMR suggested the code, which validates that the level of service is correct.” Fact: EMR do not measure Medical Necessity and therefore can produce false positives or under‐coding. Myth: I document the total time and counseling at 50%‐‐‐therefore the service level is always correct. Fact: In the case of visits which consist predominantly of counseling or coordination of care, time is the key or controlling factor to qualify for a particular level of E/M service only if documentation describes the counseling and/or activities to coordinate care. That activity must be medically needed. No payments are allowed for services solely humanistic in nature, such as spending time with a grieving family member are allowed.
Section 2: Medical Necessity
Medicare (and many other insurance plans) may deny payment for a service that the physician believes is clinically appropriate, but which is not reasonable and necessary. To distinguish between "clinically appropriate" and "medically necessary" is a fine line. There are many definitions:
Per the Social Security Act 42 U.S.C. § 1395y(a)(1)(A), Medicare only pays for medical items and services that are "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member", unless there is another statutory authorization for payment.
Medicare has a number of policies, including National coverage determinations (NCDs) and Local Coverage Determinations (LCDs). Section 522 of the Benefits Improvement and Protection Act (BIPA) defines an LCD as a decision by a Medicare carrier whether to cover a particular service in accordance with the Social Security Act.
The AMA definition of “Medical Necessity” is: “Health care services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing,
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or treating an illness, injury, disease or its symptoms in a manner that is: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate in terms of type, frequency, extent, site and duration; and (c) not primarily for the convenience of the patient, physician, or other health care provider.”
What is common acknowledged as “generally accepted”?
Standards that are based on credible scientific evidence published in peer‐reviewed, medical literature generally recognized by the relevant medical community;
Physician specialty society recommendations;
The views of physicians practicing in the relevant clinical area.
When dealing with E/M codes, there are few diagnoses that concretely fall into any of the 5 Levels of care (Outpatient) or 3 Levels of care (Inpatient). Therefore there are no NCDs or LCDs to direct a coder to an ICD‐9‐CM code that is unarguably correct.
Section 3: Evidence Based Guidelines
Let’s begin with the question of: How sick does a patient have to be in order to fall into one of the 5 Levels of care (Outpatient) or 3 Levels of care (Inpatient)? We know it is imperative to answer this correctly. Medicare contractors and carriers may identify fraud or abuse in situations where they determine Medical Necessity is not met…yet the definitions are broad, subjective, and ambiguous.
In an effort to provide reproducible coding results, utilization management, criteria for hospital admission, and to authorize payments, there are several references that are commonly employed as a “best practice”. Industry standard guidelines for evidence based determinations of Medical Necessity by payers include MCG (formerly Milliman Care Guidelines)® by MCG Health LLC of the Hearst Health network, and InterQual® by McKesson. InterQual® provides a structure of criteria for "severity of illness (SI)” and "intensity of service (IS)" to help determine if a patient is sick enough to be admitted as an inpatient. These standards are helpful insights, however are incomplete substitutes for the clinical judgment of the physician. This is because living beings are still not fully explainable by science. It is the art of practice ‐‐‐the interchange between training, experience, and intuition that produces the most effective medical outcomes. Only the treating physician is skilled at knowing what is needed.
While best practices should be implemented with such things as medical equipment usage, preventive measures, medication dosages, and safety guidelines …these are ancillary to an active patient problem ‐‐‐which is the nature of the E/M code ‐‐‐ active problems rely on forces out of complete human control…which makes Medical Necessity a very difficult thing to define.
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In an effort to find consistency in the coding of E/M services based on Medical Necessity, common (albeit imperfect) approaches are to use the Nature of the Presenting Problem as defined by the CPT®, and the Medical Decision Making (MDM) component of the CMS 1995 and 1997 Documentation Guidelines to estimate a patient’s probable medical needs. They don’t replace clinical judgement. Both tools have benefits and challenges.
Nature of the Presenting Problem and Medical Necessity
The CPT® describes the nature of the presenting problem to assist the physician in determining the appropriate Level of E/M service. It prompts the reader that the extent of the examination is dependent on clinical judgment per on the nature of the presenting problem(s). It describes five types of presenting problems:
1. Minimal: A problem that might not require the presence of the physician, but service is provided under the physician's supervision.
2. Self‐limited or minor: A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status OR has a good prognosis with management/compliance.
3. Low severity: A problem where the risk of morbidity without treatment is low; there is little to no risk of mortality without treatment; full recovery without functional impairment is expected.
4. Moderate severity: A problem where the risk of morbidity without treatment is moderate; there is moderate risk of mortality without treatment; uncertain prognosis OR increased probability of prolonged functional impairment.
5. High severity: A problem where the risk of morbidity without treatment is high to extreme; there is a moderate to high risk of mortality without treatment OR high probability of severe, prolonged functional impairment.
Further, CPT® provides clinical examples in its Appendix C to describe presenting problems that are frequently seen with a Level of service with a given specialty. The language is broad, interpretive, and warns: “Of utmost importance, is that these clinical examples are just that: examples. A particular patient encounter, depending on the specific circumstances, must be judged by the services provided by the physician….”
This approach is not wholly objective or unfailingly reproducible. Therefore, even after typically twelve years of school, four years of college, four years of medical school, residency, fellowship, licensing and certification ‐‐‐ many physicians are not able to use these definitions comparatively with the patient’s condition to confidently determine the correct Level of service.
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MDM and Medical Necessity
To solve this problem, some physician practices have adopted the MDM component of the E/M Documentation Guidelines to classify Medical Necessity. Does this work better? Let’s take a closer look to determine this by reviewing the form referenced in this workbook under Appendix A. This form is an audit tool based on the “Marshfield Clinic model”. It is an industry accepted standard that was developed jointly between the Marshfield Clinic and CMS in the 1990s as a method for Medicare Carriers to create reproducible audit results across many reviewers by better defining the key components. The form has three components displayed as tables. The component on the bottom of the page is referenced as MDM ‐Medical Decision Making. The MDM table requires two of three columns to line up with the row that classifies the MDM. If all three columns don’t line up, the column in the middle of the three rows is selected.
1. In the header of the first column, called “Number of Diagnoses and Management Options”, we see that not all diagnoses are “equal”‐‐‐ some require more work than others based on the type of diagnosis, not just the number of diagnoses. All diagnosis values are summed together to select a row in that column on the table.
2. The second column captures the work associated with compiling and analyzing outside information, from various sources, to obtain relevant facts about the patient and his or her condition. These values are summed to select a row in that column on the table.
3. The last column works to qualify the medical risk that the patient faces of complications, morbidity, and/or mortality. It is an abbreviated version of the CMS table of Risk.15 Because the determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk. The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one. The row containing the highest value, by example, is selected in that column on the table.
Example:
1. Number of Diagnoses and Management Options: A patient with a new problem is diagnosed during the same encounter with a problem that is more severe than a minor problem. This is worth “3” on the MDM scale of Number of Diagnoses and Management Options.
15Page 37 Evaluation and Management Services Guide http://www.cms.gov/Outreach‐and‐Education/Medicare‐Learning‐Network‐MLN/MLNProducts/downloads/eval_mgmt_serv_guide‐ICN006764.pdf
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2. Amount/Complexity of Data: The physician ordered and reviewed a medical test in his office. This is worth “1” on the Amount and Complexity of Data
3. Overall Risk: The problem requires a prescription medication, which the physician orders.
MDM ‐ Medical Decision Making ( 2 of 3)
Number of Diagnoses and Management Options
AMOUNT/COMPLEXITY OF DATA:
OVERALL RISK: Type LEVEL (x)
1
1 SF 1 & 2
L 3
3
Rx drug management M
4
H 5
Clinically Illustrated Example: The patient has sudden central vision loss and is sent to a Retina specialist for diagnosis and treatment. A history is obtained and both eyes are thoroughly examined. Several optic tests are used, including an Amsler grid and optical coherence tomography. A new diagnosis is made by the physician of sub choroidal neovascularization for which he recommends a monthly injection of Avastin. He explains the risk of the injections, and shares with the patient the risk of continued vision loss with or without the injection. The patient elects to have the injection the same day. Follow‐up in 3 weeks for evaluation and repeat injection.
In the clinically illustrated example, the patient was given the classification of a Moderate Level of MDM. If you are using the MDM as a driver in terms of code selection, this is a Level Four new or established Outpatient patient visit.
So, the answer is a Level Four, right? Perhaps, but let’s take a deeper look…
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1. What if the patient was sent by the physician to be worked up at an outside facility, and the patient returned with the test results for final diagnosis with the results on the same day? The patient’s medical need is not different, but this would now be a “4”, not a “3”, on the MDM scale of Number of Diagnoses and Management Options.
2. What if the provider decides that the risk of the problem is not classifiable as that associated with Prescription drug management, but rather with the risk associated with an acute illness or injury that poses a threat to bodily function (in this case vision)? This would bump the office visit classification to a High Level of MDM.
In terms of code selection, this would now support a Level Five new or established Outpatient patient.
The clinical example below further demonstrates the subjectivity (and possible lack of reproducibility among coders) associated with the MDM method of code selection:
Alternate Clinically Illustrated Example:
45‐year‐old, otherwise healthy male returns for a non‐resolved problem first seen 5 days ago ….a cough x 7 days which is now productive. This patient is also under the physician’s care for well controlled hypertension and hypercholesterolemia. The diagnosis today is URI. She reviews all the patient’s current medications and adds to it by ordering an antibiotic. No follow‐up requested.
Under this case, the MDM still objectively measures by documentation to a Moderate Level, which is what is needed for a visit Level Four. Some medical peers would argue that a patient seen in follow‐up for an antibiotic is medically indicated as Low or Straightforward, and that a Detailed History and Examination would not be needed. Therefore the coding would more accurately support a visit Level Two or Three. The code values require a combination of the coding component tables, therefore reviewing the MDM alone may not be fully conclusive. Like the Nature of the Presenting Problem, the MDM component, used to classify Medical Necessity, is not wholly objective or unfailingly reproducible. While both of these are helpful, they are not the silver bullet of proper code selection.
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Section 4: Five Most Deadly E/M Coder Mistakes
Mistake Number 1: Believing that an Audit tool can replace a physician in Medical Necessity determinations.
It takes on average 40,000 hours of training ‐‐‐that’s 20 years of full‐time work‐‐‐ to become a practicing medical doctor. 16 Only 20% of applicants are accepted to medical school and from them 10% will not graduate. There are no academic, physical, or mental concessions to excellence. Only the best of the best can be called a physician. Due to the repetitive nature of documentation
review in coding, a coder is well practiced in the analysis of the levels of service compared to the documented diagnoses. They are often able to identify possible outliers and cases when Medical Necessity might be questioned. Responding to that concern by reviewing it with the treating physician, or a medical peer of the treating physician, is an important part of correct coding.
Mistake Number 2: Ignore why the topic of payment is a source of physician frustration The most effective communication comes from coders who truly sympathize with the frustrations of physicians. Coders sometimes need to share the bad news that a service is not payable or payable at the rate the physician expected. Fewer than half of primary care physicians (47%) and half of specialists (50%) believe that they are fairly compensated. 17
16 The Deceptive Income of Physicians by Benjamin Brown, M.D. https://benbrownmd.wordpress.com/ 17 Medscape Physician Compensation Report 2015 Carol Peckham | April 21, 2015
A coder, while better educated than most
non‐clinicians, is not able to make a medical
judgment with the certainty of a medical
peer. Only a medical peer of the treating
provider has the authority to define the
medical needs of the patient.
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How Physicians are Paid
Medicare’s allowed payments for E/M levels are based on a Fee for Service (FFS) payment model, which is normally less than a physician’s usual charge. Relative Value Units (RVU) are used to calculate the Physician Fee Schedule. 18 The Physician Work RVU is based on what the government estimates is the necessary time and complexity of providing a service. To generate income, a physician must be actively providing a medically needed, or allowed, service. Since not all services are deemed “necessary,” many have no Physician Work RVU. This translates to physicians spending time providing services that will not be paid for. The last thing many of them want to hear is that there is no payment for the time required. There are also no payments allowed for physician time in meeting required documentation guidelines, which can take 3 or more hours per day19.
The formulaic approach of setting payment FFS rates for physician services using the Sustainable Growth Rate (SGR) was replaced in 2015 by Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA provides automatic, annual payment increases of 0.5% for all doctors through 2019. Payment rates stay frozen at 2019 levels through 2025. Beginning in 2019, no automatic increases will be provided but doctors’ respective rates will be altered with bonuses or penalties based on their performance under a Merit‐Based Payment Incentive System (MIPS) or through an Alternative Payment Model (APM) program. This is meant to compel physicians to shift from fee‐for‐service to “value based” medicine. In inflation‐adjusted terms, these very small annual increases constitute reductions in physician payment rates. Even before negative incentives, which will be as much as ‐9% by 2022, Medicare’s pay to physicians will not keep pace with their practice costs in the long run.20
Mistake Number 3: Fail to communicate quickly, concisely and in terms a physician relates to
18 Resource Based Relative Value Units (for Physician Work, Practice Expense, and Malpractice) where first developed by the government under the Omnibus Budget Reconciliation Act of 1989 19 The average U.S. doctor spends 16.6 percent of his or her working hours on non‐patient‐related paperwork, time that might otherwise be spent caring for patients. International Journal of Health Services 2014. Steffie Woolhandler and David Himmelstein and the Average Physician works 59.6 hours per week ‐ Anim M, Markert RJ, Wood VC, Schuster BL. Physician practice patterns resemble ACGME duty hours. Am J Med 2009;122(6):587-93. 20 4/9/2015 Memo from DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services OFFICE OF THE ACTUARY SUBJECT: Estimated Financial Effects of the Medicare Access and CHIP Reauthorization Act of 2015 (H.R. 2)
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Provide the documenting provider with a clear understanding of code selection related to Medical Necessity and the rest is…as they say: History (and Exam and MDM and the documentation guidelines thereof). When a provider is confident that their coding is for services that are consistent with medically‐accepted standards of practice compared to a Level of service, subjectivity is shored up. The chart in Appendix B is a visual tool that can help facilitate communication. It not all‐inclusive and should be used for discussion purposed only. Medical Necessity criteria is best explained in laymen’s terms that allows the physician to define the detail using their own advanced knowledge. For example, in the subsequent visit hospital setting, it is reasonable to expect higher levels of history and physical exam to be needed in the days immediately following a hospital admission. These higher levels most likely would not be medically necessary when the patient is stable and improving, particularly in the visits on days preceding discharge from the hospital. Simply stated, the provider needs to understand that a Level One hospital visit is for a patient who is getting better, a Level Two hospital visit is for a patient who isn’t getting better, and a Level Three for a patient who is rapidly declining. Once the provider is able to classify the patient into one of these Levels, the only thing left to ensure is that the documentation guidelines are met for the appropriate level. If a provider feels confident that a non‐friendly peer would have to agree with him or her, the code is correct. Likening the five base levels of service to the same logic in the Wong‐Baker children’s pain chart can be helpful to start the conversation. Many will laugh when you say: “Doctor, this is to represent the patient’s pain….not yours in the documentation process!” Levity aside, most physicians readily understand that Levels Three to Five are reserved for actively “sick” patients (Levels One to Three in the hospital setting) and that the lower levels of service are reserved for patients with minor and/or well controlled conditions. The approach here is to ask the physician about a common patient problem that he or she treats, and then to ask him or her what factors would make them more concerned about the patient or less concerned about the patient. Typically, the greater the concern, the higher the level of service.
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Sick: Level Three Outpatient (Level One Inpatient) The lower level of service represented by a “sick” patient usually consists of a presenting problem that may be 2 minor, 1‐2 stable chronic, 1‐2 acute uncomplicated conditions. Typically the diagnosis is known and/or made during the encounter and future follow‐up is often classifiable as routine. Usually, the patient is clinically responding as expected to treatment or is following a defined course.
Patient returns with productive cough x 10 days for antibiotic
Patient with choroidal revascularization to assess efficacy of anti‐VEGF
Patient with cystocele not requiring treatment
Return visit for patient with worsening plantar fasciitis
Patient with URI
Patient with well controlled hypertension and hypercholesterolemia
Sicker: Level Four Outpatient (Level Two Inpatient) The moderately high level codes represented by a “sicker” patient that has the physician concerned. It might be a comorbid problem, or complication that is causing the additional concern. It might be that the patient is failing to respond as expected to treatment. The presenting problem may be 2‐3 stable chronic, chronic exacerbated, acute with systemic symptoms or injury. Typically the diagnosis is known but worsening/complicated or yet unknown and further testing is required in order to make a final diagnosis. A key clue to Level Four is the concern of the provider – which often results in future follow‐up that is classifiable as routine or sooner.
Patient with cough and chest pain x 2 weeks sent out for CXR
Patient with choroidal revascularization on anti‐VEGF but with new central vision loss
Patient with cystocele and stress incontinence and to discuss options
Patient in follow‐up with stable angina, not tolerating medication
Patient requiring closed treatment of new metatarsal fracture
Patient with back pain and new vaginal discharge for STD testing
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Patient with well controlled asthma, hypertension, and hypercholesterolemia
Sickest: Level Five Outpatient (Level Three Inpatient) The highest level of service represents a patient with a worst‐case prognosis. The presenting problem may be an illness or injury that poses a threat to life or bodily function. Typically the patient’s situation is serious, imminent, and uncertain.
Examples:
Severe exacerbation of CHF
Hospice patient with death imminent
Patient presents confused in diabetic ketoacidosis
Morphine Sulfate IVP ordered for chest pain not controlled by Nitro
Patient brought by parents after a failed suicide attempt
Patient post fall on ski slopes with extradural hematoma
Mistake Number 4: Not Asking the Right Questions The best way to communicate with physicians is to ask questions that allow them to draw their own conclusions. Teaching a physician about the code levels is like giving the natural‐born artist a brush, paint, and canvas‐‐‐explaining the basic use for each and getting out of the way. They are able to produce the art themselves once they have the basic tools and know what they are used for. To have a better understanding of the physician’s standpoint, it is important for you to ask questions. Make sure you ask questions that move the discussion forward and not questions that only promote a “yes or no” answer. Questions like “what made you more concerned about this patient encounter than the other one?” will have a better communication impact than asking “did you understand what makes this a Level Four?” Your goal is to promote effective communication and asking well‐designed questions will help you in achieving this goal. Sample questions include:
Tell me about your worst patient case‐‐‐how did the patient present? Was the patient at risk for threat to life or bodily function?
Would a non‐friendly peer agree that the patient was “sicker” ‐‐‐albeit not at imminent risk for threat to life or bodily function?
Is it reasonable that this “sicker” patient needs to be seen in follow‐up shortly?
What lesser but related problem would have you less concerned?
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Effective communication includes the way we listen to physicians. Asking questions and listening to the answers will help you steer the rest of the conversation. Sometimes, people are not listening because they are thinking about what they are going to say when the physician stops talking. When physician is talking, give your full attention to what the he or she is saying. Only by listening will coders have a better chance in verifying if the information we are providing was successfully received.
It can be helpful to plan out what you are saying ahead of time. Having a clear idea of what you want to say will help you in presenting a well‐structured and trustworthy message. It will also prevent you from passing a confusing message to the physician. In these cases, it is very helpful to have the actual documentation you’d like to discuss handy.
Example:
“Doctor, I have reviewed this patient encounter, and your superbill. You selected a Level Four. You saw this patient 1 month ago for premenopausal syndrome mood swings and prescribed Zoloft. You saw her again today in follow‐up. You repeated a comprehensive history and exam. She is doing well with reduced mood swings and will continue with sertraline 50MG. You ask to see her back in 12 months or PRN if there is a change. I am concerned that an auditor might question the higher level of service being billed because you are not seeing her back for 12 months and there are no other problems documented. What was it about this patient that put her at a higher level of concern to be coded at a Level Four?”
It is also important to watch your body language while talking with the physician. Communication is not just words: a lot of communication comes through non‐verbal communication. The following body language mistakes to avoid are:
Arms crossed: You are defensive.
Constant eye contact: You are aggressive.
Fidgeting: You are bored or impatient
Hunched Posture: You lack confidence.
Little eye contact: You have low interest or lack confidence.
Rubbing your nose or mouth: You are lying or unsure of yourself.
Tapping: You are impatient or nervous.
Touching your face or hair: You are timid.
Watching the time: You are anxious to move on to something else.
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Don’t generalize information. Personal information is most meaningful. If you notice a pattern of possible Medical Necessity concerns, run a productivity report of the last one to three months of outpatient visits that shows the top diagnosis codes used and the frequency of their use. The best approach is to conduct a physician interview to discuss what would make the physician more or less worried about a patient.
Example Top Diagnoses Report (Primary Care Office)
786.50 Chest Pain 789.00 Abdominal Pain 845.00 Sprained Ankle 244.9 Acquired Hyperthyroidism 278.00 Obesity 346.90 Migraine 382.00 Acute suppurative otitis media 428.0 CHF 465.9 Acute URI 493.90 Asthma 626.2 Excessive Menstruation 780.60 Fever
Sample Interview Questions based on top diagnoses seen by physician:
Do any of these pose a threat to life or bodily function within 24‐48 hours? (Level Five)
Under what circumstances would you need to see a patient back in follow‐up sooner than is typically required? (Level Four)
Which patient problems have you very concerned for the patient but do not pose an imminent threat to life or bodily function? (Level Four)
Which of these can commonly be diagnosed on the first encounter and do not usually require a prompt follow‐up? (Level Three)
Which of these problems might you bring a patient back for a quick check, and on doing so discover no further medical management is needed? (Level Two)
Which of these diagnoses are self‐limited and require reassurance with no active medical management? (Level One)
Would a non‐friendly medical peer agree with your decisions?
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Mistake Number 5: Failure to Create Best Practices for your Coding Team and
Documenting Providers
Once you have inspired physicians with a clear vision of the clinical relevance to E/M levels, create policies that can be used throughout the organization to ensure speed and consistency*.
These should include:
Guidelines for clinical conditions that demonstrate probable service levels
Polices that protect against errors
Policies to do the ethical thing
Policies that can be understood and followed
You should also have physician policies for effective communication in their documentation. For example, when documenting a patient’s condition in hospital rounds, “patient improving” might be more concise than “patient stable”. “Stable” indicates that the patient is in good enough condition to be discharged.
*The risk of formality without buy‐in is fraud. Don’t create policies that you can’t or won’t follow.
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About the Author:
Stephanie Cecchini, CPC, CEMC, CHISP, AHIMA Approved ICD‐10 Trainer, VP of Products at AAPC
Stephanie is LION (Linkedin Open Network). Please feel free to connect with her at: http://www.linkedin.com/in/stephaniececchini
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Appendix A: E& M Code Selection (Reference Sheet)
New Out PT 9920(X): Default to the lowest LEVEL identified by the Hx, Ex, & MDM. Est OT 9921(X): Use the LEVEL identified by the best 2 of 3 on the Hx, Ex, & MDM (Hx History ( 3 of 3)
HPI: location quality severity timing
context mod factor duration asso. S&S
ROS: constit eyes ENMT cardio respir
GI GU MS skin
neuro psych endo hemat/lymph allerg/immuno
PFSH: past family social Type
New Out Pt LEVEL (x)
Est Pt LEVEL (x)
1 0 0 PF 1 2
1 1 0 EPF 2 3 4 (or 3 chronic) 2 1 D 3 4 4 (or 3 chronic) 10 3 or2+ (Est.) C 4 & 5 5
MDM ‐ Medical Decision Making ( 2 of 3)
95 ExamMM Body Areas:
head/face neck back abdomen genitalia chest/axillae/breast each extremity
Systems: constitutional eyes ENMT cardiovascular respiratory gastrointestinal genitourinary
musculoskeletal skin neurologic psychiatric hematologic, lymphatic immunologic
Number of Body Areas/Systems Examined
Type
New Out Pt LEVEL (x)
Est. Out Patient LEVEL (x)
1 PF 1 2
2‐7 limited EPF 2 3
2‐7 extended ( Novitas 4x4) D 3 4
8 (Systems only) C 4 & 5 5
Number of Diagnoses and Management Options
Minor =1 ea. (max 2 points)
Est. stable/improved = 1 ea. Est. worsening =2 ea. New problem(S), w/o workup =3 New problem, w workup=4 ea.
AMOUNT/COMPLEXITY OF DATA: One Point Each:
Clinical Labs test ordered or reviewed
CPT® Medicine Section Test‐ ordered/reviewed
CPT® Radiology Section Test‐ ordered/reviewed
Discuss patient results w performing / consulting Dr
Decision obtain old records or additional hx other than pt Two Points Each: Review/summarize data old records/add hx other than pt
Independent interpretation of an image, tracing, specimen
OVERALL RISK: The quick reference guide below shows excerpts from the CMS Table of Risk. * Risk is based on the disease process anticipated between the present encounter and the next one.
Type
New or Est. Out Pt LEVEL (x)
1
1
Clinical testing/management examples: Venipuncture, X‐ray, EKG, U/A, U/S, rest, superficial dressings, elastic bandage, gargles, etc. Presenting Problem Example: 1 minor / self‐limited
SF 1 & 2
2
2
Clinical testing/management examples: Biopsy, pulmonary function, barium enema, minor surgery without risk factors, OTC drugs, PT, OT, IV without additives, etc. Presenting Problem Example: 1 –2 minor, 1 stable chronic / 1 acute uncomplicated
L 3
3
3
Clinical testing/management examples: Stress tests, endoscopies, cardiovascular imaging, centesis, closed Tx of Fx, Rx drug management, minor surgery with risk factors, major elective surgery without risk factors, therapeutic radiation tx, etc. Presenting Problem Example: 1 chronic exacerbated / 2 stable chronic / New Undiagnosed with uncertain outcome / Acute with systemic symptoms / acute complicated injury
M 4
4
4
Clinical testing/management examples: Cardiovascular imaging with risk factors, endoscopies with risk factors, discography, medication toxicity management, major surgery with risk factors, emergency surgery with risk factors, etc. Presenting Problem Example: 1+ chronic severely exacerbated / Illness or injury that poses a threat to life / Abrupt change in neurological status
H 5
This tool is based on the Marshfield Clinic Model. This format is reprinted with Permission: Quick Reference Code Sheet © Copyright 2006‐2015 Stephanie L. Cecchini, CPC, CEMC, CHIS
39
Appendix B: Medical Necessity Flow Chart
Pt Actively
“sick” or injured?
Pt w/ stable or inactive
Condition/s?
Pt w/ minor or self limited problem/s?
Start: A medically necessary, separately billable, evaluation and management service.
Dr. is treating (or Tx is impacted by all diagnoses counted)
No
No
Pt risk of life or limb between now &
next encounter?5Yes Yes
3 or 4
No
More than 1 problem?
2 or 3
Yes
No
Yes
1 or 2
More than 1problem?
Yes
No
More than 2problems?
2 or 3
2 or 3
Yes Yes
No
Preventive Medicine
No
More than 3 problems?
4 or 5
3 or 4
Yes
No
40
Appendix C: Acronyms Used in this Webinar
Centers for Medicare and Medicaid Services (CMS)
Chief Complaint (CC)
Documentation Guidelines (DGs)
Electronic Medical Records (EMR)
Evaluation and Management (E/M)
Examination (PE)
Fee‐for‐Service (FFS)
Health Information Technology for Economic and Clinical Health (HITECH) Act
History (Hx)
History of Present Illness (HPI)
Local Coverage Determinations (LCDs).
Malpractice Stress Syndrome (MMSS)
Medical Decision Making (MDM)
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
Merit‐Based Payment Incentive System (MIPS)
National coverage determinations (NCDs)
Past, Family and Social History (PFS)
Physician Quality Reporting System (PQRS)
Relative Value Units (RVU)
Review of Systems (ROS)
41
Appendix D: CDI Communication Tool
Physician or NPP/Coder Medical Necessity Communication Tool
If your services produce a higher level of service by documentation elements, the coder will know the service was a
false positive by the 1995 or 1997 DGs and will lower the code based on medical necessity. If your service produces a
lower level of service by the 1995 or 1997 DGs, the coder will query you to determine if clinical documentation
improvement is needed to ensure documentation is in compliance with services actually rendered and with the level
of medical need that was addressed by you, to ensure the claim is correct before billing.
I, the provider of service, attest that I am billing for what was medically necessary for this patient. The severity of illness
and the intensity of service provided by me today is associated with medical needs that were….
Check the Highest Box that you attest to:
Level 1 Out Pt: For a new Pt with a CC
1) That required reassurance with no active medical management (or)
2) Time based: counseling or coordinating care for the patient equal to the Level
Level 2 Out Pt: For a new or established Pt:
1) With a minor CC (or)
2) To follow up to ensure efficacy of previous care
AND
Who required little or no active medical management
OR
Time based: counseling/coordinating care equal to the level
Level 3 Out Pt/Level 1 In Pt.: For a new or established Pt:
1) With a CC diagnosed during this encounter (or)
2) To follow up on known problem/s that are progressing as expected
AND
Where the planned return is routine, and/or the problem/s presented no unusual or unexpected
concerns for the medical outcome
OR
Time based: counseling/coordinating care equal to the level
42
Level 4 Out Pt/Level 2 In Pt: For a new or established Pt:
1) With a CC requiring consideration of multiple comorbidities (or)
2) With a CC not progressing as expected, (or)
3) With a CC in a “rule out” stage pending outside tests
AND
With medical management requiring consideration of the added risk to the patient’s medical outcomes
OR
Time based: counseling/coordinating care equal to the level
Level 5 Out Pt/Level 3 In Pt: For a new or established Pt:
1) With a CC that is a probable threat to life within 24‐48 hours (or)
2) With a CC that is a probable threat to limb within 24‐48 hours (or)
3) With a CC that is a probable threat to organ function within 24‐48 hours (or)
AND
With medical management requiring consideration of the imminent risk or rapid decline in the patient’s
medical outcomes
OR
Time based: counseling/coordinating care equal to the level
43
SLIDES
Crash Course in Medical Necessity for E/M CodersSpecial Presentation: Limited Edition
Fall/Winter 2016
About the PresenterStephanie Cecchini, CPC, CEMC, CHISP, is VP of Products at AAPC. Her passion is providing solutions that allow coders to help physicians to best pursue their hard-earned art in the practice of medicine. She is an executive level healthcare sales, operations, and public speaking expert with significant & broad ambulatory healthcare business experience with emphasis on multi-specialty physician groups and payers. She has served as a senior executive for over 15 years. In prior roles: as VP of Coding Operations with Aviacode, overseeing the coding operation of more than 30 million claims per year. As Chief Audit Officer for Parses, Inc, she assured physician medical coding audit accuracy & quality control for payer driven recovery audits of professional fees and was responsible for driving sales & managing new coding audit programs. Stephanie lives in Salt Lake City, Utah with her husband Jim and their three children. Stephanie is LION (Linked In Open Network). http://www.linkedin.com/in/StephanieCecchini
You
Learn how to confidently code the correct E/M level ---every time
Discover when documentation becomes a compliance problem
Stop over-coding or under-coding claims based on Medical Necessity
Gain an essential understanding of regulations that effect E/M documentation
Combat today’s most challenging E/M leveling errors with actionable info
Learn 5 things every coder should do to accurately code for Medical Necessity
3
Drowning in Documentation.
Dying of thirst for information.
Thousands of Pages in legalese Federal Register
OIG Compliance Guidance
ICD 10 Official Guidelines
CMS.gov Internet-Only Manuals (IOMs)
Chapter 12 – Physicians
Medicare Claims Processing Manual
CMS Medicare Benefit Policy Manual
CPT guidelines
CMS 1995 and 1997 DGs for EM
HIPAA
CCI National Correct Coding Initiative (NCCI)
False Claims Act and Qui Tam
Social Security Act (Medical Necessity)
Mixed Messages & Documentation
Medical Necessity &
Value Based Laws&
Malpractice
EMR HITECH Act&
CMS DGs&
Non Clinical Work
The Truth In Soapy Coding
• Subjective: Opinions
Medical Necessity is a clinically required action
It is the reason for a service
It validates the provision of service
o It is open for interpretation by all parties involved
Objective: Facts• Medical Decision Making E/M Component is a measurement of work
It is defined by:
o 1995 and 1997 Documentation Guidelines
o Marshfield Clinic audit tool.
Medical Decision Making is the mathematically formulated result of all documented components of the physician’s service, whether medically needed or not.
o It is the data driven outcome of a patient visit and not a substitute for determining the appropriateness of the services rendered or the Medical Necessity.
Assessment: Judgements
• The best way to stay compliant with Medical Necessity related laws is to think of each element of the patient’s history and physical exam as a separate procedure that should be performed only if there is a clear medical reason to do so.
This requires making a clinical judgement.
A coder, while better educated than most non-clinicians, is not able to make that judgment with the certainty of a medical peer.
Plan: Strategies• In an effort to bridge the gap between the
clinical savvy of a documenting provider and a clinically untrained coder some coding administrators have exchanged the definition of
Medical Necessity with the MDM component of E/M services.
• This mistake can leave money on the table or result in overpayments.
• A different strategy is needed
The Medical Necessity Problem• Incorrect E/M coding resulted in $1.4B in overpayments in 2015.
Problem code 99233 had a 50.4% error rate in 2015
Problem code 99214 had a 14.3% error rate in 2015
Problem code 99232 had a 16.5% error rate in 2015
• Medical Necessity errors are nearly twice as common as are coding errors.
• CMS 1995 and 1997 Documentation Guidelines are not statutes
Medical need for services rendered is the authoritative factor
o Medical necessity is not defined
How is Medical Necessity Defined?
• Government:
Per the Social Security Act 42 U.S.C. § 1395y(a)(1)(A), “SSA” Medicare only pays for medical items and services that are "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member", unless there is another statutory authorization for payment.
National coverage determinations (NCDs) and Local Coverage Determinations (LCDs). Section 522 of the Benefits Improvement and Protection Act (BIPA) defines an LCD as a decision by a Medicare carrier whether to cover a particular service in accordance with the SSA
AMA• “Health care services or products that a prudent physician would provide to a patient for the
purpose of preventing, diagnosing, or treating an illness, injury, disease or its symptoms in a manner that is:
• (a) in accordance with generally accepted standards of medical practice;
• (b) clinically appropriate in terms of type, frequency, extent, site and duration; and
• (c) not primarily for the convenience of the patient, physician, or other health care provider.”
“Generally Accepted”
• What is common acknowledged as “generally accepted”?
Standards that are based on credible scientific evidence published in peer-reviewed, medical literature generally recognized by the relevant medical community;
Physician specialty society recommendations;
The views of physicians practicing in the relevant clinical area.
Evidence Based Guidelines• Industry standard guidelines for evidence based determinations of Medical Necessity by payers
include
MCG (formerly Milliman Care Guidelines)® by MCG Health LLC of the Hearst Health network, and
InterQual® by McKesson.
o InterQual® provides a structure of criteria for "severity of illness (SI)” and "intensity of service (IS)" to help determine if a patient is sick enough to be admitted an inpatient.
• These standards are helpful insights, however are incomplete substitutes for the clinical judgment of the physician.
CPT® Nature of the Presenting Problem• Minimal: A problem that may not require the presence of the physician or other qualified health
care professional, but service is provided under the physician’s or other qualified health care professional’s supervision.
• Self-limited or minor: A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status OR has a good prognosis with management/compliance.
• Low severity: A problem where the risk of morbidity without treatment is low; there is little to no risk of mortality without treatment; full recovery without functional impairment is expected.
• Moderate severity: A problem where the risk of morbidity without treatment is moderate; there is moderate risk of mortality without treatment; uncertain prognosis OR increased probability of prolonged functional impairment.
• High severity: A problem where the risk of morbidity without treatment is high to extreme; there is a moderate to high risk of mortality without treatment OR high probability of severe, prolonged functional impairment.
MDM as a MN Driver?• Example:
Number of Diagnoses and Management Options:
o A patient with a new problem is diagnosed during the same encounter with a problem that is more severe than a minor problem. This is worth “3” on the MDM scale of Number of Diagnoses and Management Options.
Amount/Complexity of Data:
o The physician ordered and reviewed a medical test in his office. This is worth “1” on the Amount and Complexity of Data
Overall Risk:
o The problem requires a prescription medication, which the physician orders.
Clinically Stated
The patient has sudden central vision loss and is sent to a Retina specialist for diagnosis and treatment. A history is obtained and both eyes are thoroughly examined. Several optic tests are used, including an Amsler grid and optical coherence tomography. A new diagnosis is made by the physician of sub choroidal neovascularization for which he recommends a monthly injection of Avastin. He explains the risk of the injections, and shares with the patient the risk of continued vision loss with or without the injection. The patient elects to have the injection the same day. Follow-up in 3 weeks for evaluation and repeat injection.
MDM as a MN Driver?
19
Answer is a Level Four, right? Well…• What if the patient was sent by the physician to be worked up at an outside facility, and the
patient returned with the test results for final diagnosis with the results on the same day?
• What if the provider decides that the risk of the problem is not classifiable as that associated with Prescription drug management, but rather with the risk associated with an acute illness or injury that poses a threat to bodily function (in this case vision)?
In terms of code selection for Medical Necessity with an MDM driver, this could now support a Level Five new or established Outpatient patient.
• Another example: 45-year-old, otherwise healthy male returns for a non-resolved problem first seen 5 days ago ….a cough x 7 days which is now productive. This patient is also under the physician’s care for well controlled hypertension and hypercholesterolemia. The diagnosis today is URI. She reviews all the patient’s current medications and adds to it by ordering an antibiotic. No follow-up requested
MDM is moderate….is this a Level Four clinical example?
Five Secrets to Success
Accept That There Is No Tool That Can Replace A Physician In Medical Necessity Determinations on E/M codes.
Five Secrets to Success
Understand why the topic of payment is a source of physician frustration Let’s take a closer look…
Can be a physician. Only the best
Devaluation of the work by a physician
• 50% of physicians feel devalued
RVUs are used in the Physician Fee Schedule
The Physician Work RVU is based on government estimates on time and complexity
RVUs are used by employers who measure productivity and calculate salaries or bonuses
To generate income a physician must be actively providing an allowed service.
o No payments for work solely humanistic in nature, such as time with a grieving family
o No payments for time in meeting required documentation requirements
o Can take 3 or more hours per day
Five Secrets to Success
Communicate with physicians quickly, concisely and in terms they can relate to
Inspire me Provide a clear vision
o What makes your heart sing?
Energy, Energize, Edge, and Execution
o Dopamine
• Be memorable
o Work in emotionally charged moments
o Teach in a new way, or an unusual place
• Be novel
o Fresh, new and unexpected twist
o Tell a story
o Tell someone else’s story
Scale of 1-5• Levels 3-5* are reserved for “sick” or injured patients.
Lower levels are for patients who present with minor and/or well controlled condition/s.
*This presentation refers to levels of service for outpatient visits.
Sickest (5/3)• Presenting Problem: An illness or injury that poses a threat to life, chronic severely
exacerbated, abrupt change in neurological status
Typically the patient’s situation is serious, imminent, and uncertain
o Severe exacerbation of CHF
o Patient presents confused in diabetic ketoacidosis
o Morphine Sulfate IVP ordered for chest pain not controlled by Nitro
o Patient brought by parents after a failed suicide attempt
o Patient post fall on ski slopes with extradural hematoma
o hospital inpatient who is rapidly declining
Sick (3/1)• Typical Presenting Problem: 1 –2 minor, 1-2 stable chronic, 1-2 acute uncomplicated
Typically the diagnosis is known and/or made during the encounter
Future follow up is often classifiable as routine
o Patient returns with productive cough x 10 days for antibiotic
o Patient with choroidal revascularization to assess efficacy of anti-VEGF
o Follow up Patient with cystocele not requiring treatment
o Patient in follow up with stable angina and no new symptoms
o Return visit for patient with worsening plantar fasciitis
o Non pregnant female with resolving hyperemesis
o Patient with well controlled hypertension and hypercholesterolemia
o Hospital patient who is getting better and progressing to discharge
Sicker (4/2)• Presenting Problem: 2-3 stable chronic, chronic exacerbated, acute with systemic symptoms
or injury
Typically the diagnosis is known and worsening/complicated or further testing is required
Future follow up is often classifiable as routine or sooner
o Patient with choroidal revascularization now with new central vision loss
o Patient in follow up with stable angina, not tolerating medication
o Patient with suspected cellulitis of the lower leg
o Patient with heel ulcer and drainage
o Hospital inpatient who isn’t getting better or progressing to discharge but is not declining
Five Secrets to Success
Master the Art of Asking the Right Questions
CDI: The Physician Interview
• The best way to communicate with physicians is to ask questions that allow them to draw their own conclusions.
Your goal is to promote effective communication
Ask questions that are not answered with yes or no
“what made you more concerned about this patient encounter than the other one?” versus
“did you understand what makes this a Level Four?”
Effective Communication• Listen: Don’t think about what you will say next while the physician is talking
• Have a clear idea of what you want to say so you can be organized in your delivery
Example:
o “Doctor, I have reviewed this patient encounter, and your superbill. You selected a Level Four. You saw this patient 1 month ago for premenopausal syndrome mood swings and prescribed Zoloft. You saw her again today in follow-up. You repeated a comprehensive history and exam. She is doing well with reduced mood swings and will continue with sertraline 50MG. You ask to see her back in 12 months or PRN if there is a change. I am concerned that an auditor might question the higher Level of service being billed because you are not seeing her back for 12 months and there are no other problems documented.
o What was it about this patient that put her at a higher Level of concern to be coded at a Level Four?”
Provider Interview • Always customize CDI
Run a productivity report of the last one to three months of Outpatient visits that shows the top diagnosis codes used and the frequency of their use.
Ask Questions: Dr., what about these diagnoses make you more (i.e. 4) or less (i.e. 3) concerned about a patient?
Code
Count of
Occurrence Short Description
Threat to
Life/Function 4 3 2 1
D64.9 99 Anemia Yes/No
E03.1 96 Congenital hypothyroidism s goiter Yes/No
F41.1 76 Generalized anxiety disorder Yes/No
I10 42 Essential (primary) hypertension Yes/No
Sample Interview Questions • Do any of these pose a threat to life or bodily function within 24-48 hours? (Level Five)
• Under what circumstances would you see a patient in follow-up sooner than typically required? (Level Four)
• Which patient problems have you very concerned for the patient but do not pose an imminent threat to life or bodily function? (Level Four)
• Which of these can commonly be diagnosed on the first encounter and do not usually require a prompt follow-up? (Level Three)
• Which of these problems might you bring a patient back for a quick check, and on doing so discover no further medical management is needed? (Level Two)
• Which of these diagnoses are self-limited and require reassurance with no active medical management? (Level One)
• Would a non-friendly medical peer agree with your decisions?
Five Secrets to Success
Address the problems head on ---and use effective tools to communicate effectively and code confidently.
Let’s address the 2 main problems:
Over-coding Problem
99214
MN is a 3
Under-coding Problem
99204
MN is a 5
Confidential Planning Document - IP - DO NOT DISTRIBUTE 9/21/2016
The Solution: Communication Improvement
Fixing the communication problem
Medical Necessity Noted in the Record
o Coder can prevent over-coding
o Coder can identify CDI needs to prevent under-coding
Level 1
I attest that I am billing for what was medically necessary for this patient. The severity of illness and the intensity of service provided by me today is associated with medical needs that were….
Level 1 Out Pt: For a new Pt with a CC
1) That required reassurance with no active medical management (or)
2) Time based: counseling or coordinating care for the patient equal to the Level
Level 2 I attest that I am billing for what was medically necessary for this patient. The severity of
illness and the intensity of service provided by me today is associated with medical needs that were….
Level 2 Out Pt: For a new or established Pt:
1) With a minor CC (or)
2) To follow up to ensure efficacy of previous care
AND
Who required little or no active medical management
OR
Time based: counseling/coordinating care equal to the level
Level 3/1 I attest that I am billing for what was medically necessary for this patient. The severity of illness
and the intensity of service provided by me today is associated with medical needs that were….
Level 3 Out Pt/Level 1 In Pt.: For a new or established Pt:
1) With a CC diagnosed during this encounter (or)
2) To follow up on known problem/s that are progressing as expected
AND
Where the planned return is routine, and/or the problem/s presented no unusual or unexpected concerns for the medical outcome
OR
Time based: counseling/coordinating care equal to the level
Level 4/2 I attest that I am billing for what was medically necessary for this patient. The severity of illness and the
intensity of service provided by me today is associated with medical needs that were….
Level 4 Out Pt/Level 2 In Pt: For a new or established Pt:
1) With a CC requiring consideration of multiple comorbidities (or)
2) With a CC not progressing as expected, (or)
3) With a CC in a “rule out” stage pending outside tests
AND
With medical management requiring consideration of the added risk to the patient’s medical outcomes
OR
Time based: counseling/coordinating care equal to the level
Level 5/3
I attest that I am billing for what was medically necessary for this patient. The severity of illness and the intensity of service provided by me today is associated with medical needs that were….
Level 5 Out Pt/Level 3 In Pt: For a new or established Pt:
1) With a CC that is a probable threat to life within 24-48 hours (or)
2) With a CC that is a probable threat to limb within 24-48 hours (or)
3) With a CC that is a probable threat to organ function within 24-48 hours (or)
AND
With medical management requiring consideration of the imminent risk or rapid decline in the patient’s medical outcomes
OR
Time based: counseling/coordinating care equal to the level
Communication is Key To accuracy in medical necessity coding
To preventing overpayments
To minimizing underpayments with clinical documentation improvement training
To reducing the need to query physicians or turn them into coders
To increasing the accuracy and confidence of the coder
Thank you for your work and for supporting the delivery of excellent healthcare
Stephanie Cecchini, CPC, CEMC, CHISP is LION (Linked In Open Network). http://www.linkedin.com/in/StephanieCecchini