Research and Ask Questions

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As coders and even auditors, we don’t always have the answers.  We have to know how to research and know when to ask for help.  I always tell coders that if you think you know it all, get out of the industry because you’re a liability to yourself, your employer, and your physicians.

Our coding books and resources for coding clarification are our primary tools.  We also need to have resources such as a medical dictionary, a book of medical abbreviations and terminology, and anatomy references.

I audited a newly hired coder and met with her to review the findings.  I had many disagreements with her E/M levels to discuss with her.

We reviewed each note, and I abstracted the key components with her.  We then concentrated on the areas where we disagreed – HISTORY, specifically the HPI and the EXAM.  Each time, I abstracted more elements of HPI or EXAM than the coder.  That was the pattern!

I asked the coder why she didn’t count specific terms or abbreviations documented by the provider.  According to the coder, she didn’t know the terms or abbreviations, so she just ignored them.

She down coded levels of services when the documentation supported higher levels.  She did not research the abbreviations or terms, she did not reach out to her supervisor or coworkers for help, and she did not make any effort to strengthen her area of weakness.

It wasn’t her lack of knowledge that concerned me.  It was her lack of commitment to learning.  “Can’t do” is a teachable opportunity but “Won’t do” is grounds for termination.

 

Problem Pertinent Examination

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According to CMS, medical necessity is the overarching criterion in determining the level of Evaluation and Management services.  CMS has published  Evaluation and Management Services Guide that states. “You should not use the volume of documentation to determine which specific level of service to bill.”    How do we as coders determine what in the documentation is medically necessary for coding purposes?

I had an extensive discussion with a provider regarding the medical necessity of his documented examination. According to CMS, “The levels of E/M services are based on four types of examination:  

Problem Focused – A limited examination of the affected body area or organ system  

Expanded Problem Focused – A limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s) 

Detailed – An extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s)  

Comprehensive – A general multi-system examination or complete examination of a single organ system (and other symptomatic or related body area(s) or organ system(s) – 1997 documentation guidelines)”[1]

Each level requires documentation of examination of the affected body area or organ system.  This means the problem pertinent body area or organ system that requires evaluation and/or management. 

I met with a small group of Pediatricians to review their audit results. I gave each one his results and my plan was to meet with each provider individually, but they wanted a group session.

So, we sat around the conference table, and I started with the first physician. It went well, I explained why I disagreed with the E/M levels and we reviewed a few together. On to the next physician, but I observed one of the other providers looked agitated. I made a mental note to save him for last. 

It was really good feedback and discussion with each of the providers. By this time, I was prepared for Dr. Agitated. 

Dr. Agitated pushed an audit form over to me and asked why I failed the record.  He said that he performed an expanded problem-focused history, a comprehensive examination, and he documented moderate complexity medical decision-making for an established patient diagnosed with Otitis Media. 

I pointed out the chief complaint (presenting problem) was ear pain and we reviewed and agreed with all of the elements of HPI, ROS, and PFSH.  Next, we reviewed his documented exam.  I agreed that he documented a head to toe exam, but I did not allow credit for the exam because he did not document an examination of the ears (the problem pertinent area).  The chief complaint was ear pain!

The provider has to document the exam of the problem pertinent area before he can expand the exam.  I assured him that I was confident that he performed an examination of the ears (the problem pertinent area), but because he did not document it, the exam did not “count.”  

[1] https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf

 

 

 

Stop The Fakery

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In this industry, preparation is critical.  We have to anticipate questions.  When I’m preparing material, I already know the talking points that will generate questions or additional discussion from the group and I do everything I can to be prepared.

It means thinking outside of me.  If the information was presented to me, what questions would I have? As a new coder, what questions would I ask the presenter?

I had to go onsite to audit some coders and I checked in with the coding manager before leaving for the day.  She suggested I check out a coding seminar that was being done for providers before I left.

I went over, signed in, and sat in the back of the auditorium. I didn’t know the presenter because she was with another coding consulting firm.

The providers had many questions. The presenter did not have the answer to the first question and she said that she would research and get back to the provider.  I thought it was odd because it was a simple question.

Another provider asked a question and again the presenter said that she had to research and get back to him.  There was a palpable negative energy in the auditorium so I raised my hand and answered his question.  The presenter thanked me and continued her presentation.

Then another provider asked a question and once again, the presenter could not provide the answer. The provider turned to me and asked if I knew the answer. By this point, I felt so awkward, but I answered his question.  This time, the presenter sarcastically invited me to come down to the front with her, but I just smiled and declined.

As expected, she didn’t have an answer to the next question either.  I just gathered my books and left the room.  One of the doctors followed me and asked who I was.  I told him I was the coding consultant for the facility.  He asked if I was available to have a session with his group.  I gave him my business card and advised him to call to get on my schedule.

If the presenter cannot answer questions or provide details, the presenter will lose all credibility.  If you put yourself out there as the expert, the expectation is that you have high-level knowledge of the subject matter.  You cannot just read from a script.  You also cannot do quick research to learn the subject and then present yourself as an expert.

Know your subject and anticipate questions.