You may walk the walk, but do you talk the talk?
Documentation critical to accurate billing
Here are five strategies for addressing areas of practice billing that are often riddled with errors, as well as ways to improve your billing processes and keep federal fraud investigators off your back:
1. Document all findings. Many physicians, especially surgeons, frequently fail to document the number of a patient’s bodily systems they review, which could lift an office visit out of a level one exam. This is the case despite the fact that Medicare’s evaluation and management (E/M) documentation guidelines require a history of present illness, a review of systems, and medical, social, and family histories.
"You find the docs often forget to note that the results of a review of a particular system were negative, even though they’d get credit for reviewing that system if they did," says Lisa Warren, of Warren, Averett, Kimbrough & Marino, a consulting firm located in Birmingham, AL.
For instance, if you find the cardiovascular system was negative, you can get credit for reviewing that system if you write "regular rate and rhythm."
2. Verify consults. Many physicians don’t adequately document consults in the medical records, notes Warren. For example, coding rules say the consulting physician must explicitly state that "this is a consult for Dr. X" to qualify as a consult. The lesson is that it is not enough to use a consult code without also documenting in the dictation who the consultation was for. As such, physicians need to get in the habit of saying, "This patient was referred to me by Dr. X and we are looking at Y."
It is also important for consulting physicians to stay in communication by copying the ordering physician in the dictation. "Part of the definition of a consult is that you communicate with the referring doctor what you did with this patient," says Warren.
3. Note the little things. Physicians frequently fail to document routine parts of an exam, such as taking the patient’s temperature, blood pressure, weight, and height. "This is all part of the exam," Warren says. "Some physicians don’t realize this counts toward the bullets for the exam" in the Medicare E/M documentation guidelines.
Tip: Even if the nurse checks vital signs and writes the results in the chart, the doctor still gets credit, because a physician still has to sign off on the exam and dictate what happened for transcription.
4. Report lab results. Failing to report lab results reduces the complexity of medical decision-making, which lowers the level of service that can be billed. "When you order lab tests or review the results of an X-ray, for example, be sure to dictate that you looked at the data and took whatever action was appropriate," says Warren.
If you have an in-house lab in your office, reporting lab results in your notes or transcription and recording how it affected your treatment plan is a particularly important part of the documentation process.
5. Look for what’s missing. One cause of undercoding is that physicians often fail to give their coders the full story about the procedures they perform each day. For example, a surgeon may tell his clerk he performed an appendectomy that morning, but he may forget to report that he performed another procedure, so the clerk submits a bill for less than what could legitimately be billed.
Tip: Many experts recommend waiting until you’ve received a copy of the hospital’s operation notes before billing a surgery, because the surgeon may have misstated something or the clerk may have misunderstood the type and number of procedures performed, which could lead to either underbilling or overbilling.
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