Audit Challenges with E/M Services Questions Answers

Audit Challenges with E/M Services

Questions Answers

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Can the term "non contributory" be used for PFSH? It depends upon your MAC carrier. Some allow the use,

while others require that the specific questions asked be

documented.

For inpatient rounding E/M servcies, is a chief complaint Yes the chief complaint is still required. Each note must be

required for every note? able to stand alone.

If ROS is unavailable due to patient being intubated in a Yes. The provider just needs to indicate why the ROS was

coma can credit be given if they note what all they did to unobtainable.

tery and collect the ROS?

If an established patient presents to the office location and It depends if you are using MDM as a required element for

the provider documents a detailed history and exam but the 2 of the 3 key components. If you are then the correct code

overall medical decision making is of "low complexity," selection would be 99213. If not then you would look at

how would you code this service? The risk would be the nature of the presenting problem to see if using the

moderate. Would this be a 99213 or 99214? history and exam as your 2 components is appropriate and

code 99214. You need to consider possible over-

documentation when using just history and exam. Also,

you would need to know what your MAC carrier allows.

For inpatient rehab-can a chief complaint be pulled from For all visits types CMS does state that the CC can be
the assessment? inferred from the HPI. It does not state it can be inferred
from the Assessment and plan however we can use the
entire record. Just use caution and do not count plan
elements for HPI. Because this is a grey area you should
define in your practice.

Follow up to my ROS question...do you give the provider a You could allow a complete ROS as if 10+ systems were
score of comprehensive ROS or how else would you score documented.
it?

When the provider states "HPI/ROS/PFSH" same as from I would not recommend using the HPI documentation from
prior visit, does the same level of history from the prior a previous visit. CMS states that the ROS and PFSH can
visit carry over? be referenced from previous visits, they do not say the HPI
can. The definition of the HPI implies that these
For established visits, it seems that many carriers require documented elements need to be a description of events
MDM as one of the elements (out of 3) . Is this correct? from the previous visit or from the first sign/symptom to
the present.
What is the source document for slide 12?
Correct. You need to know what your MAC carrier
Do you have the CMS regulation that states they have requires. Requiring MDM as 2 of the 3 supports the
adopted the Marshfield guidelines or a reference for us to medical necessity of the E/M level. We work with
use? practices that even though their MAC may not require
Can we pull something from the chief complaint to use in MDM for 2 of the 3, they do and have made this a
the HPI? requirement as part of their compliance standards.

CMS Internet Only Manual (IOM) Medicare Claims
Processing Manual, Publication 100-04, Chapter 12,
Section 30.6.1,
The link that I had no longer is in use. I will have research
and get back to you.

If the provider documented the chief complaint and
included elements of HPI then yes, you could count these
elements towards you HPI. You do not want to count
elements more than once. If the provider did not document
the CC then no, this would not be best practice.

At what point in the audit process do you make a note non- In this example the entire service does not need to be non-
billable, other than the blatant omissions. Example: Do billable. If the date can be inferred or an amendment done
you make a consult non-billable if the providers does not then you could bill using a different E/M category.
have a date and/or referring physician in his note, although
he dictated on the date he saw the patient.

When auditing a note and determining the MDM level, If the EHR system auto populates previous tests, it would
how would you score results from lab work or x rays that be appropriate to count toward the MDM. However, if the
are pulled forward from a previous note. Also, if the provider references these test or pulls the tests
provider orders the test on 1 date and reviews the results himself/herself then you could. Tests that are pending are
on the next date of service, would you give credit for counted in MDM under DATA as tests "ordered" or
reviewing/ordering test on both dates of service? reviewed. You could also count this a new problem with
work up IF in fact the problem is new to the provider.

Isn't it required that out of the 2/3 for MDM, one must be I have not seen this requirement. That is not to say that a

the risk? MAC carried has not provided further clarification of their

requirements.

Where could we find written documentation regarding http://www.cms.gov/Outreach-and-Education/Medicare-Learning-
authentication for all users? In our EMR it does not print Network-
out on the note. MLN/MLNProducts/downloads/Signature_Requirements_Fact_Sheet_ICN9
05364.pdf

What would you recommend if the ROS/PFSH (not You could code the E/M level based all elements of the

cloned/carried over) are complete, because the provider history or exam, using MDM as 2 of the 3 components. So

chooses to document this way, but the HPI, CC, and MDM if MDM was SF you would level your E/M as SF.

are straightforward? Since medical necessity is over-

arching for most carriers, code then to the lower level?

When providers restate the complete history of a condition If I'm understanding the question correctly, it appears that
and then state "today the pt. is ...", is it appropriate to use the provider us documenting the history as the interval
the restating of the condition has past history and the HPI history, the events between visits or leading up to this
start from the statement of Today the pt is experiencing? visit. In which case, yes you could count elements for HPI.
Just use caution and never count 1 element twice.

Can providers use "10 point review of systems done" Yes, as long as they also document the pertinent positives
or negatives for the systems related to the reason for visit.
If the provider states ROS/PFSH "as before" (referencing Only stating a 10 point review of systems was done is not
date of last encounter), do they still need to state acceptable.
"reviewed"?
The date in which the past ROS/PFSH was documented
needs to be included in the provider's note. The statement
does not necessarily need to also say "reviewed". The
statement "as before" implies the provider reviewed the
previous elements and there were not changes. Again, look
to your MAC carrier for guidance.

When providers restate the complete history of a condition Yes, you can use the elements starting from "Today the
and then state "today the pt is ...", is it appropriate to use patient is experiencing." as HPI elements.
the restating of the condition has past history and the HPI
start from the statement of Today the pt is experiencing?

When auditing ROS and or exam elements not pertinent to As coders, we are not qualified to determine what specific
the chief complaint, how can this be supported as a valid elements should or should not be documented. This is up
over documentation issue vs the physician performing to the provider and his/her clinical judgment. This is an
good medicine? Is it not good medicine to check heart area in which the coder/audit needs to work closely with
and lungs on all patients even if coming in for say pink eye their providers and make a determination together.
or sprained ankle?

is "all other negative" under ROS acceptable ? Yes if the pertinent positives and negatives based on the
reason for visit are documented. Stating only "all other
negative" is not acceptable. Look for guidance from your
MAC carrier as to whether or not they allow counting
associated signs and symptoms for ROS.

If the provider states patient returned for review of This visit could be leveled using time based coding as long

diagnostic results (labs, imaging), but no HPI, ROS, PFSH, as the documentation supported this. If no time is listed

documented, and no exam done, do we go by time then you would have to level based on the key

(counseling on next steps)? or just code lowest level E&M? components. If there are not enough key components then

this visit may be support reporting an E/M.

Can elements of the HPI be pulled from other areas of the When the provider documentation includes elements of
note like the A/P? ex: HPI-breast Ca = location; A/P=Stage HPI in the plan, you can count these elements for HPI
II Breast Ca, ER/PR +; Can I use the stage II and ER/PR + in points. We can use the entire medical records for counting
the A/P for severity and quality in the HPI? E/M elements. Use caution with double dipping. For this
specific example, in my opinion, I would not consider the
description of the provider's final assessment as HPI
elements.

How do you obtain a complete HPI/ROS and PMSH on a If the physician is unable to obtain additional HPI/ROS
newborn that is 3 hours old? Mom is unavailable due to and documents why then we can count full credit for these
newborn in nicu. Do you use the nurse documenation , elements. We can use the nurse documentation for ROS
may the physician document that due to the patient age but not for HPI.
HPI/ROS unobtainable?
For RAT/STAT, OIG does extrapolation (in terms of I would recommend just expanding your audit sample.
potential overpayment). Would you recommend doing Expand the sample as far as you need to, to obtain a clear
some type of extrapolation for internal purposes? or just understanding of the potential issue.
expand the audit sample?
Can the ROS/PFSH from another provider in the same Yes, the provider can do this if its part of the same patient
practice (most recent visit) be used if referenced? If the medical record, the provider references it with the date and
doctor of one specialty references the ROS/PFSH of a if there are any updates.
doctor in a different specialty in the same practice, it
would still count as new patient (because of different
specialty/subspecialty), regardless of the ROS reference;
correct?

So signature log should contain signature of scribes or Yes. The signature logs should include anyone that makes
other ancillary staff as well as the physicians? entries into the medical record.
My question with regard to a provider documenting
history as HPI would I use the old information as past If I understand the question correctly, you are using the old
medical history and only the portion that is stated as history as Past history and using the "interval history" for
current for the HPI of that current encounter? your HPI. If my understanding is correct, yes you can use
interval history for HPI point.

can a resident be a scribe? can an APRN or PA be a scribe? Yes they can. The documentation would still need to meet
the CMS or MAC carrier scribe requirements and the claim
could not be billed under their NPI.

For new condition with work-up planned (4 points) and lab You can count the 4 points for new problem with work and
ordered (to performed on another day) worth one data the order/review of the lab for 1 point.
point, do you also get 4 (new condition with lab) and 1
data point (lab ordered), or is this double-dipping on the
lab point?
Can you count past medical, family, or social history if it is No, the provide needs to reference it when collected from a
present in an electronic medical note for a specific date of previous date of service.
service but it is not specified that it was reviewed and
updated on that date of service?

is it okay to bill an office E/M with a dialysis code? When reporting an E/M service on the same day as a
procedure, the E/M needs to be significant and separate
from the routine or pre procedure evaluation. If not, then
reporting and E/M would not be appropriate.

So you are saying that is a provider orders lab work on one The guidelines to not specify the time in which the order or

visit and then reviews that same test on the next visit, he reviewed results can be counted. Think of it this way,

is given credit in both situations? MDM is about the provider considering all diagnoses,

options to treat the patient and what tests to perform and

how all of these things impact the patient and their other

conditions. So if the initial decision is to order a lab, that is

1 element of MDM. Then when the lab results come back

then the provider has to make another decision on what to

do next. If that decision happens at the next visit, then you

can count it during that visit.

can an ED physician bill for their ER servcies if the patient If the ED provider is the one admitting the patient then no.
is admitted from the ER?m Do we change the code to If the ED physician saw the patient and called in another
some other hospital f/u code? Thanks provider who made the decision to admit the patient then
yes. Each provider who evaluated the patient can bill for
their E/M service in most instances.

Is there a sample of the acceptable table to have our Look for guidance on acceptable E/M benchmarks from

physicians review for E&M coding via graph or color chart? CMS and MGMA.

How do you get a complete HPI/ROS on a 3 hour old CPT states that the ROS should be age specific so there
newborn? Is it appropriate for the physician to document may not be evidence of 10+ systems for the provider to
"unable to obtain HPI due to the patient age?" document on. As an auditor we need to remember the
documentation for baby's and small children is different
For new condition with additional lab work-up, can you and should be age specific.
count 4 points for the new condition and 1 for the lab in
data, if your practice does the draw on the same day, but In this instance I do not believe this is double counting.
not the actual analysis? I know you're not supposed to
double-count the additional work-up if you actual do it
and bill for it on the same day.

Is there an industry standard on the accuracy rate that a There is not an "industry standard" for accuracy of a coder.
coder should be? This is something each practice needs to determine and
include as part of their compliance standards.

For moderate MDM based on prescription drugs, do they Remember the CMS risk table state's prescription drug
have to the drugs prescribed by the doctor, or can it be management. If the provider is not managing Rx drugs
sufficient to score based on note of the drugs in the during the visit then it would not be appropriate to count
medical history (so member seeing a doctor in one this in your MDM. What is Rx drug management? This is
specialty, taking drugs ordered by another doctor in another grey area. Look to your MAC carrier to see if they
another specialty for a different condition)? Would the have defined or define this in your practice as part of your
doctor at least have to comment on how the drugs were compliance standards.
considered in part of the treatment being rendered?