I wonder how many millions of dollars are lost due to coding errors that have nothing to do with ICD-10 but everything to do with complex and confusing requirements and new rules. I’ve said this before: I don’t believe folks make mistakes intentionally, especially when it impacts reimbursement, but I think there is a lot of coding compliance confusion. And, in my humble opinion, it’s not the coders “fault” when errors are encountered. Continue reading
How many of us have worked for providers who, regardless of showing them the descriptor in the CPT book, insist upon charging critical care time for a patient in the ICU? For coders, the directions are clear: Regardless of the location of the patient, if the provider treated a critically ill or critically injured patient for 30 or more minutes, it is appropriate to report that service with a critical care code. So, when we see those magic words within the provider’s note, we submit the appropriate code(s). But, some coders don’t see the record. Some are just given a charge slip with the patient’s identifying information, procedure and diagnosis information. What is the right thing to do in this case? Because the critical care reimbursement is much higher than other E&M codes, some clinics review documentation for all critical care codes before submitting. Each group must decide how to handle the coding of these services. Continue reading
In keeping with the theme of previous blog posts–the professional realm of E&M coding–I’d like to discuss medical necessity as it relates to the final level of care. CMS has stated that medical necessity is the over-arching criterion for payment of E&M services, which, in pure CMS fashion, gives us a goal, but not guidelines as to how to get there. We have no medical necessity policies for the differing E&M codes.
I think we all understand the intent of that statement, which I interpret as “don’t game the system”. But how do I, as a coder, teach a provider how to do that? And, how does the provider document a record to reflect the medical necessity clearly? So, let’s put a pin in that and talk about the calculation of the E&M codes, then circle back. Continue reading
As healthcare professionals, we have a lot of acronyms to keep straight, don’t we? Feels like alphabet soup in my head some days. I’m reminded of a scene in the movie, Good Morning Vietnam, where Robin Williams’ character has an entire conversation using acronyms, making fun of the military jargon. We could do the same in healthcare, especially in E&M coding.
Today, let’s think a bit about HPI, not to be confused with PHI. If you have a translator in your head the way I do, these two don’t even sound the same, but for those outside the realm of coding, these acronyms can get confusing. PHI is Protected Health Information. HPI, or History of Present Illness, is the portion of the E&M (Evaluation and Management) visit during which the patient describes why they are seeing the physician. Continue reading
In my May blog, I talked about the cost of non-compliance versus the cost of implementing ICD-10. My hypothesis: human nature is the real cost driver in health care – not code set changes. A recently released study by OIG revealed that physicians increased the billing of all E/M (Evaluation and Management) services from 2001 to 2010 (the years studied). The higher the level of E/M codes assigned, the greater the reimbursement. CMS found that E/M services are 50 percent more likely to be paid in error than other Part B services. Why? Because they are coded to a higher level which results in more money paid to the provider – physician and non physician alike. CMS identified the root cause of the overpayments – no surprise here, coding error and poor documentation. Continue reading
On May 3, 2013, CMS hosted a daylong meeting titled, “Billing and Coding with EHRs.” It was an interesting and exciting exchange between insightful speakers representing physicians, EHR vendors, CMS administrators, regulators, and industry experts on coding, documentation and medical informatics. Steven J. Stack, MD chairman of the American Medical Association’s Board of Trustees, charged that EHRs have largely become a tool for billing, compliance and litigation. He further asserted that physician productivity has been negatively impacted due to the EHR use mandate. According to Dr. Stack, “documenting a full clinical encounter in an EHR is pure torment.” Add to this that in the 2013 Work Plan, OIG intends to look at ”potentially inappropriate (E/M) payments in 2010” because CMS Contractors have noted “an increased frequency of medical records with identical documentation across services.” Continue reading