Denials Chapter 9 Evaluation & Management Flashcards
Evaluation and Management Denials
Specific information is required to describe the patient encounter each time the patient presents for medical services. Clinicians may review past records or speak with other healthcare professionals, gather specific information from the patient through a series of questions, and physically assess the patient. The clinician will then summarize their findings and create a plan to treat the patient. Each encounter will generally contain:
The chief complaint is a description of why the patient is presenting for healthcare services. It can also be referred to as the reason for the patient visit.
The history of present illness (HPI) is how the patient describes the symptoms they are experiencing, and which have prompted the patient to seek medical attention.
The physical examination is performed by the healthcare provider through a series of assessments and observations, focused around the symptoms described by the patient.
The healthcare provider makes a determination (also known as a diagnosis) about the cause of the symptoms, which is the provider’s assessment of the problem. Based on that assessment, the provider creates a plan to relieve or resolve the patient’s symptoms.
The most common format used in medical records is the SOAP format:
S — Subjective: where the patient provides information about their symptoms and what, if anything, they have done to relieve the symptoms.
O — Objective: indicates the physical exam findings of the provider.
A — Assessment: the provider’s assessment of the patient’s condition, and where the provider indicates either a definitive or working diagnosis. In absence of a diagnosis, signs and symptoms may be documented until further testing can be performed.
P — Plan: the provider’s plan is documented in direct relation to the assessment above. In cases where a definitive diagnosis has not been reached, the documentation should reflect tests that are being ordered, with an indication of the provider’s thought process.
Regardless of the format used by the provider, it is imperative the documentation of an evaluation and management visit accurately reflect the work performed during the visit.
If a minor office procedure is performed during an evaluation and management service, the documentation for that procedure can be included in the notes for the evaluation and management service. It is not necessary to have a separate operative report.
A documentation specialist must be familiar with the documentation requirements of the E/M and procedure codes used by physicians and NPPs to bill for their services.
The E/M Documentation Guidelines (DGs) have perhaps inspired more discussion than any other non-clinical topic based in the industry. In an ever-increasing effort to ensure that correct payments are made for visits and consultations, Medicare and the AMA have been working together for well over a decade. In 1992, Medicare transitioned to the Resource-Based Relative Value Scale (RBRVS) physician payment system and the AMA introduced E/M codes in CPT® to report visits and consultations.
By 1994, in response to confusion and the inaccurate interpretation of the codes, the Office of Management and Budget mandated that Medicare adopt DGs to expand the definition that was, at that time, only provided by CPT®. Medicare and the AMA jointly developed this initial set of E/M DGs which were deployed in 1995 and became known as the 1995 DGs or DGs. Medicare also worked with the Marshfield Clinic to design an E/M audit worksheet from the 1995 DGs. The tool could be used by local carriers in their review of the documentation of E/M claims. As auditing showed a pattern of continued misuse of the E/M codes, the 1995 DGs were criticized as unfair to specialists because they seem to account for extended single system examinations with as much weight as limited multiple system exams. Within two years, the E/M DGs were revised to improve physician and provider understanding and payment accuracy by extending the definitions to include specialty specific guidance.
This set of DGs was scheduled to replace the 1995 DGs and became known as the 1997 DGs. The only problem with this is that the physician community loudly objected to the 1997 DGs. They were criticized as burdensome with documentation requirements that were too detailed and very difficult to achieve. In fact, some physician felt that the administrative requirements were taking them away from the core objectives of their clinical care. In response to this, Medicare decided to not replace the 1995 DGs but to instead allow physicians and providers to choose between the 1995 and the 1997 DGs. In turn, Medicare audits E/M documents by whichever set of DGs provide the physician or provider with the greatest benefit, and to protect the Medicare Trust Fund from inaccurate payments.
In an effort to reduce the burden of documentation, CMS and AMA revised the guidelines for Office or Other Outpatient Services in 2021.
CMS continues to assess documentation guideline mechanisms — including the Medicare Learning Network — which will support physicians and providers and allow them to consistently bill correctly. It is important to note that many non-Medicare payers follow Medicare DGs but for specific payer policy, it is necessary for physicians to confirm the rules with each of their payers in their state.
Question: We have been using CPT® codes 99396 or 99397 for preventive medicine visits/annual wellness visits for patients on Blue Cross Medicare Advantage plans, but we have been getting denials and patients are being billed for the services. Are these codes covered, or should we be using G0402 or G0438/G0439?
Answer: Payment for 99396 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years or 99397 … 65 years and older may depend on the Blue Cross Medicare Advantage plan in question.
Anthem Blue Cross, for example, recognizes the services and state that there “are no out-of-pocket expenses for the member … when the routine physical is completed by an in-network provider in an HMO and/or PPO plan”. Traditional Medicare, however, does not cover 99396 and 99397, and other Blue Cross Medicare Advantage plans may follow traditional Medicare in this regard.
These services are not the same as G0402 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment, which is commonly known as the Welcome to Medicare visit. These services are also distinct from G0438 Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit and G0439 … subsequent visit.
The initial preventive physical examination (IPPE) and annual wellness visit (AWV) are described as preventive, but they vary in their content. For instance, they do involve a physical exam, but clinical responsibilities for the IPPE and AWV involve more counselling and education than might occur in 99396/99397. Codes 99396/99397, on the other hand, tend to involve a more thorough physical exam.
In fact, you can actually bill for an IPPE or an AWV in addition to 99396/99397, providing you append modifier 25 to the 99396/99397 if it is performed on the same day.
Question: A patient of ours was hospitalized for a urinary tract infection. On the same day he was discharged, he also came to our office to be treated for anemia. When we tried to bill for the visit, we were denied because the procedure code/bill type was deemed inconsistent with the place of service, even though we had appended modifier 25 to the E/M visit. Is there any way we can get paid for this encounter?
Answer: There could be several reasons for the denial. The first reason could be that your claim used the wrong place of service (POS) code. As the E/M service occurred at your provider’s office, make sure you use POS code 11 Office and not 21 Inpatient hospital on the claim.
Another reason could be that the anemia is related to the infection which, in turn, was the reason for the hospitalization. An office E/M service on the same day as a hospital discharge won’t get paid unless the condition your provider is treating in the E/M is unrelated to the discharge. This is because the hospital discharge codes — 99238 Hospital inpatient or observation discharge day management; 30 minutes or less on the date of the encounter and 99239 … more than 30 minutes on the date of the encounter — include everything medically necessary for the patient to continue their recovery, rendering an additional E/M service related to the condition unnecessary. As noted in a parenthetical instruction following 99239 in CPT®, “These codes are to be utilized to report all services provided to a patient on the date of discharge, if other than the initial date of inpatient status.” Consistent with this understanding, the NCCI has edits that prohibit payment for an office/outpatient E/M service for the same patient on the same date as either of the two hospital discharge day codes. Further, NCCI does not permit any modifier to override these edits. If the payer in question uses NCCI edits, that may explain the denial for the office visit.
If the office visit was truly unrelated to the hospital discharge and the reason for the patient’s hospitalization, then you may be able to appeal the denial on that basis with appropriate documentation. As always, you should check with your payer to confirm the reason for the denial and whether you can adjust the claim to enable reimbursement for your provider’s services.
Question: We were recently audited, and an established patient visit was marked as incorrect because the auditor considered the patient to be new. We had seen the patient within the last three years, so can you advise what could have gone wrong?
Answer: A close reading of CPT®’s new and established patient guidelines reveals much more than the simple definition that a new patient is one that has not received services from your practice in three years prior to seeing your provider. CPT® also requires that:
1.The services need to be professional. “Professional” means services following the CPT® definition of being performed by a physician or other qualified healthcare professional.
2.The services need to be face-to-face. CMS has determined that services such as diagnostic tests or radiologic interpretations do not affect a patient’s status unless they are accompanied by an E/M or other face-to-face service.
3.The services need to be in the same specialty or subspecialty. This part of the definition can be significant for large practices that may employ subspecialists, as patients that may be regarded as established in one specialty may be classified as new when they are seen for the first time by a specialist in a different field.
It’s unclear which one of these three criteria your office may have misinterpreted, but if, for instance, the patient merely bought glasses from your office and never saw a practitioner face-to-face in the last three years, that patient would likely be considered “new” rather than “established.”
Question: We reported 99213 as well as the colonoscopy screening code G0121, and we used modifier 25 on the E/M code. Our payer used to reimburse us for this but we’re now seeing denials. Should we appeal?
Answer: Probably not. If your gastroenterologist frequently reports an E/M code (99202-99215) along with her screening colonoscopy services, check the documentation for notes that would support the E/M code — in most cases, this information is insufficient to report both an E/M and a colonoscopy.
For instance, you note that your physician reported 99213 with most of her screening colonoscopies, such as G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk.
Ask this: When reviewing the documentation, question what the chief complaint is for the E/M visit. A patient presenting solely for the purpose of a screening colonoscopy would likely not have a chief complaint to report. Therefore, it’s clear that the documentation does not meet the medical necessity for an E/M service.
In addition, NCCI does typically bundle these codes together. You note that you append modifier 25 to the E/M code, but you can only bill this way if you provide a separately identifiable and medically necessary E/M service. If the gastroenterologist is only seeing the patient for the screening colonoscopy and no other issues, your notes most likely do not support the use of this modifier.
Therefore, in most cases, for Medicare patients, you will not use the E/M code for your colonoscopy visits. The circumstances differ however for patients in commercial plans governed by the Affordable Care Act (rather than, for example, some ‘grandfathered’ plans such as plans offered through self-insured employers); in these circumstances, the Department of Labor issued guidance that patients are entitled to a pre-screening colonoscopy visit even in the absence of symptoms. Some plans expect use of E/M codes for outpatient office visits (99202-99205, 99212-99215, most typically at a lower level if there are no serious medical issues to be assessed or treated); some plans may expect a preventive care service; and some recognize only the BlueCross BlueShield code S0285. There should be no cost-sharing (deductible or copay) imposed by the payer. Check with the payer to see what they require.
Consider this example: During a 15-minute visit with an established patient, your physician spends more than eight minutes discussing treatment outcomes and possible problems of hepatitis. The patient also has several other conditions including diabetes and resolved colon cancer. The gastroenterologist documents a detailed history, an expanded problem-focused exam, and medical decision making (MDM) of moderate complexity.
In this case, coding based on time would warrant 99213, which has a reference time of 15 minutes for this visit if the documentation is sufficient to support the medical necessity for spending the time.
However, the history and MDM justify 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; a detailed examination; medical decision making of moderate complexity…), which pays more than 99213 when performed in the outpatient setting. Therefore, you’d be shorting your practice if you billed based on time in this instance.
Question: My physician performs mostly high-level consultation visits, some justified, some possibly not. What can I do?
Answer: Some providers see very sick patients with complex medical disorders, prompting them to report mostly higher-level E/M.
Medical necessity is the key to successful coding and reimbursement, and you can’t support your code choice without it. In the Social Security Act (Title XVIII of the Social Security Act, Section 1862 [a] [1] [a]) Medicare says, “No payment may be made under Part A or Part B for expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”
If, during consultations, for example, your physician appears to be ticking off exam and history elements that insurers won’t deem medically necessary, sit down with the doctor and have a chat about insurance rules. For instance, if a patient presents for GERD and the doctor performs a complete integumentary and ophthalmological exam, you may want to ask if those were medically necessary for that diagnosis. If not, explain to the physician that it’s the medical necessity that should drive the code choice rather than the E/M bullets alone.
Question: We’ve had multiple insufficient documentation denials. What can we look for to combat this?
Answer: Although the documentation may look thorough, if you look deeper, you can often find things like unsigned forms, lack of detail, and missing treatment orders — and all of these things can prompt denials. Take a good look at the providers’ documentation to see if there’s room for future improvement.
Tips: There are things you can do to help lower the percentage of payment errors blamed on insufficient documentation. These examples can help guide you as you look for these issues:
Educate yourself on when your providers signatures are needed on documents or when they need to provide forms.
Educate your physicians on documenting everything they do during an encounter to ensure you can code what they actually did.
Spot check the physician’s documentation, looking for consistent errors for which you can provide education.
Do a pre-bill review either periodically or until you have a comfort zone for the physician’s documentation supporting the billed services.
Example: An established patient comes to your office for a colonoscopy. Your gastroenterologist sees the patient prior to the scope and performs an unrelated E/M service because the patient says he has acid reflux. The physician says he examined the patient and prescribed an antacid; however, the history, exam, and MDM only relate to the colonoscopy. The doctor’s notes don’t mention the reflux condition or prescription.
Therefore, you can only report the scope. Because there are no notes to support the unrelated symptoms needing a problem-oriented encounter, you cannot separately report an E/M service for the reflux evaluation and treatment.
Question: When selecting an E/M code based on time, what documentation is required?
Answer: Before using time as the controlling factor, check the type of E/M encounter you are reporting. The time-based coding rules differ for office/outpatient encounters, thanks to the 2021 E/M guideline changes.
According to CPT® guidelines, “Time may be used to select a code level in office or other outpatient services whether or not counseling and/or coordination of care dominates the service. Time may only be used for selecting the level of the other E/M services when counseling and/or coordination of care dominates the service.”
For an office/outpatient encounter that you are reporting with 99202-99205 Office or other outpatient visit for the evaluation and management of a new patient … or 99212-99215 Office or other outpatient visit for the evaluation and management of an established patient …, you’ll choose a code based on the total time for E/M services performed on the date of the encounter. Each code descriptor lists the time range which applies to the code.
For other E/M services, check off these requirements that must be documented before billing based on time alone:
The total time spent with the patient
That more than 50 percent of the face-to-face time the physician spent with the patient/and or family is counseling/ coordination of care. For instance, “Saw the patient for 25 minutes face-to-face; 20 minutes of that visit was spent in counseling.”
A description or summary of the counseling/coordination of care provided. For the example above, you could consider, “Done to address coping strategies for the patient’s diagnosis of overactive bladder and treatment options.”
Background: When medical auditors review non-office/outpatient E/M claims, they typically code the reports based on history, exam, and medical decision-making, unless the physician meets the criteria to code a claim based on time spent with the patient. However, full-time auditors will tell you that they hear from physicians at least once a day who argue that, although their documentation may not support levels four or five, the codes are justified based on the fact that the patient had many questions and counseling took up to an hour of their time.
Myth: Your provider’s argument that they spent a significant amount of time counseling the patient justifies high-level codes.
Reality: The physician’s memory may be pristine, but it can’t be relied upon if the payer asks for a refund due to insufficient documentation. Instead, your physician must note the content of the conversation with the patient in the record as well as the time spent.
Coding for a provider’s services must be based exclusively on the documentation of the service, experts say. Therefore, it is imperative that the documentation accurately portrays the services provided not only for coding compliance but also malpractice risk management. Payer reviews often do not occur within a week of services. It is difficult for providers to remember the specifics of a patient visit a week ago, let alone a month ago, a year ago or even several years ago.
Avoid templated documentation: While you want to encourage your provider to document the time criteria when time-based billing is most appropriate, you don’t want your provider to go too far in the opposite direction.
Providers who use a templated statement in all of their documentation such as “I spent greater than 50% of the ___ visit counseling the patient” in which they routinely fill in the blank with the time required for a level-four or level-five service, risk repercussions during a payer review. The documentation does not provide the required detail regarding what the provider counseled the patient on.
Key: Medical necessity must also be a key factor in your code choice. Be sure that the time spent with the patient is warranted. Just because the patient and provider talked for a long time doesn’t mean it was medically necessary to do so.
