The rules and regulations for accurate coding and documentation are becoming more complex. New American Medical Association – Health Care Financing Administration (AMA/HCFA) guidelines for Evaluation and Management (E&M) documentation were proposed in 1997 only to be tabled for further revision. However, if your documentation is audited now by Medicare, their 1997 rules will apply.
Current Procedural Terminology (CPT) describes the rules for coding procedures and patient encounters. Insurance carriers, Medicare, Medicaid, managed care plans, and worker compensation carriers are all at liberty to interpret these rules. Where CPT guidelines are unclear, Medicare administrators, in particular, might choose to apply their own interpretation.
Both Medicare and private payers have stepped up their documentation audit efforts to prevent both fraudulent activities and overpayments. Although any practice may be audited through random sampling, there are certain coding and documentation behaviors that can send up the “audit me” red flag to payers. Minimize your chances for an audit by following these recommendations.
Recommendations
- Code correctly based on your documentation. Both noncompliance and documentation requirements and aberrant coding patterns can be red flags for audits. One example for a red flag is overuse of a particular category of E&M code (i.e. 9924x). Carriers expect physicians to utilize all categories of E&M codes; however, sometimes an aberrant coding pattern is legitimate. For example, most neurosurgeons see patients only at the request of another physician. The neurosurgeons over-utilization of the outpatient consultation codes might send up a red flag to the payer, but they would be an entirely appropriate use of codes.
- Require physicians to code and document services. The neurosurgeon who is in the exam room or operating room knows best what happened and why. The cashier, or secretary, does not have the medical education or understanding to make coding judgements. Similarly, the billing clerk may not adequately understand what was done, even when attempting to code from an operative report.
In our experience, the involvement of the physician is directly related to successful reimbursement. The neurosurgeon who codes typically experiences higher reimbursement and less risk for submitting incorrect codes. The accuracy rate for the support staff coding from the physician chart notes was less than 20 percent at one practice we recently visited. Therefore, coding and documentation are the steps in the reimbursement process that should be performed only by the neurosurgeon. - Use appropriate code combinations. Unbundling, or breaking down an all-inclusive CPT code into two or more codes, may send up the “audit me”flag. When you bill for incorrect code combinations, such as the 63030 (posterior lumbar discectomy) with a 22630 (posterior lumbar inter-body fusion), one code is usually denied by the carrier as “part of another code.” Medicare’s Correct Coding Initiative (CCI) is an attempt by a payer to reject certain coding combinations.
- Understand how and when to use modifiers.
Certain modifiers are red flags to carriers and overuse of these modifiers may result in an audit. Anytime you use a modifier and increase your fee accordingly, you will alert the payer. For example, the use of the -22 modifier (unusual services) normally will trigger a documentation review.
In addition to looking at the category of E&M code, payers also analyze the level of code for over-utilization patterns. If a level four code is chosen on all outpatient consultation codes, a red flag is raised at the carrier, as they expect to see the utilization of E&M codes to follow a bell-shaped curve. Since neurosurgeons typically see patients with complex problems, their utilization of higher level codes might be justified.
Stay On Top of Coding Issues It is important for the neurosurgeon and key office staff to have a thorough understanding of coding and reimbursement issues. To stay aware of and comply with such changes, the neurosurgeon should attend refresher courses, read publications, and keep up-to-speed with coding changes published in the Federal Registrar.
Kim Pollock, RN, MBA, is an instructor for the AANS PDP Courses on Coding and Reimbursement, and a consultant specializing in coding and reimbursement issues for neurosurgeons at Karen Zupko & Associates, a medical practice management consulting firm based in Chicago.