Doing It Right the First Time - E&M Auditing 101

Steven A. Adams, CPC, CPC-H, COA Doing It Right the First Time -E&M Auditing 101

Ever Feel Like This? You Will

2005 CPT Coding Update Recent Medicare Audit Findings what did “The Man” find last year 2005 OIG Workplan what is “The Man” looking for this year Auditing new patients & established patient notes using my tools to audit successfully Questions & Answer Period Topics

Doing It Right The First Time!Five Steps to Proper Reimbursement 1. Understand the Guidelines 2. Perform the Service 3. Document What You Did (according to the guidelines) 4. Bill what you documented 5. Collect what you billed

Hide not your talents. They for use were made. What's a sundial in the shade. Ben Franklin 2005 Coding Update

2005 Changes 171 new codes 61 revised codes 46 deletions 1.5 Increase in Reimbursement The Conversion Factor (CF) for 2005 will be 37.8975 up from 37.3374 in 2004.

2005 Changes ICD-9-CM has more than 800 changes in the tabular section alone October 1st April 1st http://www.instacode.com/news-2005-changes.htm

Avoiding trouble is largely a matter of knowing the rules & remembering your audience.

CPT What you did Here Are The Rules ICD-9 Why you did it

Here’s Your Audience Criminal Justice Field Accountants Biologists “Most individuals do not have training in the health care field.” CMS and OIG

Recent Findings Optimism is essential to achievement and it is also the foundation of courage and true progress. Nicholas Murray Butler

CMS 2004 E&M Report 20 Billion in Overpayments

CMS 2004 E&M Report 1 Billion in Under payments

All Specialties: 43.7% Failed to have sufficient documentation to support the code submitted 29.7% Did not respond to request for error rate reviews (and deemed to have insufficient documentation) 17.2% Prescribed medically unnecessary services 7.7% submitted incorrect codes. The most common coding mistake physicians made in 2004: billing one level of E&M higher or lower than allowable .

Expect Audits... Infectious Disease 23.7% Nephrology 23.2% Cardiac Surgery 22.3% Pulmonary Disease 20.2% Radiation Oncology 18.2% Endocrinology 17.8% Pediatrics 17.7% Intreventional Radiology 17.3% Plastic Surgery 16.8% Internal Medicine 16.2%

2005 OIG Workplan He who can, does - he who cannot, teaches. George Bernard Shaw

2005 Watch For... • Billing Services :The preferable method for compensating a billing company for their services is a flat fee per month or a fee based on the number of claims processed rather than a percentage of collections. • Care Plan Oversight(CPO) • Ordering Physicians Excluded by Medicare • Physician Pathology Services • Coding for Evaluation and Management Services • Use of Modifier 25 • Use of Modifiers With National Correct Coding Initiative Edits (CCI) • The complete Work Plan is available on the OIG Web site at http://oig.hhs.gov/publications/docs/workplan/2005/2005%20Work%20Plan.pdf

1 E&M Coding & Auditing There are liars, damn liars, and statistics. Mark Twain

7 Components First Established 1992 • History • Examination • Decision-making • Counseling • Coordination of care • Nature of presenting problem(s) • Time

Outpatient Visit New / Consults 99201 - 99245 “Requires All Three Key Elements”

Medicare Transmittal 1644 • Consultation Versus Visit - Pay for a consultation when criteria is met: • …opinion is requested by another physician • …need for consultation is documented in note • …written report is provided to referring physician Payment may be made regardless of treatment initiation unless a transfer of care occurs. A transfer of care occurs when the referring physician transfers the responsibility for the patient’s complete care at the time of the referral.

Medicare Transmittal 1644 • Consultation for Preoperative Clearance - Pay for the appropriate consultation code for a pre-operative consultation for a new or established patient performed by any physician at the request of a surgeon, as long as all of the requirements for billing the consultation codes are met.

Remember • If you bill it as a consultation visit you must state it is a consult. • Thank you for allowing me to see your patient in consultation for…. • Patient being seen in consultation at the request of Dr……

Level 1 Level 2 Level 3 Level 4 Level 5 Self limited problem Self limited problem OTC, minor surgery Undiagnosed problem Rx management Endoscopy surgery without risk factors Major surgery risk factors Major surgery with risk factors Complex problem with data review New - Consults

History 1 1. Problem Focused 2. Expanded Problem Focused 3. Detailed 4. Comprehensive

Audit Form HPI: location duration severity quality context timing signs/symptoms modifiers ROS: cons eye ent resp muscle psych cv gi gu skin neuro lymph endo allergy all other systems negative – counts as 10 EXAM: Systems: cons eye ent resp muscle psych cv gi gu skin neuro lymph Areas: head chest abdomen neck back genitalia each extremity

Just Do It • New Patients / Consults • Get a Comprehensive History • Do Comprehensive Exam • Select Code Based Upon MDM

History Component 12,13 99205 60 • Comprehensive • Chief Complaint • Extended HPI (4+) • Complete Review of Systems (10) • Complete PFSH (3)

History Component 99205 60 • Comprehensive • Chief Complaint • Extended HPI (4+) • Complete Review of Systems (10) • Complete PFSH (3)

1995 Exam 1 1. Problem Focused 2. Expanded Problem Focused 3. Detailed 4. Comprehensive

Audit Form HPI: location duration severity quality context timing signs/symptoms modifiers ROS: cons eye ent resp muscle psych cv gi gu skin neuro lymph endo allergy all other systems negative – counts as 10 EXAM: Systems: cons eye ent resp muscle psych cv gi gu skin neuro lymph Areas: head chest abdomen neck back genitalia each extremity

Examination Component 14 • Comprehensive • 8 System Exam Const: Well Developed Eyes: PERRLA CV: RRR Lungs: CTA Abd: + Bowel Sounds Skin: Warm, Dry Neuro: Intact Psych: A & O X 3

1997 Exam 1 Single System Examinations Cardiovascular Male GU / Female GU Neurological Eye Psychiatric ENT Musculoskeletal Hematological Respiratory Skin

1997 Single System Exam Based on Elements Problem focused = 1 Expanded problem focused = 6 Detailed = 12 Comprehensive = All in a “shaded area” one in each non-shaded area

Based on Elements Problem focused = 1 Expanded problem focused = 6 Detailed = 12 Comprehensive = All in a “shaded area” one in each non-shaded area

Which One Should I Use I recommend the 1995 guidelines However If your doctor is doing a “specialty exam” it better match the 97 guidelines Exactly

Medical Decision Making 6 1. Straightforward 2. Low Complexity 3. Moderate Complexity 4. High Complexity

Auditing Notes • What you might find initially during your audits

Note #1

Doing It Right the First Time - E&M Auditing 101