5E-Emergency Physician E/M Coding

through the Eyes of the Medicare

Administrative Contractor (MAC)

Presented by:

Stephanie Cecchini, CPC, CEMC, CHISP

steph@aviacode.com

Objectives

• The participant will learn

– Why ED E/M coding is under high MAC scrutiny

• & vulnerable for audit

– How to select an ED level of service, including Critical Care

– How to safeguard accuracy and avoid E/M Coding mistakes

– How to help health providers (enjoy) documentation improvement education

• Plus…a guided review of the professional coding of real ED (redacted) services will be conducted to demonstrate the correct use of codes.

CODING TRENDS On the Radar

• May 2012 OIG study found high level coding trends on the rise.

• The most dramatic surges were found in emergency rooms.

– During the study period, physicians increased billing the highest code (99285) by a startling 21 percent.

MAC scrutiny

• ED E/M coding is under MAC scrutiny & vulnerable for audit

– Audits show increased use of 99285 and 99284

– ED coding results in two claims – both use CPT

– Hospitals are permitted to set their own rules for billing outpatient charges

– When they don’t match it sends a flag

Why is MAC interested?

• Healthcare spending to increase avg 17% by 20148

– Control costs & save Medicare

• Increased audits

– Recovery up from $75M in 2010 to $670M in 2011.

– E/M audits added by Connolly in 15 states 2 territories

• Technology

» EHR use on the rise

» HIPAA and HITECH: MU 1 and 2 increased to

» ICD-10

Relationships

• MU + EMR CDI = (Increased Bill - RAC audit)

– Letter from Attorney General

• “troubling indications” of abuse 12

• Cloning

• Template abuse

• Provider Education

• Secondary Staff Education

Compliance

Necessity Technology

No Room for Innocent Mistakes

Current Events… • CMS issued its annual Medicare Recovery Auditor report to Congress,

confirming that recovery audit contractors collected $797.4 million in overpayments from hospitals and other providers and repaid $141.9 million in underpayments in fiscal year 2011.

• “E/M services are vulnerable to abuse, with payments jumping 48 percent, from $22.7B to $33.5B in a decade” –OIG (5/8/2012)

• CMS plans to increase prepayment reviews to 2.7M from 1.2 M

• HHS boasts record year in 2011 $4.1B healthcare fraud recovery

• The Affordable Care Act significantly increased HHS’ ability to suspend

payments until an investigation is complete.

Select an ED level of Service

• ED

– 99281

– 99282

– 99283

– 99284

– 99285

• Critical Care

– 99291

– +99292

closer look...

9

Hx 9928x HPI:

1.Location

2. Quality

3. Severity

4. Timing

5. Context

6. Modifying Factors

7. Duration

8. Associated S&S

ROS:

1. Constitutional

2. Eyes

3. ENMT

4. Cardio

5. Respiratory

6. GI

7. GU

8. MS

9. Skin

10. Neuro

11. Psych

12. Endo

13. Hemat/Lymp

14. Allergic/Immuno

PFSH:

1. Past

2. Family

3. Social Type

New

Patient

LEVEL

Brief:

1

N/A N/A Problem

Focused 1

Brief:

1

Problem Pertinent:

1

N/A Expanded

Problem

Focused 2-3

4

or

1997:

status of 3 chronic

Extended:

2

Pertinent:

1 Detailed 4

Extended:

4

or

1997:

status of 3 chronic

Complete:

10

Complete:

3

Comp 5

10

Hx 9928x

HPI:

1.Location

2. Quality

3. Severity

4. Timing

5. Context

6. Modifying Factors

7. Duration

8. Associated S&S

ROS:

1. Constitutional

2. Eyes

3. ENMT

4. Cardio

5. Respiratory

6. GI

7. GU

8. MS

9. Skin

10. Neuro

11. Psych

12. Endo

13. Hemat/Lymp

14. Allergic/Immuno

PFSH:

1. Past

2. Family

3. Social Type LEVEL

Brief:

1

N/A N/A Problem

Focused 1

Brief:

1

Problem Pertinent:

1

N/A Expanded

Problem

Focused 2-3

4

or

1997:

status of 3 chronic

Extended:

2

Pertinent:

1 Detailed 4

Extended:

4

or

1997:

status of 3 chronic

Complete:

10

Complete:

3

Comp 5

CC: knee pain

Pt states “I fell off a step stool about four hours ago and landed on my knee.

It has been tight, red and painful. It’s swollen”. Pt denies motor disturbances including

balance, coordination. Pt takes Zoloft 25 mg QD.

Special Circumstance

• Special Circumstance

– Patient is unable to give a history.

– (ROS) and (PFSH) History taken from an earlier encounter

• May not be medically necessary

– A comprehensive service may be performed and documented but …

• A comprehensive service is not always medically necessary or billable.

– Unless Preventive, a Chief Complaint (CC) must be identifiable

• This is the first step in establishing medical necessity.

12

95 DGs 9928x

Body Areas:

Head/Face

Neck

Back

Abdomen

Genitalia

Chest/axillae/breast

Each Extremity

Systems:

Constitutional

Eyes

Ears, nose, mouth and throat

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Musculoskeletal

Skin

Neurologic

Psychiatric

Hematologic, lymphatic immunologic

Number of Areas/Systems Examined Type LEVEL

1 PF 1

2 Limited EPF 2-3

2 Extended Detailed 4

8 (Systems only) Comprehensive 5

13

95 DGs 9928x

Body Areas:

Head/Face

Neck

Back

Abdomen

Genitalia

Chest/axillae/breast

Systems:

Constitutional Eyes

Ears, nose, mouth and throat

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Musculoskeletal Skin

Neurologic

Psychiatric

Hematologic, lymphatic immunologic

BP 120/80. The patient’s gait is

normal. Some tenderness. There

is no knee effusion. The medial and

lateral collateral ligaments are

intact.

Number of Areas/Systems Examined Type New Patient LEVEL Est. Patient LEVEL

1 PF 1

2 Limited EPF 2-3

2 Extended Detailed 4

8 (Systems only) Comprehensive 5

14

MDM

• Different audit forms vary in this component and may produce different codes – Before coaching, obtain the audit form used by the physician’s local

Medicare carrier

• Code selection is based on the relative level of difficulty in making a diagnosis and by the status of the problem (controlled versus worsening.)

• The amount of work involved in reviewing the necessary data and the immediate risk of the patient are very important aspects of documentation

15

Number of Dx

- Minor =1 ea. (max 2) - Est. stable/improved = 1 ea. - Est. worsening =2 ea. - New problem, w/o workup =3 ea. (max 1) - New problem, w workup=4 ea.

Example

Type

New or Established Outpatient LEVEL

Minimal:

1 point as totaled from above

Uncomplicated, non-

infected insect bite

Straight-

forward 1 Limited:

2 points as totaled from above

Controlled HTN and

tachycardia

Low

2 Moderate:

3 points as totaled from above

New patient with migraine

headaches

Moderate

3-4 Extensive:

4 + points as totaled from above

Patient seen today for f/u

on OA knees and 1 year

THR check. C/O knee pain.

MRI ordered for possible

meniscus tear. R/O

symptom of osteoarthritis

and sprain

High

5

16

Data 9928x One Point Each:

Clinical Labs test ordered or reviewed

CPT® Medicine Section Test- ordered or reviewed

CPT® Radiology Section Test- ordered or reviewed

Discuss patient results with performing or consulting

physician

Decision to obtain old records or additional history

from other than patient

Two Points Each:

Review and summarize data from old records or

additional history gathered from other than patient

Independent (2nd) interpretation (from another

physician) of an image, tracing, specimen (not just

review of the report)

Type

LEVEL

Minimal:

1 point as totaled from above

Straight-forward 1

Limited:

2 points as totaled from above

Low 2

Moderate:

3 points as totaled from above

Moderate 3-4

Extensive:

4 + points as totaled from above

High 5

17

Risk 9928x

CMS TABLE OF RISK Overall Risk between planned encounters

Any example listed from a row below for any of the three columns will equal a level of risk.

1. Presenting Problem(s) 2. Diagnostic Procedure(s) Ordered 3. Management Options Selected Type

New or Established Outpatient LEVEL

• One self-limited or minor problem, eg

cold, insect bite, tinea corporis

• Laboratory tests requiring venipuncture

• Chest x-rays

• EKG/EEG

• Urinalysis

• Ultrasound, eg, echocardiography

• KOH prep

• Rest

• Gargles

• Elastic bandages

• Superficial dressings

Straight-forward 1

• Two or more self-limited or minor

problems

• One stable chronic illness, eg, well

controlled hypertension or non-insulin

dependent diabetes, cataract, BPH

• Acute uncomplicated illness or injury,

eg, cystitis, allergic rhinitis, simple sprain

• Physiologic tests not under stress, eg,

pulmonary function tests

• Non-cardiovascular imaging studies

with contrast, eg, barium enema

• Superficial needle biopsies

• Clinical laboratory tests

requiring arterial puncture

• Skin biopsies

• Over-the-counter drugs

• Minor surgery with no identified

risk factors

• Physical therapy

• Occupational therapy

• IV fluids without additives

Low 2

• One or more chronic illnesses with mild

exacerbation, progression, or side effects

of treatment

• Two or more stable chronic illnesses

• Undiagnosed new problem with

uncertain prognosis, eg, lump in breast

• Acute illness with systemic symptoms,

eg, pyclonephritis, pneumonitis, colitis

• Acute complicated injury, eg, head

injury with brief loss of consciousness

• Physiologic tests under stress, eg,

cardiac stress test, fetal contraction stress

test

• Diagnostic endoscopies with no

identified risk factors

• Deep needle or incisional biopsy

• Cardiovascular imaging studies with

contrast and no identified risk factors, eg

arteriogram, cardiac catheterization

• Obtain fluid from body cavity, eg,

lumbar puncture, thoracentesis,

culdocentesis

• Minor surgery with identified risk

factors

• Elective major surgery (open,

percutaneous or endoscopic) with

no identified risk factors

• Prescription drug management

• Therapeutic nuclear medicine

• IV fluids with additives

• Closed treatment of fracture or

dislocation without manipulation

Moderate 3-4

• One or more chronic illnesses with

severe exacerbation, progression, or side

effects of treatment

• Acute or chronic illnesses or injuries

that pose a threat to life or bodily function,

eg multiple trauma, acute MI, pulmonary

embolus, severe respiratory distress,

progressive severe rheumatoid arthritis,

psychiatric illness with potential threat to

self or others, peritonitis, acute renal

failure

• An abrupt change in

neurologic status, eg, seizure, TIA,

weakness, or sensory loss

• Cardiovascular imaging studies with

contrast with identified risk factors

• Cardiac electrophysiological tests

• Diagnostic Endoscopies with identified

risk factors

• Discography

• Elective major surgery (open,

percutaneous or endoscopic) with

identified risk factors

• Emergency major surgery (open,

percutaneous or endoscopic)

• Parenteral controlled substances

• Drug therapy requiring intensive

monitoring for toxicity

• Decision not to resuscitate or to

de-escalate care because of poor

prognosis

High 5

ED Audit Reference 9928x

Critical Care

• 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes

– Critical illness: Acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition. Examples:

• Stroke

• Acute MI

• Acute Kidney Failure

• Trauma

• Respiratory Failure

Critical Care

• Time counted must be exclusively devoted to patient

• Teaching time does not count

• Does not have to be continuous

• Physician must document total time on chart per calendar day

• Includes pro fees interpretation of labs, diagnostic studies, and procedures inherent in critical care. – Blood gases, Chest films, Measurement of cardiac output, Other

computer stored information, Pulse oximetry, Gastric intubation, Transcutaneous pacing, Ventilation assistance and management, Venous access, arterial puncture

• 99292 = each additional 30 minutes (after 75)

Safeguard Accuracy

• Know what the rules and risks are:

– OIG work plan

• Claims Submitted by Top “Error-Prone” Providers (using CERT data)

• Submitting claims that are not medically necessary

• Incident to services

• Unbundling

• Failure to properly use coding modifiers

• Clustering

• Up coding the level of service

• Cloning

• HITECH payments

Compliance Resources

• CPT guidelines

• ICD-9 Official Guidelines

• CMS.gov Internet-Only Manuals (IOMs)

– Medicare Claims Processing Manual

• Chapter 12 - Physicians/Nonphysician Practitioners

– Medicare Benefit Policy Manual

• Associations

• Medical policies by private payers

• Joint Commission

• Code of Federal Regulation and the Federal Register

Documentation Improvement Education

• Help clinicians with documentation

– Doctors don’t see documentation requirements as having an effect on the patient outcome, making it classified as a very low priority

– Learning that no matter how hard they work, how hard they try, how much effort they have given for the patient may not correlate with coding and payment is difficult.

– This can lead to a barriers in the coder-physician working relationship

Growing Numbers Need Help • 700K physicians in the US1

– 63% (442K) bill E&M services2

– 20% (and growing) are employed by hospitals3

• 2011 average medical school grad debt = $161K

• 5K- 63K fewer doctors than needed by 20154

• 33% are in Private practice ↓ From 57% in 2007

• 46% would NOT choose medicine again as a career5

• On again, off again regulations (SRG, ICD-10), difficult compliance

rules (E/M, HIPAA, MU), other high costs (malpractice)

• 80% of those in pre-med will not be accepted to medical school

• Medical school

– Average student financial debt in 2007 was $139,517

– 75.5% of students graduate with debt of at least $100,000

– 87.6% of graduating students have outstanding loans

Appreciating Physician Development

2008 2023

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023

2008 - 2012

Under-Grad

2012 - 2015

Medical School

2019 - 2020

Fellowship

2016 - 2023

Residency

2019

License to Practice

• Effective Education promotes change

– Get buy in from the provider

• Discuss risk

– Lost Revenue, Fines, Penalties, Denials, Post Payment Audits & Recovery

• Use current accurate authoritative information

• Use actual records

• Equate to loss recovery

– It’s not personal

• Know your provider and how they respond best

Educating Clinicians

Problem • Without supporting documentation: Physicians can’t be paid

properly

• Codes are based on a scale of how sick your patient is

– A physician is best qualified to make that judgment

• Codes are supported by documentation

– Documentation can be a time consuming, “big brother” distraction from care

• Solution for Physicians:

– We are here to help you

• Learn to code based on how sick a patient is (and you decide that)

• Understand what documentation is required to support that code

Just tell me: What’s a Level 5?

• YOU tell us!

– The level of service coded is based on how sick a patient is and meeting documentation requirements.

– There is no one better qualified to determine medical necessity than the physician.

oDuring the next few minutes, you’ll learn how to use your clinical expertise to quickly ascertain the correct code and what you need to document to support the services you render.

Scale of 1-5

• Levels 3-5* are reserved for “sick” or injured patients.

– Lower levels are for patients who present with minor and/or well controlled condition/s.

*This presentation refers to levels of service for outpatient visits.

How sick is sick?

Pt

Actively

“sick” or injured?

Pt

w/ stable or inactive

Condition/s?

Pt w/ minor or self

limited problem/s?

Start:

A medically necessary, separately billable, evaluation and management service.

Dr. is treating (or Tx is impacted by all diagnoses counted)

No

No

Pt risk of life or

limb between now &

next encounter?5Yes Yes

3 or 4

No

More than 1

problem?

2 or 3

Yes

No

Yes

1 or 2

More than 1

problem?Yes

No

More than 2

problems?2 or 3

2 or 3

Yes Yes

No

Preventive

Medicine

No

More than 3

problems?4 or 5

3 or 4

Yes

No

*This chart should only be used for the purpose of guiding discussion: it references new outpatient visits

Sickest (99285)

• Presenting Problem: An illness or injury that poses a

threat to life, chronic severely exacerbated, abrupt change in

neurological status

– Typically the patient’s situation is serious, imminent, and

uncertain

• Severe exacerbation of CHF

• Patient presents confused in diabetic ketoacidosis

• Morphine Sulfate IVP ordered for chest pain not

controlled by Nitro

• Patient brought by parents after a failed suicide attempt

• Patient post fall on ski slopes with extradural hematoma

Sick (Example: 99283)

• Typical Presenting Problem: 1 –2 minor, 1-2 stable chronic, 1-2 acute uncomplicated

– Typically the diagnosis is known and/or made during the encounter

– Future follow up is often classifiable as routine

• Patient returns with productive cough x 10 days for antibiotic

• Patient with choroidal revascularization to assess efficacy of anti-VEGF

• Follow up Patient with cystocele not requiring treatment

• Patient in follow up with stable angina and no new symptoms

• Return visit for patient with worsening plantar fasciitis

• Non pregnant female with resolving hyperemesis

• Patient with well controlled hypertension and hypercholestorolemia

Sicker (99284)

• Presenting Problem: 2-3 stable chronic, chronic exacerbated, acute with systemic symptoms or injury

– Typically the diagnosis is known and worsening/complicated or further testing is required

– Future follow up is often classifiable as routine or sooner

• Patient with choroidal revascularization now with new central vision loss

• Patient in follow up with stable angina, not tolerating medication

• Patient with suspected cellulitis of the lower leg

• Patient with heel ulcer and drainage

Real World Examples

• Guided review of the professional coding of real ED (redacted) services will be conducted to demonstrate the correct use of codes.

Guided Review

Patient Sally Smith DATE OF VISIT: 12/02/2012

CHIEF COMPLAINT: High blood sugar.

HISTORY OF PRESENT ILLNESS: This is a 77-year-old male, who had been hospitalized (past) at XXX Hospital last week (duration) apparently with pancreatitis secondary to common bile duct stones. He had an ERCP it sounds like and a stent placed and did well. For some reason, the doctors in that hospital cut his insulin dose in half (modifying factor). He had been taking 43 units of glargine insulin at bedtime and they reduced him to 20. His blood sugars have been running high (context) in the 300 to 400 range since he got home. He does have sliding scale insulin and today, his fingerstick was 554 (severity) and the on-call nurse told him to go to the emergency department. He has no symptoms. He says he is feeling well. He denies any fever or chills (constitutional), vomiting, diarrhea, (GI) cough (respiratory) , dysuria (Urinary), or other sign of an infection (immunologic).

ED Audit Reference 9928x

Guided Review

PAST MEDICAL HISTORY: Congestive heart failure, hypertension, elevated cholesterol, cardiomyopathy, coronary artery disease, and incontinence. MEDICATIONS: Hydrochlorothiazide. Simvastatin. Ramipril. Oxybutynin. Insulin. Finasteride. Aspirin. Carvedilol. Isordil.Vicodin. (Past)

ALLERGIES: PEANUTS AND NUTRASWEET. (Allergies or Past)

SOCIAL HISTORY: The patient is a nonsmoker. He does have wine daily. (Social)

FAMILY: Parents deceased (Family)

REVIEW OF SYSTEMS: All negative except as documented in HPI (ROS)

ED Audit Reference 9928x

Guided Review

PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.6, pulse 84, respirations 18, blood pressure 173/69. (constitutional) GENERAL: This is an alert, well groomed, male SKIN: Warm and dry, color is good. Without rash. Intact no wounds. (skin) HEENT: Pupils are equal and react to light. conjunctivae and lids normal. (eyes) NECK: supple without adenopathy. (lymphatic) CHEST: Normal breathing effort. Clear. (respiratory) HEART: Regular rhythm without murmur. S1 S2 normal (cardio) EXTREMITIES: Without tenderness, edema, or cyanosis. pedal pulses normal. NEUROLOGIC: Alert and Oriented x 3. Cranial nerves 2 through 12 grossly intact. No sensory or motor deficits. Deep tendon reflexes normal (neuro)

ED Audit Reference 9928x

Guided Review

EMERGENCY DEPARTMENT COURSE: The patient had laboratory obtained. He had an IV established of normal saline and was given a 500 mL fluid bolus and then 200 mL/hour and regular insulin 8 units IV (Rx Drug). In 1 hour, his sugar was rechecked and it is 229. Laboratory obtained here today show a WBC of 5,700, 71 neutrophils, 18 lymphocytes, 4 monocytes, 2 eosinophils and 1 basophil, hemoglobin 12.4, hematocrit 36.3. Sodium 138, potassium 3.7, chloride 103, CO2 27, glucose 352, at the time of the initial labs, BUN 13, creatinine 1.0, bilirubin 1.5, ALP 397, ALT 71, AST 45, negative serum ketones. Lipase low at 70. Urine shows 4+ glucose, negative ketones, no bacteria, 29 white cells, 5 red cells. Urine culture will be set up. (labs)

ED Audit Reference 9928x

Guided Review

IMPRESSION: Diabetes, poorly controlled.

PLAN: The patient will increase his insulin tonight to 30 units. He will contact Dr XXX tomorrow for advice on adjusting his insulin dosage. He will return here p.r.n.

Dr Jonny Jones, M.D

Electronic signed in EMERGENCY DEPARTMENT REPORT 12/02/2012 by Dr Jonny Jones, M.D

ED Audit Reference 99284

Questions?

• Stephanie Cecchini, CPC, CEMC, CHISP – VP Coding Operations Steph@aviacode.com