What a Week!

Featured coffee –Tiramisu

Last week was exhausting for me.  I had a group of coders who worked overtime to find reasons to disagree with my findings.

They used everything but coding guidelines to defend their coding.  One coder cited a specialty society’s practice parameter recommendations as a defense.  Another quoted an article that did not cite sources, and another coder gathered opinions from social media groups.

Credible sources include AMA, the Medicare Claims Processing Manual,  Current Procedural Terminology (CPT®), ICD-10-CM®,  AHACoding Clinic^®, or CPT® Assistant or payer-specific guidelines.

I’m not discounting specialty society’s coding guidance – as long as credible sources such as AMA, CPT®, ICD®, CMS, or other payers are cited in their guidance.

Specialty Societies such as American College of Obstetricians and Gynecologists (ACOG), American Society of Anesthesiologists (ASA), American College of Cardiology (ACC), just to name a few, have coding resources on their sites that cite coding guidelines specific to each specialty. Still, I recommend that coders review the cited sources for additional information.

Practice parameters established by the societies are not coding guidelines.  American College of Radiology (ACR), is an excellent example of recommended practice parameters.  These recommendations are educational tools to assist Radiologists in providing care to patients, not coding guidelines to be used by coders.

Articles, including blogs, are not official coding guidelines.  I write blogs, but I include hyperlinks to the official guidelines or resources that coders can use for validation.

And of course, we all know, Cite Your Source (Your Opinion Doesn’t Matter)

I encourage coders to defend their codes, but I expect coders to cite credible sources to defend their coding.

 

 

ICD-10® is copyrighted by the World Health Organization (WHO)

Coding Clinic® is a registered trademark of the American Hospital Association

CPT® is a registered trademark of the American Medical Association

AMA 2021 E/M Introductory Guidelines Published

Featured coffee –Oatmeal Latte

The AMA, which publishes CPT®, has released the updated Introductory Guidelines for evaluation and management services effective January 1, 2021.

I’ve included links for the E/M Code and Guideline Changes and the revised Medical Decision-Making Grid.

Significant changes for 2021!

Here’s a summary of the significant changes:

• Sunset requirements for three of three key components for new patients and two of three key components for established patients.

Providers should still document the medically appropriate history and/or physical examination.  For coding, history and physical examination are not components in selecting office or other outpatient E/M levels.

• The level of service may be selected based upon the level of medical decision-making or the total time for E/M service performed.
• 99201 will be deleted for 2021.
• Except for 99211, time may be used to select E/M levels for 99202-99205 and 99212-99215. 99211 will no longer have associated time in CPT®.
• Before 2021, E/M levels can only be assigned based upon time if greater than 50% of the time was spent counseling and/or coordinating care.

Effective January 2021, for office or other outpatient services, time may be used to assign E/M level whether or not counseling and/or coordination of care dominates the service.

• The time descriptors for E/M levels will change in 2021.

• If time is spent supervising clinical staff who performed the face-to-face service, the physician or other qualified health care profession should use 99211.

• A shared or split visit based upon time is defined for services effective January 2021.
• The time personally spent by the physician or other qualified health care professional assessing and managing the patient on the date of the encounter is summed to define the total time for shared/split visits.
• Medical decision-making is completely redefined for 2021. My advice is to laminate the MDM grid because that page in the book will be ripped and torn quickly.

The Amount and/or Complexity of Data to be Reviewed is very different effective January 2021.  It’s now the Amount and/or Complexity of Data to be Reviewed and Analyzed.

This section includes categories that must be documented.  For example, 99204 or 99214 includes three categories for Amount and/or Complexity of Data to be Reviewed and Analyzed, and the requirements of at least one of the three categories must be met to assign Moderate complexity.

CPT is a registered trademark of the American Medical Association.

How Do Coders Determine Medical Necessity?

Featured coffee – Baklava Latte

A coder asked how she should determine what’s medically necessary for an evaluation and management service and how she should explain the rationale to her physicians.

Well, we know, according to CMS IOM Publication 100-04, Chapter 12 Sec. 30.6 E/M Services Codes, “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.”

We all quote this guideline, but how do we explain it to a clinician?  This does not advise a coder how to determine medical necessity, and each time we quote this guideline, we are challenged by practitioners to cite a source that documents what is “medically necessary” to treat the patients’ complaints.

Non-clinical coders are hesitant to downcode an evaluation and management service because we don’t possess the clinical knowledge to determine what is medically necessary to treat patients, and CMS’ guideline does not provide sufficient detail for a discussion with the providers.

As a result, let’s look further.

According to CMS’ Evaluation and Management Services Guide, “The documentation of each patient encounter should include Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results.”

What stands out to me in this statement is “relevant.”

Also, in the document, “When billing for a patient’s visit, select codes that best represent the services furnished during the visit. A billing specialist or alternate source may review the provider’s documented services before submitting the claim to a payer. These reviewers may help select codes that best reflect the provider’s furnished services. However, the provider must ensure that the submitted claim accurately reflects the services provided. 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. Services must meet specific medical necessity requirements in the statute, regulations, and manuals and specific medical necessity criteria defined by National Coverage Determinations and Local Coverage Determinations (if any exist for the service reported on the claim). For every service billed, you must indicate the specific sign, symptom, or patient complaint that makes the service reasonable and necessary.”

Any provider can use a template, check off every box, and document a comprehensive history and exam, but is it relevant to the reason for the encounter?

For example, the provider documented Comprehensive History and Examination for a 21-year-old otherwise healthy male established patient who presented for a complaint of ankle pain after running a marathon.

It’s simple to abstract four HPI elements, but let’s go to the documented Complete Review of Systems.

Ask your provider if it is relevant to the presenting problem.  This is where your knowledge of anatomy, physiology, and disease process comes in when you have the discussion.  You’re not questioning the quality of care that the physician is providing to the patient (you’re not qualified), you’re asking if it’s relevant to the presenting problem for coding – based upon guidance from CMS.

Is it pertinent to the presenting problem to abstract review of Eyes, Ears, Nose, Mouth, Throat, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Psychiatric, or Endocrine? Or that all others are negative (if allowed by your Fiscal Intermediary)?

Is it pertinent to the presenting problem to abstract that both parents are alive and well for Family History?

Is it pertinent to the presenting problem to abstract that the patient is a single college student for Social History?

That Comprehensive history is now detailed.  Let’s look at the Comprehensive 1995 Exam.

Is it pertinent to the presenting problem to abstract examination of body areas: Head, including the face; Neck; Chest including breasts and axillae; Abdomen; Genitalia, groin, buttocks; Back, including spine?

Is it pertinent to the presenting problem to abstract examination of organ systems: Eyes; Ears, nose, mouth, and throat; Cardiovascular; Respiratory; Gastrointestinal; Genitourinary; or Psychiatric?

For coding purposes, we no longer have a Comprehensive Exam.

Therefore, the way to approach your physicians is to not discuss what is or is not medically necessary.  Remember, we’re not treating the patients, and we’re not qualified to assess that quality of care.

Focus on what is relevant for coding the level of service based upon the above guidance from CMS.