E&M Coding Errors That Cost You Money Everyday

1. Steven A. Adams, CPC, CPC-H, COA E&M Coding Errors That Cost You Money Everyday

2. Doing It Right!Five Steps to Reimbursement 1. Understand the Guidelines 2. Perform the Service 3. Document What You Did (according to the guidelines) 4. Bill what you documented 5. Collect what you billed

3. Table of Contents • Outpatient Scenarios • Observation • Inpatient Scenarios • Consultation Scenarios • ER Critical Care Scenarios • Question & Answer

4. Outpatient Scenarios The time to repair the roof is when the sun is shining

5. Outpatient Scenarios • Dr. Riley went to a conference and is convinced that when documentation rules read 2 of 3 requirements he can document a detailed history, detailed examination, and low complexity and still bill a level 99214. Does medical necessity really drive code selection. • The rule states 2 of 3 - so Necessity isn’t important. 1

6. Answer Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

7. Outpatient Scenarios • Dr. sees patient for f/u and spends 40 minutes with the patient talking about an upcoming surgery. Only thing in the note states “lengthy discussion with patient.” Can you select E&M codes based upon that statement? • Unless you document a history, exam and medical decision making, you can’t select an E&M code without committing fraud. 2

8. Answer Selection Of Level Of Evaluation and Management Service Based On Duration Of Coordination Of Care and/or Counseling.--Advise physicians that when counseling and/or coordination of care dominates (more than 50 percent) the face-to-face physician/patient encounter or the floor time (in the case of inpatient services), time is the key or controlling factor in selecting the level of service. In general, to bill an E/M code, the physician must complete at least 2 out of 3 criteria applicable to the type/level of service provided. However, the physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided. Documentation must be in sufficient detail to support the claim.

9. Outpatient Scenarios • Dr. Smith is an Dermatologist who routinely brings her Medicare patients back to the office on a separate date to perform minor surgery so the claim will be paid. She states she’s confused about the “25” modifier. • Since you can’t bill an office visit and surgery on the same day, you have to bring them back. 4

10. Answer CPT Modifier 25-Significant Evaluation and Management Service By Same Physician On Date of Global Procedure.--Pay for an evaluation and management service provided on the day of a procedure with a global fee period if the physician indicates that the service is for a significant, separately identifiable evaluation and management service that is above and beyond the pre- and post-operative work of the procedure.

11. Outpatient Scenarios • Dr. Black left his practice is Warner Robbins and moved down the road to Macon. He is seeing his former patients at the new practice and bills them as “new patients” because he has a new Tax ID number. • Since he has to create a new chart, he has extra costs, and that’s why he can bill as new patient. 5

12. Answer • Definition of New Patient For Selection Of Visit Code.--Interpret the phrase "new patient" to mean a patient who has not received any professional services from the physician within the previous 3 years. • If no face to face encounter has previously occurred between the physician and the patient, then the patient may be coded as a new patient the first time a face to face encounter does occur. For example, if a professional component of a previous procedure is billed in a 3 year time period, e.g., a lab interpretation is billed but a face to face encounter does not take place, then this patient remains a new patient for whenever the initial evaluation and management service occurs. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of a face to face encounter does not affect the new patient designation.

13. Outpatient Scenarios • Dr. Cohen sees a patient in the morning for HTN. At 5pm the patient presents to the office with a large laceration that leads to a hospital admission. Dr. Cohen submitted a claim for 2 E&M codes on the same day - an office visit and hospital admission. • You can never bill an office and hospital visit on the same day. 5

14. Answer Office/Outpatient Visits Provided On Same Day For Unrelated Problems.--Do not pay two office visits billed by a physician for the same beneficiary on the same day unless the physician documents that the visits were for unrelated problems in the office or outpatient setting which could not be provided during the same encounter (e.g., office visit for blood pressure medication evaluation, followed 5 hours later by a visit for evaluation of leg pain following an accident).

15. Outpatient Scenarios • Dr. Elliott was told at a conference to have his nurse bill code (99211) when she gives a patient an injection on a date when the patient is not see the physician. He was told the nurse code pays more than a standard therapeutic injection code (90782). • Since 99211 pays more than 90782, my rep told me its ok to bill the 99211. 5

16. Answer Injection and Evaluation and Management Code Billed Separately on Same Day of Service.--Advise physicians that CPT code 99211 cannot be used to report a visit solely for the purpose of receiving an injection which meets the definition of CPT codes 90782, 90783, 90784, or 90788. Do not pay CPT codes 90782, 90783, 90784, or 90788 if any other physician fee schedule service was rendered. The drug is billed as a J code, whether the injection is separately billable or not.

17. Outpatient Scenarios • Dr. Rawlings is a busy OBGYN who sees several women needing counseling for hormone replacement therapy. Her initial visit takes approximately 120 minutes and she bills these as a level 4 new patient visit (99204). • She could use a 21 or 22 modifier to show this took longer than usual 16 / 17

18. Answer Code Time for Code 99354 99354 & 99355 99201 10 40 85 99202 20 50 95 99203 30 60 105 99204 45 75 120 99205 60 90 135 99212 10 40 85 99213 15 45 90 99214 25 55 100 99215 40 70 115 99241 15 45 90 99242 30 60 105 99243 40 70 115 99244 60 90 135 99245 80 110 155

19. Observation Scenarios Forgive your enemies, but never forget their names.

20. Observation Scenarios • Dr. Hancock wants to know what needs to be documented in order to show his patient was in observation status at the hospital. 6

21. Answer For a physician to bill the initial observation care codes, there must be a medical observation record for the patient which contains dated and timed physician’s admitting orders regarding the care the patient is to receive while in observation, nursing notes, and progress notes prepared by the physician while the patient was in observation status. This record must be in addition to any record prepared as a result of an emergency department or outpatient clinic encounter.

22. Observation Scenarios • Dr. Mays puts his pregnant patient in observation for pre-mature labor at 9AM on Monday. Later that day the patient is discharged with an appointment to f/u with Dr. Mays next week. He selects CPT code 99219 to reflect this service. • He should have picked his observation and his discharge - he did two services. 6

23. Answer Physician Billing For Observation Care Following Admission To Observation.--If the patient is discharged on the same date as admission to observation, pay only the initial observation care code because that code represents a full day of care. 99234, 99235, 99236 wrong in MCM

24. Observation Scenarios • Dr. Ramos has a patient in observation for three days. On day one he bills an initial observation code (99218) and day three an observation discharge code (99217). On day two Dr. Ramos selects a subsequent hospital code 99214. • 99214 can only be used in the office and not in the hospital 6

25. Answer In the rare circumstance when a patient is held in observation status for more than two calendar dates, the physician must bill subsequent services furnished before the date of discharge using the outpatient/office visit codes. The physician may not use the subsequent hospital care codes since the patient is not an inpatient of the hospital.

26. Observation Scenarios • Dr. Riley sees puts her patient in observation on Monday morning and then admits the patient to the hospital later that night. She coded both the initial observation code (99219) and initial hospital admission code (99222) on the same day. • If patient is admitted 3 or more hours after their office visit you can bill both codes with a -59 modifier. 6

27. Answer Admission To Inpatient Status From Observation.--If the same physician who admitted a patient to observation status also admits the patient to inpatient status from observation before the end of the date on which the patient was admitted to observation, pay only an initial hospital visit for the evaluation and management services provided on that date.

28. Observation Scenarios • Dr. Woods places a patient in observation on Monday and admits them to the hospital on Tuesday. She selects the initial observation code (99219) on Monday. For Tuesday she selects an observation discharge code (99217) and initial hospital care code (99222). • If you discharge from observation and admit to hospital you can bill all codes since this is a different sight of service 21 vs 22. 6

29. Answer If the patient is admitted to inpatient status from observation subsequent to the date of admission to observation, the physician must bill an initial hospital visit for the services provided on that date. The physician may not bill the hospital observation discharge management code (code 99217) or an outpatient/office visit for the care provided in observation on the date of admission to inpatient status.

30. Inpatient Scenarios We must use time as a tool, not a crutch.

31. Inpatient Scenarios • Dr. Bhagat admits her patient in morning, and must f/u with the patient later in the day because of increased N/V/D. She billed for both her admission (99223) and subsequent hospital visit (99233). • When a separate visit occurs in the afternoon, after admission, you can bill the second visit with a -59 modifier if you have an additional diagnosis. 8

32. Answer Two Hospital Visits Same Day (same physician).--Pay a physician for only one hospital visit per day for the same patient, whether the problems seen during the encounters are related or not. Advise physicians that they may not report two hospital visits on the same day to the same patient. The inpatient hospital visit descriptors contain the phrase "per day" which means that the code and the payment established for the code represent all services provided on that date. The physician should select a code that reflects all services provided during the date of the service.

33. Inpatient Scenarios • Dr. Bhagat sees her patient in the morning for her pre-term labor and another physician not in her group - Dr. Shaw - who is covering call that night, is called into the hospital because the patient has increased abdominal pain unrelated to the pre-term labor. Dr. Bhagat and Dr. Shaw both bill for their services. • Dr. Shaw is not in Bhagat’s group and has a different provider number so he can bill 8

34. Answer Hospital Visits Same Day But By Different Physicians.--In a hospital inpatient situation involving one physician covering for another, if physician A sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening, do not pay physician B for the second visit. The hospital visit descriptors include the phrase "per day" meaning care for the day.

35. Inpatient Scenarios • Dr. Howard admits his patient into the hospital at 1:00AM for dizziness. At 10PM he discharges the patient and bills an initial hospital code of 99223 and discharge of 99238. • Patient is in for less than 24 hours so we can bill for both the admission and discharge on same day if we use a -25 modifier to show a separately identifiable service in the morning. 8

36. Answer Initial Hospital Care and Discharge on Same Day.-- Pay only the initial hospital care code when a patient is admitted as an inpatient and discharged on the same day. Do not pay the hospital discharge management code on the date of admission. Instruct physicians that they may not bill for both an initial hospital care code and hospital discharge management code on the same date. – 99234, 99235, or 99236) – wrong in MCM

37. Inpatient Scenarios • Dr. Strickland discharges his patient from the hospital and admits them to an area nursing home on the same day. Dr. Strickland bills for the hospital discharge only and does not bill for the nursing home admission. • Doctors can never bill two E&M Codes on the same day - you’ve already taught us that. 9

38. Answer Hospital Discharge Management (CPT Codes 99238 and 99239) and Nursing Facility Admission Code When Patient Is Discharged From Hospital and Admitted To Nursing Facility on Same Day.--Pay the hospital discharge code (codes 99238 or 99239) in addition to a nursing facility admission code when they are billed by the same physician with the same date of service.

39. Consultation Scenarios We stand for freedom. That is our conviction for ourselves; that is our only commitment to others.

40. Consultation Scenarios • Dr. King is a Gynecologist who was told to never bill a consult code if a patient presented to him with an established diagnosis. • Consultations can only be billed on patients who present without a specific diagnosis. 10

41. Answer • Consultation Versus Visit.--Pay for a consultation when all of the criteria for the use of a consultation code are met: • (1) Specifically, a consultation is distinguished from a visit because it is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source (unless it is a patient-generated confirmatory consultation). • (2) A request for a consultation from an appropriate source and the need for consultation must be documented in the patient’s medical record. • (3) After the consultation is provided, the consultant prepares a written report of his/her findings which is provided to the referring physician.

42. Consultation Scenarios • Dr. Kusuma is a GYN doc who ordered a diagnostic endoscopy procedure on a patient with severe abdominal pain. • When a doctor decides to treat a patient during the initial visit, he is not able to bill a consultation code. This is abuse and would be easily detected during a review. 10

43. Answer A physician consultant may initiate diagnostic and/or therapeutic services at an initial or subsequent visit. Subsequent visits (not performed to complete the initial consultation) to manage a portion or all of the patient’s condition should be reported as established patient office visit or subsequent hospital care, depending on the setting.

44. Consultation Scenarios • Drs. Johnson and Adams are Orthopedic surgeons in the same group. Dr. Johnson does hands and Dr. Adams does legs. Dr. Johnson requested a consult from Dr. Adams regarding a patients knees. Dr. Adams billed his visit with the patient as an established patient visit 99213. • Of course doctors in the same group can bill consultations, even if they are the same specialty. 10

45. Answer Consultations Requested by Members of Same Group.--Pay for a consultation if one physician in a group practice requests a consultation from another physician in the same group practice as long as all of the requirements for use of the CPT consultation codes are met. (See §§15506A and 15501.H.)

46. Consultation Scenarios • Dr. Wiloghby is an interest in Augusta. On any given day he is asked to do a pre-operative consult on his patients needing cataract surgery. Because these patients have already been seen by Dr. Wiloghby, he bills them as 99214 - established patient visits. • You can not bill a consultation on your own patient. Consultations are only for new patients to your office. 11

47. Answer • Consultation for Preoperative Clearance.--Pay for the appropriate consultation code for a pre-operative consultation for a new or established patient performed by any physician at the request of a surgeon, as long as all of the requirements for billing the consultation codes are met.

48. ER & Critical Care Scenarios We need men who can dream of things that never were.

49. ER / Critical Care Scenarios • Dr. Murphy is an Ophthalmologist and receives a call from one of his patients complaining of severe floaters. Dr. Murphy is playing golf and does not want to drive all the way back to the office so he asks the patient to meet him in the ER. The patient does not register with the hospital. Dr. Murphy bills an ER code (99283). • The only codes you can use in the ER are ER codes. 12

50. Answer Advise physicians that if the physician asks the patient to meet him or her in the emergency department as an alternative to the physician’s office and the patient is not registered as a patient in the emergency department, the physician should bill the appropriate office/outpatient visit codes.