Two Out of Three Ain’t Bad

Featured Coffee – Orange Coconut Flavored Coffee

As auditors/educators, we sometimes encounter scenarios where the coding just does not “feel right.”  Unless we have a coding guideline or credible source to validate us, our “feeling” doesn’t matter.

There was a recent post on social media.  The poster was concerned that a provider did not document an examination for an established patient.  The provider documented a Detailed History and Moderate Complexity MDM to support the E/M level.

We all know that an established patient visit only requires documentation of two of the three Key Components, and everyone who responded was in agreement.  Some added comments about coding based upon time, but the original post did not indicate the documentation supported time-based coding.

What made me pause, were comments that a physical examination is not needed for an established patient.  This is inside the mind of a medical coding auditor, so here are my thoughts:

• What condition(s) (nature of presenting problem(s))would an established patient have that requires a detailed history and moderate medical decision-making, but does not require an examination of the problem-pertinent body area/organ system?

It was the detailed history that bothered me.  I mentally processed several scenarios and could not think of one.  According to any documentation on billing and coding published by CMS, medical necessity, rings in my head.  “The provider must ensure that medical record documentation supports the level of service reported to a payer. You should not use the volume of documentation to determine which specific level of service to bill.”¹

So, these were my mental scenarios:

1. Established patient presented for results of studies ordered during the last visit.
2. Established patient presented for follow-up of chronic condition(s).
3. Established patient presented for new complaint(s).

At that moment, it clicked.

 CMS guidance for Evaluation and Management Services do NOT specify a physical examination must be one of the two Key Components for an established patient.

There’s nothing in the Medicare Claims Processing Manual that states examination must be one of the two key components for an established patient visit.

Therefore, it doesn’t matter that IMHO, the provider should document an examination, if it’s the provider’s clinical judgment that an examination is not medically necessary.

 

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

You’re Dismissed

Featured coffee – Black Forest Mocha Cappuccino

I was scheduled to have a joint meeting with a group of physicians.  This was a joint meeting with a representative of the IT department.  My responsibility was to review clinical documentation improvement recommendations, and the IT guy’s responsibility was to provide technical support for the electronic health record software.

I began my discussion by reviewing medical necessity (from the payers’ perspective) of services and the importance of documentation.  The department chief interrupted me and said they only needed to know what to document to support a level 4 E/M service.  I responded they needed to document the reason for services, the services provided and planned, and the complexity of decision-making.   The level would be the level.  He cut me off and said they just wanted to know what to document to support the higher level.

The IT guy spoke up and showed the chief an E/M worksheet (for some reason, he just happened to have one with him).  He told the Chief that if they documented all of the elements on the worksheet, they would get a higher E/M level.  The chief looked at me and told me to leave!

I waited for IT Guy outside.

I’ll buy you a Starbucks®

Featured coffee – Fall in a cup Latte

Years ago, I audited a coder, and I failed all of her records.  I met with the coder and reviewed the results, and she threatened to kill me!

I joked with her manager that I would have to pay someone to start my car.

The same coder who threatened to kill me called me about a year later.  Her providers were concerned that she was under coding the E/M levels.  She asked me to audit her!

She said if I did the audit, she would buy me a Starbucks^® coffee.  I reached out to her manager first because I needed the audit added to my work order.

The manager approved the work, and I went on-site to perform the audit.  I reviewed my results with the coder, and I agreed with her coding.

She was happy, and I was relieved!