American College of Physicians: Internal Medicine — Doctors for Adults ®

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Clinicians crucial to avoiding coding errors

From the January ACP Internist, copyright 2010 by the American College of Physicians

By Stacey Butterfield

DENVER—Consultant Nancy M. Enos knows that many physicians don’t see coding as an important part of their job, but she also knows what happens when they pay too little attention to the topic. In addition to consulting for MGMA Healthcare, Ms. Enos does auditing and coding education for medical practices.

Open dialogue between doctors and coders avoids po...

Open dialogue between doctors and coders avoids potential for abuse or underpayment.



“There are horror stories about coders who took too many liberties,” she said. Ms. Enos used one of those stories to begin her lecture on coding essentials before a packed audience at the Medical Group Management Association’s annual meeting in October.

“A coder was trying to do a really good job,” she explained. The doctor and owner of the practice, a dermatologist, had written a letter of medical necessity for one procedure that should have been covered by insurance. “She [the coder] got overexcited because the letter was sent in and the company paid the claim. So she copied it and sent it in with all the claims.”

It took a while for the insurers to notice the pattern, but when they did, the companies demanded all of the inappropriate payments back. When Ms. Enos heard the story, the dermatologist had already paid one insurer $660,000 and was working out arrangements with others.

This sort of problem can be avoided by a physician and/or practice administrator paying attention to coding and billing and being aware of certain common trouble spots, Ms. Enos said. “You should be taking a pulse on your billing.”

The Medicare Recovery Audit Contractor (RAC) program should provide an additional motivation to keep an eye on coding. It expanded from a pilot to a nationwide system last August, and under the pilot phase, at least $700 million in payments were retracted for being inappropriate or excessive.

Common problems, easy fixes

One of the main causes of returned payments is underdocumentation for higher-level services, Ms. Enos said. It’s a common problem, and one to which physicians with electronic medical records are not as immune as they might think. “You should be very cautious in relying on software to code your E/Ms exclusively,” she said.

An electronic system might assign a higher-level code of 99204 or 99245 based on the quantity of content in a field, but the required components and medical necessity have to be fully documented to justify the larger payments.

For example, the higher-level office consult codes (99244 and 99245) require a comprehensive history and exam. “So if one thing is not documented in the history of present illness, the review of systems, and the past family/social history, that becomes a level 3, even though the doctor could have done a very thorough exam and a very complicated assessment and plan,” Ms. Enos said. (See chart for a list of common codes and their requirements.)

She offered some tips for making sure that thorough exam has the documentation to back it up. For example, a higher-level visit requires a comprehensive review of systems and recording of both positive and negative results, but that doesn’t mean a physician has to list all 15 systems in the note. “In order to have complete review of systems, they say three magic words: all others negative,” said Ms. Enos. “When I audit charts, that makes all the difference.”

A word of caution should go with that advice, however, Ms. Enos said. Many Medicare carriers frown on the liberal use of the phrase “all others negative,” although it is allowed under the CMS 1997 documentation guidelines. Concerned that the catchphrase could lead to overlooking stable chronic conditions, carriers may reject the documentation when they feel that the review was not actually done.

Another thing Ms. Enos likes to find on chart audits is good time documentation. The amount of time spent can be an easily documented justification for a higher-level code when more than half of the patient encounter is spent on counseling or coordination of care. How does an efficient doctor record that? “They just write 35/40 minutes and summarize the issues discussed. There’s really not that much they need to do to document if they are putting down the amount of time,” Ms. Enos said.

The documentation of time can be particularly valuable when a patient is being discharged from the hospital. In the inpatient setting, all time spent at the bedside or on the hospital floor or unit counts toward your total, meaning that conversations with family and other typical day-of-discharge activities can contribute to justifying a higher code.

“It doesn’t have to be continuous,” Ms. Enos pointed out. If five, 10, or 15 more minutes eventually adds up to more than 30 minutes spent on discharge, it’s a 99239. “And that pays $110 versus 99238 for $80. Many physicians don’t put time in their discharge summaries,” she said.

Misused modifiers

Many physicians also don’t use code modifiers. Coders do, because they know that the extra numbers are an effective way to get rejected claims paid, but that’s not the way modifiers are meant to work, Ms. Enos said. “The modifiers really shouldn’t be used as a way to fix claims. They should be used from the front end of the revenue cycle process as a means to provide additional information.”

That means physicians have to understand the modifiers, especially the common and commonly misused ones, because proper use is based on information gleaned during the patient encounter.

For example, modifier 24 (unrelated visit during post-op) could be triggered by a hand-on-the-doorknob moment during a post-op visit. “The patient says, ‘Oh, by the way,’ and it becomes a more extensive visit,” said Ms. Enos. The physician should document the separate issue to get it paid outside of the global surgical period.

Other commonly misused modifiers include 25 (separately documented E/M and procedure), which indicates that the patient’s appointment was for something other than the procedure. “The problem with modifier 25 is that sometimes an aggressive coder will put an office visit code every time a patient comes in for an appointment for a procedure. You really need to ask the question, ‘Did the patient know when they came in today that they were having that procedure done?’”

Modifier 25 is such an issue that Medicare has a lengthy paper on it, Ms. Enos said. (It’s available online.)

Avoid these common mistakes

Annual physicals are an area where physicians need to be careful to avoid Medicare fraud. “Doctors want to be kind to their Medicare patients and call it a comprehensive visit, instead of a yearly physical, because Medicare doesn’t cover physicals. But that is absolutely fraud,” Ms. Enos said. Instead, practices should bill Medicare for any covered services that were provided as part of the physical, and then only bill patients for the remainder.

Another way that visits mistakenly become comprehensive is the carrying over of chronic diagnoses into unrelated visit notes. “Only report a diagnosis as long as it pertains to the current episode of care,” Ms. Enos said.

Much of Ms. Enos’s advice is targeted at avoiding overcoding, but she also frequently encounters the problem of undercoding. Just because a visit seems simple doesn’t mean that you’re not entitled to more payment for it. “It’s easy, but that’s not really the criteria for coding. If a doctor calls most of his [level] 4s a 3, then most of the 3s get called 2s,” she said.

For example, a physician might not see anything complex about diagnosing a new patient with otitis media and prescribing amoxicillin, but it meets Medicare’s standard for moderate medical decision-making. “Assuming the doctor wrote down a good history of present illness, even if only that area was examined, it is a 99214.”

On the subject of sick visits, here’s another common error: If you’re seeing a patient you’ve never met before because you’re covering for another physician, that’s not a new patient. The covering physician should code as the usual physician would. Such patients may be new to you, but to the insurer, your access to their medical records makes them established.

It’s only one example of the ways in which coding language differs from normal communication. Ms. Enos once audited a clinician who coded all of her visits as consults because she “consulted” with the patient and family.

To make sure no one in your practice is committing similar mistakes, it’s a good idea to regularly compare your practice’s codes to benchmark data for your specialty, on as specific a basis as possible. “Try to do it on a provider basis. If you have one doctor who overcodes, one doctor who undercodes, you’re not going to get a full picture,” said Ms. Enos.

She also recommends building good lines of communication between physicians and coders. “If there’s open dialogue, then you can avoid huge problems that have potential for abuse or not collecting money.”

Coders should also attend seminars to keep up on the latest in the field. And someone, whether it’s a coder or a physician from inside the practice or an auditor hired from outside, should do the occasional audit of 10 to 20 charts per provider to make sure everyone’s coding is on track.

“With the RAC auditors being so active, you want to make sure you’re checking yourself before they check you,” Ms. Enos said.

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