Taking the Risk out of E&M Coding-Avoiding Cloning

1. Taking the Risk out of E&M Coding-Avoiding Cloning Making notes “authentic” and retaining quality Nancy M. Enos, FACMPE, CPC-I, CEMC, CPMA October 7, 2013 MGMA Annual Conference San Diego, CA

2. Agenda • Hot topics in E/M coding – the OIG is watching high levels of service • Electronic Health Records and Physician Documentation- Risk of copied and cloned notes • The Chart Audit Process

3. 2012 OIG Work ListE/M Trends in Coding of Claims OIG reviewed evaluation and management (E/M) claims to identify trends in the coding of E/M services from 2000-2009. • Medicare paid $32 BILLION for E/M services in 2009, representing 19% of ALL Medicare part B payments. Providers are responsible for ensuring that the codes they submit accurately reflect the services they provide. E/M codes represent the type, setting, and complexity of services provided and the patient status, such as new or established.

4. 2012 OIG Work List E/M improper documentation due to cloned notes, identical documentation • OIG will assess • the extent to which CMS made potentially inappropriate payments for E/M services due to • the consistency of E/M medical review determinations • multiple E/M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments.

5. OIG Report released in May 2012 • OIG released a report on Coding Trends of Medicare Evaluation and Management Services • The report reflects OIG’s and CMS’ continuing suspicions about the increase in higher level billing • indicating a need for physicians to audit their E/M coding • “ I hereby direct executive departments and agencies to expand their use of Payment Recapture Audits, to the extent permitted by law and where cost-effective.” –Daniel R. Levinson, Inspector General

6. OIG Report • From 2001 to 2010 Level 1 to 3 dropped 17% while Level 4 and 5 increased 17% • The OIG identified 1,700 providers who billed level 4 or level 5 at least 95% of all E/M claims in 2010 • OIG has sent the names of these “high billing” doctors to CMS, along with a recommendation for review and possible recoupment. • http://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf

7. OIG Report • From 2001 to 2010 Level 1 to 3 dropped 17% while Level 4 and 5 increased 17% • The OIG identified 1,700 providers who billed level 4 or level 5 at least 95% of all E/M claims in 2010 • OIG has sent the names of these “high billing” doctors to CMS, along with a recommendation for review and possible recoupment • http://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf

8. Who are the 1,700? States • California 17.1% • New York 11.3% • Florida 9.6% • Texas 6.7% • Arizona 4.3% • Michigan 3.8% • Illinois 3.5% • Maryland 3.3% • New Jersey 3.2% • Pennsylvania 3.2% Specialties • Internal Medicine 19.8% • Family Practice 12.2% • Emergency Med. 9.9% • Nurse Practitioner 4.4% • Ob-Gyn 4.3% • Cardiovascular 4.0% • Orthopedic Surgery 3.9% • Psychiatry 3.8% • General Surgery 3.2% • Ophthalmology 3.2%

9. Is the Increase Justified? • Electronic Medical Records provide a better way to capture patient acuity (more diagnosis codes) and template guided E/M notes may document and support a higher level of E/M Service • Medical necessity is the key • Completion of a Comprehensive History, and a Comprehensive Examination, does not justify a level 5 service if it is not medically reasonable and necessary.

10. Correcting “Undercoding” • The uptick may be a correction of undercoding-many primary care doctors were overusing 99213 for complex patients with multiple chronic diseases, because handwriting a SOAP note for their follow up visits was time consuming • Ancillary staff can complete the Chief Complaint, Review of Systems, Past, Family and Social History • The provider MUST validate these entries

11. Risks of Electronic Health Records • Templates can assist • Coder’s adage…If it wasn’t documented, it wasn’t done • Auditors adage…if it wasn’t necessary, don’t bill for it • Auto-complete - check Review of Systems (ROS) • Were they all really reviewed? • Was it necessary? • Physician training

12. Cloned Notes- History • Does your EMR have templates that create a Complete 14-point Review of Systems (ROS) automatically? • Issues and risks • Each element of the ROS must be supported by the History of Present Illness for medical necessity • For instance, a patient comes in to the Emergency Department for a hand injury • Review of systems includes Genitourinary system • “patient denies pregnancy, dysmenorrheaand has a normal menstrual cycle”

13. Cloned Notes- History • Does your EMR have templates that create a Complete 14-point Review of Systems (ROS) automatically? • Issues and risks • Each element of the ROS must be supported by the History of Present Illness for medical necessity • For instance, a patient comes in to the Emergency Department for a hand injury • Review of systems includes Genitourinary system • “patient denies pregnancy, dysmennorhea and has a normal menstrual cycle” • Patient is an 87 year old male

14. Validity of Data • Systems that are documented in the HPI (patient presents with a rash on the left arm) contradict the systems documented in the ROS “list” (skin negative) • Systems that are documented in the ROS that make no sense for the patient (female denies any erectile dysfunction) • Systems that are documented in the HPI and conflict with personal or family history (HPI pt is here for full skin check, mother has malignant melanoma) and the Family history is “noncontributory”.

15. Cloned notes-Physical Exam • Automated Text for a “Female exam” or “Male exam” • Includes Organ systems and Body areas that are unrelated to the reason for the visit • Findings such as “HEENT negative” do not indicate why the exam was done • Neck-negative- what does this mean? • Musculoskeletal- neck, full range of motion • Cardiovascular- neck, no jugular venous distention • Lymphatic- neck, no adenopathy • Neurological- neck, no stiffness or pain (meningitis)

16. Coding based on documentation or risk? • According to the OIG, if a visit is documented with a physical exam that is more extensive than the problem described in the HPI- • If the code level agrees with the level of risk, the superfluous items in the PE are not a problem • If the code level is based on the extent of the documentation in the physical exam, the visit may be overcoded • Example: Detailed History, Detailed Exam, Low MDM • This should be billed as 99213 based on risk

17. Risk Based Coding • The most important element of the 3 key components of History, Exam and Medical Decision Making is the MDM • A comprehensive history and comprehensive exam cannot be billed at 99215 if the MDM is at Low or Moderate Risk • Unless, time is the controlling factor and is documented • “greater than 50% of the face-to-face encounter was spent in counseling and coordination of care” • “Total time of the visit was 45 minutes”

18. Cloning and Fraud • Providers who use EMR templates that create identical records for multiple patients on the same date of service will be reviewed for CLONING • Using the same template for the same ROS and Physical Exam, for every patient, regardless of the reason for the visit, is considered CLONING • Each entry should be AUTHENTIC to the patient visit, on that date • Copying/pasting from a previous note is not allowed.

19. Medical Necessity • Acuity is a good indicator of medical necessity. The more diagnosis codes (as long as the problems were addressed) the higher the severity • Do you run reports by Diagnosis code and view your E/M levels?

20. Auditing Processes- validating the authenticity of Documentation

21. What to Audit • Baseline Audit • Identify areas in need of increased documentation to maintain compliance • Recommended 10-15 records per provider • Random records but should reflect • trends of provider • specific problem areas • triggers or areas of concerns • Include Evaluation and Management and surgical encounters • Use reports to help decipher what types of services to review for your physicians

22. Auditing the Records • Audit based on information provided to auditor • Evaluated on information specific to the date of service • Records must be “fused” • Evaluate documentation content and medical necessity of visit • Three notations of each performed audit: • Services billed • Documentation level • Medical necessity level

23. S O A P Exam History MDM SOAP Notes • Subjective (History) • Describes the patients symptoms and reason for visit • Questions • Presently experiencing • Have experienced • Other signs/symptoms • PFSH can be asked to help identify possible risk factors

24. S O A P Exam History MDM SOAP Notes Objective (Examination) • Hands on examination of the patient by provider • Includes: Vital signs , Eyes, Ears, Nose, Throat, Neck, Cardiovascular, Chest, Respiratory, GI, GU, Lymphatic, Musculoskeletal, Skin, Neurologic, Psychiatric

25. S O A P Exam History MDM SOAP Notes Assessment (MDM) • Patient diagnosis • Other information important to the diagnostic assessment

26. S O A P Exam History MDM SOAP Notes Plan (MDM) • What the provider has developed for plan of treatment, referrals, consultations, medications and re-evaluations

27. Counseling Documentation • Counseling • The physician spends a majority of the visit talking with the patient, and due to this is unable to fulfill all of the necessary components needed in order to meet documentation guidelines. • Test results consume the visit • Risks and benefits of a treatment are discussed • Patient education • Multiple treatment options are discussed

28. Time Documentation • Provider spends more than 50% of the visit counseling the patient • Example: I spent more then 50% of the visit or a total of 45 minutes counseling the patient about their depression. • Document in patient medical record • Time can not be used with Emergency Department codes

29. Components • E/M services are scored based on the documentation of necessary components • History - 1st component • Examination - 2nd component • Medical Decision Making (MDM) – 3rd component • Contributing factors • Counseling, coordination of care, nature of presenting problem, and time

30. History • History of the medical record documentation should include four areas: • Chief Complaint • History of Present Illness • Review of Systems • Past , Family and Social History • This area is scored on the area of history documented with the least amount of information.

31. Chief Complaint • Chief Complaint is recommended of every medical record. • Concise statement that describes the problem/condition for the patient encounter. • Usually in the patient’s own words • This is usually documented by the nurse or medical assistant • Beware of “routine reasons”

32. Routine Reasons for visit • Here to establish care • Here for lab results • Here for MRI or radiology results • Here for annual exam (and an E/M code is reported) • Here for “routine” recheck • Ugh! Actually used a word that says the visit is unnecessary! Share this list with your Medical Assistants!

33. History of Present Illness - HPI • HISTORY COMPONENT • Must be personally documented by the provider • History of Present Illness • Patient symptoms and Chief Complaint – What they are presently experiencing

34. History of Present Illness (HPI) • Location • Severity • Timing • Modifying Factors • Quality • Duration • Context • Associated Signs and Symptoms • HPI must be documented personally by the clinician.

35. First Component of HPI • Brief History • 1-3 Elements • Extended History • 4 or more elements for 95/97 guidelines • 3 or more chronic/inactive for 97 guidelines

36. Review of Systems • HISTORY COMPONENT • Review of Systems -ROS • Inventory of body systems obtained by questions from provider to identify signs/and symptoms the patient may be experiencing or has experienced.

37. Review of Systems - ROS • Constitutional – Weight, fever, sweating • ENT – Ears, Nose, Throat • Eyes – Glasses, vision problems, • Cardiovascular – Heart, palpitations, chest pain • GI – Diarrhea, vomiting • GU – Urinary, Male/Female problems • Respiratory – SOB, coughing • Musculoskeletal – Joint pains, backaches, stiffness • Psychiatric – Depression, anxiety, mood swings • Integumentary – Rashes, dryness, hair, nails, lesions • Endocrine – Thyroid, excessive sweating • Hem/Lymph – Easy bruising or bleeding, swollen glands • Allergy/Immunology – Allergies to food, hepatitis. HIV • Neurologic – Blackouts, seizures, memory loss, speech

38. Past, Family, Social History - PFSH • HISTORY COMPONENT • PFSH – Past Medical, Family & Social History • The provider asks the patient information about past history of illnesses and diseases, social history, and, family history of diseases and illness.

39. Past, Family, Social History - PFSH • Past- prior illnesses, surgery, hospitalizations, allergies, medications • Family- age and cause of death of immediate family members, or family members with diseases that are related to the patient’s visit • Social- lifestyle such a marital status, alcohol or tobacco use, occupation, education, living situation, sexual activity

40. History in Children • Past History • Specifics regarding birth • Family History • Pregnancy of mother • History of birth mother/father • Social History • Parents alcohol or smoking habits • Child care settings

41. Unobtainable History • Sometimes it is impossible to obtain a history due to the status of the patient. • Document why the history was unobtainable • How to score • 1st view – Omit the history as scorable component • 2nd view – Allow a complete history • Recommendation: • Let doctor’s decide and documented in your compliance manual

42. Examination • An examination based on either the 1995 or 1997 documentation guidelines. • 1995 examinations are based on the organ systems and body areas. • 1997 examinations are based on bullets outlined through specific system examinations.

43. Examination • Examination is the “hands on” examination performed by the provider • Unremarkable and non-contributory do not meet the necessary requirements (Think “no comment”) • Negative or normal meets documentation guidelines • If abnormal – reason it is abnormal must be documented

44. Template Risks for Physical Exam • The biggest risk in EMR documentation is the exam • Using the same exam for every patient, every visit, may lead to ‘over-documentation’ of the exam Examples: Patient is seen for a sore throat • Comprehensive exam is documented, mostly negative other than ears, nose, throat, respiratory and constitutional • Why is an exam done of unrelated systems?

45. 95 Examination • Body areas and systems can be acceptable for all levels of examination with the exception of the comprehensive level • Body areas: • Head, neck, chest, abdomen, genitalia, back, each extremity • Body systems: • Constitutional, eyes, ears, nose, throat, mouth, cardiovascular, • respiratory, GI, GU, musculoskeletal, skin, neurologic, psychiatric, • lymphatic

46. 95 Examination Body Areas

47. 95 Examination Organ Systems=OS

48. 95 Examination OR

49. 97 Examination General Multisystem Constitutional• Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3} pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (may be measured and recorded by ancillary staff) • General appearance of patient e.g. development, nutrition, body habitus, deformities, attention to grooming Eyes • Inspection of conjunctivae and lids • Examination of pupils and irises e.g. reaction to light and accommodation, size, symmetry •Ophthalmoscopic examination of optic discs e.g. size, C/D ratio, appearance and posterior segments e.g. vessel changes, exudates, hemorrhages Ears, nose, •External inspection of ears and nose mouth & •Otoscopic examination of external auditory canals and tympanic membranes throat • Assessment of hearing e.g. whispered voice, finger rub, tuning fork • Inspection of nasal mucosa, septum and turbinates • Inspection of lips, teeth and gums • Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx

50. 97 Examination General Multisystem Respiratory • Assessment of respiratory effect e.g. intercostalretractions, use of accessory muscles, diaphragmatic movement • Percussion of chest e.g. dullness, flatness, hyperresonance • Palpation of chest e.g. tactile fremitus • Auscultation of lungs e.g. breath sounds, adventitious sounds, rubs Cardiovascular Palpation of heart e.g. location, size, thrills • Auscultation of heart with notation of abnormal sounds and murmurs Examination of: • Carotid arteries e.g. pulse, amplitude, bruits • Abdominal aorta e.g. size bruits • Femoral arteries e.g. pulse, amplitude, bruits • Pedal pulses e.g. pulse amplitude • Extremities for edema and/or varieosities Chest (breasts) • Inspection of breasts e.g. symmetry, nipple discharge • Palpation of breasts and axillae e.g. masses or lumps, tenderness Gastrointestinal • Examination of abdomen with notation of (abdomen presence of masses or tenderness • Examination of liver and spleen • Examination for presence or absence of hernia • Examination when indicated of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses • Obtain stool sample for occult blood test when indicated