Drug Coding Advisor-Pick an E/M guideline and stick with it
Self-audits can find holes in your operation
Selecting the correct evaluation and management (E/M) code can be more art than science This is especially true given the current state of flux over issuing a final set of revised E/M guidelines. Until finalized — which may take two
more years — the Health Care Financing Administration (HCFA) says that practices can use either the 1995 or 1997 E/M guidance when making coding decisions.
Barb Pierce, a coding consultant with Professional Management Midwest, in Des Moines, IA, advises that you "pick whichever guideline works best for you, then stick with it."
She prefers the 1997 guidelines because the 1995 guidance is more vague in specialty-specific issues. For instance, the 1995 E/M guidelines provide no related definitions, but still require a comprehensive multi-organ system exam.
No matter which E/M version you choose, unless there's proper documentation to go along with your codes you risk triggering bells and whistles in the HCFA audit office.
One sure way to set yourself up for an audit is to code E&M consultation consistently at a level 4 or 5. Always claiming a high consultation level will put your claims outside the curve compared to what other physicians are submitting for similar situations, which is just the kind of thing auditors look for.
Prospective reviews help spot errors
Conducting so-called prospective reviews of claims before they are filed is a powerful way to cut down on costly errors and prevent hassles with HCFA and its intermediaries.
Here are recommendations from Pierce to help improve your prospective review of E/M codes:
• Don't take the physician's word that the documentation is adequate. Do regular sample reviews to spot any patterns of improper coding.
• Make sure medical records are complete and legible. "It's not whether you can read them, but whether a consultant or outside auditor can read them," Pierce stresses.
• Document patient encounters. This needs to include the reason for the encounter and relevant history, physical examination findings and prior diagnostic test results; assessment, clinical impression, or diagnosis; plan for care; and date and legible identity of the observer. If there is no documentation, the rationale for ordering diagnostic and other ancillary services should be easily inferred. "Medical necessity must be proved. You must link diagnosis with procedure code," she emphases.
• Other past and present diagnoses need to be available to the current treating and/or consulting physician; appropriate health risk factors should be identified. The patient's progress, response to and changes in treatment, and revision of diagnosis should be documented.
• The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record. "If the physician did a 99214, there must be documentation for a 99214," she says.
• Encounter forms and the medical record should relay the same information. "Oftentimes, the physician doesn't do documentation for days or weeks or longer," which creates the possibility of a conflict, she notes.
Tip: One way to avoid this situation is to create a "progress notes" system for physicians who don't immediately dictate their notes. This is a system in which they simply check appropriate boxes on a form when they see a patient. It is somewhat crude, but it also "prompts the physician to document certain procedures," notes Pierce.
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