E/M coding workshop. The risk of not getting it
right.
PAMELA PULLY CPC, CPMA
BILLING/CLAIMS SUPERVISOR
GENESEE HEALTH SYSTEM
Disclaimer
This information is accurate as of December 1, 2014
and is designed to offer basic information for coding
and billing. All information is based on experience,
training and has been researched, interpreted and
carefully reviewed by this trainer. Medical
compliance/coding and billing information changes
quickly. This can become outdated. This is intended
to be an educational guide and should not be
considered as legal or consulting opinion.
Disclaimer cont.
 I use CPT, HCPCS and ICD-9 books for coding
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information.
Rules come from AMA, ICD-9, CMS and other
carriers.
HIPAA and PPACA laws.
Any questions on information I am presenting please
ask. I will give you the source document used.
It is important to me to give the best and most up to
date information I can.
Presenter
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Pamela Pully
8 years at Genesee Health System
30+ years billing/coding/auditing most specialties.
Two national certifications from the American Academy
of Professional Coders (AAPC)
CPC - Certified Professional Coder
CPMA – Certified Professional Medical Auditor
Member of (AAPC), Past officer of local chapter.
Member of the National Alliance of Medical Auditing
Specialist (NAMAS)
Current officer of Michigan Association of
Reimbursement Officers (MARO)
Goals for Training
 Understand the over all risk of not coding
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evaluation and management correctly.
Bell curves and the important role they play in
assessing risk.
Have a better understanding of Evaluation and
Management (E/M) codes.
Understand the components and elements of an
E/M code.
Understand where to find rules and information
related to E/M codes.
How to achieve the goals
1.
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Risk--% of claims coded incorrectly.
Bell curves—How they help you find the outliers.
Evaluation and Management (E/M) codes.
The 7 Components of E/M.
Documentation requirements for each level of
E/M.
1995/1997 Exam Rules.
What makes someone a New patient vs Established
patient.
Different E/M codes for different places of services.
The perfect storm
Medical Economics April 09
-4 practices audited after
implementing EHR’s and using
them as instructed and intended
-Audit failures ranged from 20%
to 95% of charts
-Fines ranged from $50,000 to
$175,000+ per physician
-Non-compliant documentation
also called a “canary in the coal
mine” showed problems with
usability, data integrity, and
quality of care & liability
protection.
Interesting facts about recovery audits
 How would you like an investment that returns
$7.20 for every dollar you invest? Our government
has found just such an investment — healthcare
providers
 E&M coding, is a potential target; the 99213 and
99214 office codes were the top two CPT codes in
terms of both charges and unit volume.
See more at: http://www.physicianspractice.com
Recovery audits no longer if but when
Medicare Administrative Contractors (MAC)
Recovery Audit Contractors (RAC/RA)
Comprehensive Error Rate Testing (CERT)
Zone Program Integrity Contractor (ZPIC)
Health Care Fraud Prevention and Enforcement Action
Team (HEAT) .
 Office of Inspector General (OIG)
 Payment Error Rate Measurement (PERM)
 3rd party payer audits
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With all these audits you can see it really is only a matter of
time before you have one or more reviewing your records.
Interesting fact about PERM
WPS Medicare e-News
 Are You Billing these Evaluation and Management (E/M) Services
Correctly?
 Review of recent Comprehensive Error Rate Testing (CERT) findings
for WPS Medicare providers in J8 reveals the three CPT codes used to
report E/M services listed below were incorrectly coded at a rate of at
least 44%.
 99215 - Office or other outpatient visit for the evaluation and management of
an established patient
 99223 - Initial hospital care, per day, for the evaluation and management of a
patient
 99222 - Initial hospital care, per day, for the evaluation and management of a
patient
 If you bill E/M services to Medicare, we highly recommend performing a selfaudit of your billing and documentation processes to determine if the medical
records support the level of service billed and the medically necessity of the
level.
Timeliness requirement
 3.3.2.5 - Late Entries in Medical Documentation
 (Rev. 377, Issued: 05-27-11, Effective: 06-28-11, Implementation:
06-28-11)
 The MACs, CERT, Recovery Auditors, and ZPICs shall
give less weight when making review determinations
to documentation, including a provider’s internal
query responses, created more than 30 calendar days
following the date of service. If the MACs, CERT, or
Recovery Auditors identify providers with patterns of
making late (more than 30 calendar days past the date
of service) entries in the medical documentation,
including the query responses, the reviewers shall
refer the cases to ZPIC and may consider referring to
the RO(regional office) and State Agency.
What can we do to minimize risk?
 Do not cross walk codes
 Do not use time as the only factor for E/M
coding
 Do not treat all places or carriers the same
 Do not use only one set of rules
 Do not rule out getting a certified coder.
Mental health is new to E/M. E/M is not
new to coding.
Risk of doing things wrong
 If you cross walk , the old medication review to one
E/M code you run the risk for not meeting the
documentation requirements. You will also be an
outlier. (review on bell curve slide)
 Using only time its wrong. You must have a time
statement to use time. You might not have
documented to that level. You may have “up coded”.
 Using the same code for easy and difficult cases.
Doing this can lead to rejections and flags for audit.
 Only following one carriers rules. They are different,
you run the risk of rejection and monetary take backs.
Risk of doing things wrong, continued
 You can only use new patient codes when the client is new
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to your group or has not been seen by a provider of that
specialty for more than 3 years.
Every carrier has there own set of rules. Many are similar
however you need to review and stay familiar if you want to
make the most or your coding and billing revenue.
Watch your codes and your documentation. Monthly peer
reviews with staff can prove to be enlightening for all. You
can easily spot and outlier. Don’t give them an easy target.
Hire a certified coder.
Keep in mind 1% error is 100% wrong.
Review of documentation requirements
90862
 Must include the
condition for which the
medication is needed,
type of medication,
dosage, directions for
use, any frequent side
effects and the effect
the medication is
having on the patients
symptoms/condition
99213
 2 of 3 key elements for
established patient
 Expanded problem
focus history
 Expanded problem
focus exam
 Low Medical Decision
Making (MDM)
Evaluation and Management
There are 7 components to E/M 3 key elements and
3 contributory factors and time.
1. History
2. Exam
3. Medical Decision Making
4. Counseling
5. Coordination of care
6. Nature of Presenting Problem
7. Time
Evaluation and Management
 Chief Complaint (CC) sets the medical necessity.
 (CC) and Medical Decision Making (MDM) are the
most important part of an E/M code
 Your E/M code can never be a higher level then
your MDM.
 Time factor: You can only use time if more than
50% of the visit is spent counseling and it is
documented.
 You can have a higher level of E/M codes with less
time.
Chief Complaint
 The Chief Complaint also known as CC, is part of
the medical history taking, and is a concise
statement describing the symptom, problem,
condition, diagnosis, physician recommended
return, or other factors that are the reason for a
medical encounter. (the medical necessity of this
visit)
 The patient's initial comments to a physician, nurse,
or other health care professional help form the chief
complaint.
Understanding History Element of E/M
CMS required history elements
]
Type of
history
CC
HPI
ROS
Past, family, and/or social
Problem
focused
Required
Brief
N/A
N/A
Expanded
problem
focused
Required
Brief
Problem
pertinent
N/A
Detailed
Required
Extended
Extended
Pertinent
Comprehensive
Required
Extended
Complete
Complete
Billing Provider Must Document the HPI
Per CMS rules: E/M services guide.
1. The Review of Systems and the Past, Family and/or
Social History may be recorded by ancillary staff or on
a form completed by the patient. To document that the
physician reviewed the information, the physician must
add a notation supplementing or confirming the
information recorded by others.
2. Only the physician or NPP that is conducting the E/M
service can perform the HPI. This is considered
physician work and not relegated to ancillary staff. The
exam and medical decision making are also considered
physician work and not relegated to ancillary staff.
Understanding the Exam element
1995 rules are simplistic. Usually not best rule to use
for specialty physicians and NPP.
 Limited to affected body or organ system (1 body area
or system related to problem) Problem Focused
 Affective body area or organ system and other
symptomatic or related organ system (additional
systems up to 7) Expanded Problem Focused
 Extended exam of affected area (up to total of 7 or
more in depth then above) Detailed
 General Multi-system exam (8 or more systems)
Comprehensive
1995/1997 Exam rules
 Best advise decide what works best for your
practiced and use it.
 You can use 1995 for one claim and 1997 for
another.
 Eliminate the potential risk from an audit. Make
decision to use 1995 or 1997.
 Write in policies and/or procedures. “We use 1997
exam rules for E/M” or “1995 rules”.
1995/1997
 Lets look at the 1997 exam for psych.
https://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNProducts/downloads/eval_mgmt_serv_gui
de-ICN006764.pdf
Understanding MDM Element of E/M
 A-number of diagnosis or treatment
options
 B-Risk of Complications and/or
Morbidity or Mortality
 C-amount and/or complexity of data
reviewed
A. number of diagnosis or treatment options
A
Number of Diagnoses or Treatment Options
A
Problem(s) Status
B
xC=
D
Number
Points
Max = 2
1
Self-limited or minor (stable, improved, or
worsening)
1
Est. problem (to examiner); stable, improved
2
Est. problem (to examiner); worsening
New problem (to examiner); no additional
Max = 1
3
workup planned
New problem (to examiner); add. Workup planned
4
Result
Risk of complications and/or morbidity or mortality
 There is much information in this area.
 Let review CMS.gov site again.
 Important factor in using the high level of toxic
medicine. You need to identify this either by
machining it and the fact it can be toxic or using
wording, phrases like: ‘checked for toxicity none
found’
Amount and/or complexity data reviewed
C
Amount and/or Complexity of Data Reviewed
Reviewed Data
Review and/or order of clinical lab tests
Points
1
Review and/or order of tests in the radiology section of CPT
1
Review and/or order of tests in the medicine section of CPT
Discussion of test results with performing physician
Decision to obtain old records and/or obtain history from someone other than patient 1 point
1
1
Review and summarization of old records and/or obtaining history from someone other than
patient and/or discussion of case with another health care provider.
Independent visualization of image, tracing or specimen itself (not simply review of report)
2
2
AIMS test adds to E/M
 Aims tests are not individually billable. Usually done
by non-physician provider.
 If you review test positive or negative and document
you reviewed this is, an additional point is added to
review of test data. The is in the MDM section of the
E/M code.
 This test falls under the Amount of data reviewed
and adds one point.
 The only way to get points for reviewing old history
is if you summarize this information.
Time for counseling/coordination of care
 You must spend more than 50% of the visit
on counseling or coordinating care.
 It must be documented: Total time and the
amount of time spent on counseling or
coordinating care.
 You do not have to use start stop time of
counseling. You can think of the process as
time spent as part of the entire visit.
N.A.M.A.S. 5/9/2014
 Documentation of Time with Evaluation and
Management Services:
 Time is built into the E/M codes. Providers are told to
base their E/M selection on the 3 key elements :
History, Exam and Medical Decision Making. Times are
listed in the CPT manual with each level of service as a
guideline only.
 If a provider spends more than 50% of a face-to-face
visit counseling and/or coordinating patient's care, the
provider can code the visit based on time spent even if
the History, Exam and MDM elements are lacking.
N.A.M.A.S. 5/9/2014
 Time must be documented as well as the detailed
description of the circumstance (counseling patient
or coordinating care). For example: 55 minutes spent
with patient, 30 minutes was spent in discussion
with patient and family regarding care.
 Prolonged service codes can be reported in addition
to an E/M code when the length of time a provider
spends with a patient in an outpatient setting
exceeds greater than 30 minutes beyond the typical
for the level of service selected.
Bell curves/understand outliers
99211
 This code is for the office setting only.
 If there is a nurse visit done in the home you have
to follow the rule: CPT code first HCPCS codes
second.
 There is no CPT code for nurse visit in the home so
you look to HCPCS.
 The best HCPCS code for a nurse visit in the home
is T1002.
 Do not use T1002 for nurse visit in the office.
99211
 This is the most basic service done in the
office.
 Usually done by nurse when patients is not
being seen by doctor.
 Can be billed same day as doctor visit when
it is a separately, identifiably different
service by using a 25 modifier.
Difference in New patient and Established patient
 A new patient for a group practice is
one that has not been seen by anyone in
the group with the same discipline in
the last 3 years.
 A new patient E/M code must meet 3 of
3 to be coded at that level.
 An established patient only requires 2
of 3 to be coded at that level.
E/M codes for different place of service
 AFC/Group home.
 There are two groups of codes. New and
Established.
 New 99324-99328
 Established 99334-99337
 Residential home POS 12
 New 99341-99345
 Established 99347-99350
Documentation
Documentation Guidelines
a) They are in place and you need to familiarize
yourself with them.
b) Medical necessity is the most weighted elements in
a E/M.
c) There needs to be a reason for the visit the Chief
Complaint.
d) There are different guidelines for different carriers
when it come to billing.
Documentation rules for E/M
 We now know the parts of E/M. We need to be
reminded that documentation must be complete in
these areas.
 You can lose or increase revenue with your
documentation.
 You must put down what you are doing and the
calculations in your head must be documented.
 One doctor I worked with put it like this.
“Document what you did do and why did you do it.
Explain your thought process.”
Fiscal Year 2015 HHS OIG Work Plan
 Outpatient evaluation and management
services billed at the new-patient rate.
 Questionable billing patterns for Part B
services during nursing home stays.
 Physicians—Place-of-service coding errors
 Physical therapists—High use of outpatient
physical therapy services. Need to follow all
the rules around scripts, dx and certification
of the plan.
Reduce risk, get it right
 Understand there are areas of risk.
 Identify by looking for your outliers. Create bell curves,
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compare to national standards.
Learn rules and bill CPT (especially your E/M codes)
properly insuring Medicaid funds are used as payer of
last resort.
Review your policies on coding and billing. Add
language to help reduce risk.
Have ongoing internal audits for proper documentation.
Have external audits and trainings. This is a moving
target ever changing and we need to keep up.
Good News
 This is not rocket science---You can do it.
 Many doctors have embraced the fact you have to
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documents all you do.
You can start getting it right today.
Start a self audit plan. Review what you have done
right and fix what is wrong.
Keep up to date ALWAYS.
There are many in the industry that can help.
Any questions ?
Thank you
Pamela Pully CPC, CPMA