Coding

Health care reform has triggered considerable discussion both in print and online about the administrative problems it has created for private practitioners, including decreased cash flow, increased paperwork and business expenses, and an increasing number of high-deductible insurance exchanges with the infamous 90-day “grace periods.” Extending discounts to patients who pay at the time of service or out of pocket may mitigate damage caused by all 3 of these issues; however, caution is necessary, as discounts often can run afoul of federal and state laws, including anti-kickback statutes,¹ the anti-inducement provision of the Health Insurance Portability and Accountability Act,² the Medicare exclusion provision,³ and state insurance antidiscrimination provisions.⁴

Avoid Kickback Penalties From Patient Discounts

From a legal standpoint, any discount is technically a kickback of sorts because you are returning part of your fee to the patient, and many laws designed to thwart true kickbacks can apply to patient discounts. Take the relatively straightforward case of time-of-service discounts for cosmetic procedures and other services not normally covered by insurance. You would think that these transactions are strictly between you and your patients, but if these discounts appear to be marketing incentives to attract patients, you may face a penalty.⁵

Patient discounts also may impact third-party payers. Many provider agreements contain “most favored nation” clauses, which require you to automatically give that payer the lowest price you offer to anyone else, regardless of what would be paid otherwise. In other words, the payer could demand the same discount you offer any individual patient. A time-of-service discount is, of course, exactly that: it is offered only when payment is made immediately. Third parties never pay at the time of service and would not be entitled to it, but they may try to invoke their agreement.

If you want to extend discounts for covered services, you must be sure that the discounted fee you charge the patient also is reflected on the claim submitted to the insurer. Billing the insurer more than you charged the patient invites a charge of fraud.⁶ It is important to avoid discounting so regularly that the discounted fee becomes your usual and customary rate in the eyes of the insurer.

Waiving Costs and Kickbacks

Waiving coinsurance and deductibles can be trouble too, particularly with Medicare and Medicaid. You might intend it as a good deed, but the Centers for Medicare & Medicaid Services (CMS) will see it as an inducement or kickback, especially if you do it routinely, and similar to private carriers, they will consider the discounted fee your new customary fee. The CMS has no problem with an occasional waiver, especially “after determining in good faith that the individual is in financial need,” according to the Office of Inspector General,⁷ but thorough documentation is necessary in such cases.

Waiving co-pays for privately insured patients can be equally problematic. Nearly all insurers impose a contractual duty on providers to make a reasonable effort to collect applicable co-pays and/or deductibles. They view the routine waiver of patient payments as a breach of contract, and litigation may occur against providers who flout this requirement.⁸ As with the CMS, accommodating patients with individually documented financial limitations is acceptable, but if there is a pattern of routine waivers and a paucity of documentation, you will have difficulty defending it.

Antidiscrimination Laws

In addition to kickback laws, some states also have antidiscrimination laws that forbid lower charges to any subset of insurance payers or to direct payers.⁴ Some states make specific exceptions for legitimate discounts, such as individual cases of financial hardship, or if you pass along your lower billing and collection expenditures to patients who pay immediately, but other states do not.

Determining Discount Amounts

The discount amount depends on the physician’s situation and deserves careful consideration. If the amount or percentage that you choose to offer as a discount is completely out of proportion with the administrative costs of submitting paperwork as well as the hassles associated with waiting for third-party payments, you could be accused of running a discount policy that is in effect a de facto increase to insurance carriers, which also could result in charges of fraud.²

In cases of legitimate financial hardship, the most effective and least problematic strategy may be to offer a sliding scale. Many large clinics and community agencies as well as all hospitals have written policies for this system, often based on federal poverty guidelines. To avoid any potential issues, contact your local social service agencies and welfare clinics, learn the community standard in your area, and formulate a written policy with guidelines for determining a patient’s indigence.

Final Thoughts

Consistency of administration, objectivity in policies, and documentation of individual eligibility will ensure that the discounts you offer patients are in line with legal and payer regulations. Before you establish a discount policy, be sure to check your state’s applicable laws, and as always, run everything by your attorney.

Health care reform has triggered considerable discussion both in print and online about the administrative problems it has created for private practitioners, including decreased cash flow, increased paperwork and business expenses, and an increasing number of high-deductible insurance exchanges with the infamous 90-day “grace periods.” Extending discounts to patients who pay at the time of service or out of pocket may mitigate damage caused by all 3 of these issues; however, caution is necessary, as discounts often can run afoul of federal and state laws, including anti-kickback statutes,¹ the anti-inducement provision of the Health Insurance Portability and Accountability Act,² the Medicare exclusion provision,³ and state insurance antidiscrimination provisions.⁴

Avoid Kickback Penalties From Patient Discounts

From a legal standpoint, any discount is technically a kickback of sorts because you are returning part of your fee to the patient, and many laws designed to thwart true kickbacks can apply to patient discounts. Take the relatively straightforward case of time-of-service discounts for cosmetic procedures and other services not normally covered by insurance. You would think that these transactions are strictly between you and your patients, but if these discounts appear to be marketing incentives to attract patients, you may face a penalty.⁵

Patient discounts also may impact third-party payers. Many provider agreements contain “most favored nation” clauses, which require you to automatically give that payer the lowest price you offer to anyone else, regardless of what would be paid otherwise. In other words, the payer could demand the same discount you offer any individual patient. A time-of-service discount is, of course, exactly that: it is offered only when payment is made immediately. Third parties never pay at the time of service and would not be entitled to it, but they may try to invoke their agreement.

If you want to extend discounts for covered services, you must be sure that the discounted fee you charge the patient also is reflected on the claim submitted to the insurer. Billing the insurer more than you charged the patient invites a charge of fraud.⁶ It is important to avoid discounting so regularly that the discounted fee becomes your usual and customary rate in the eyes of the insurer.

Waiving Costs and Kickbacks

Waiving coinsurance and deductibles can be trouble too, particularly with Medicare and Medicaid. You might intend it as a good deed, but the Centers for Medicare & Medicaid Services (CMS) will see it as an inducement or kickback, especially if you do it routinely, and similar to private carriers, they will consider the discounted fee your new customary fee. The CMS has no problem with an occasional waiver, especially “after determining in good faith that the individual is in financial need,” according to the Office of Inspector General,⁷ but thorough documentation is necessary in such cases.

Waiving co-pays for privately insured patients can be equally problematic. Nearly all insurers impose a contractual duty on providers to make a reasonable effort to collect applicable co-pays and/or deductibles. They view the routine waiver of patient payments as a breach of contract, and litigation may occur against providers who flout this requirement.⁸ As with the CMS, accommodating patients with individually documented financial limitations is acceptable, but if there is a pattern of routine waivers and a paucity of documentation, you will have difficulty defending it.

Antidiscrimination Laws

In addition to kickback laws, some states also have antidiscrimination laws that forbid lower charges to any subset of insurance payers or to direct payers.⁴ Some states make specific exceptions for legitimate discounts, such as individual cases of financial hardship, or if you pass along your lower billing and collection expenditures to patients who pay immediately, but other states do not.

Determining Discount Amounts

The discount amount depends on the physician’s situation and deserves careful consideration. If the amount or percentage that you choose to offer as a discount is completely out of proportion with the administrative costs of submitting paperwork as well as the hassles associated with waiting for third-party payments, you could be accused of running a discount policy that is in effect a de facto increase to insurance carriers, which also could result in charges of fraud.²

In cases of legitimate financial hardship, the most effective and least problematic strategy may be to offer a sliding scale. Many large clinics and community agencies as well as all hospitals have written policies for this system, often based on federal poverty guidelines. To avoid any potential issues, contact your local social service agencies and welfare clinics, learn the community standard in your area, and formulate a written policy with guidelines for determining a patient’s indigence.

Final Thoughts

Consistency of administration, objectivity in policies, and documentation of individual eligibility will ensure that the discounts you offer patients are in line with legal and payer regulations. Before you establish a discount policy, be sure to check your state’s applicable laws, and as always, run everything by your attorney.

Health care reform has triggered considerable discussion both in print and online about the administrative problems it has created for private practitioners, including decreased cash flow, increased paperwork and business expenses, and an increasing number of high-deductible insurance exchanges with the infamous 90-day “grace periods.” Extending discounts to patients who pay at the time of service or out of pocket may mitigate damage caused by all 3 of these issues; however, caution is necessary, as discounts often can run afoul of federal and state laws, including anti-kickback statutes,¹ the anti-inducement provision of the Health Insurance Portability and Accountability Act,² the Medicare exclusion provision,³ and state insurance antidiscrimination provisions.⁴

Avoid Kickback Penalties From Patient Discounts

From a legal standpoint, any discount is technically a kickback of sorts because you are returning part of your fee to the patient, and many laws designed to thwart true kickbacks can apply to patient discounts. Take the relatively straightforward case of time-of-service discounts for cosmetic procedures and other services not normally covered by insurance. You would think that these transactions are strictly between you and your patients, but if these discounts appear to be marketing incentives to attract patients, you may face a penalty.⁵

Patient discounts also may impact third-party payers. Many provider agreements contain “most favored nation” clauses, which require you to automatically give that payer the lowest price you offer to anyone else, regardless of what would be paid otherwise. In other words, the payer could demand the same discount you offer any individual patient. A time-of-service discount is, of course, exactly that: it is offered only when payment is made immediately. Third parties never pay at the time of service and would not be entitled to it, but they may try to invoke their agreement.

If you want to extend discounts for covered services, you must be sure that the discounted fee you charge the patient also is reflected on the claim submitted to the insurer. Billing the insurer more than you charged the patient invites a charge of fraud.⁶ It is important to avoid discounting so regularly that the discounted fee becomes your usual and customary rate in the eyes of the insurer.

Waiving Costs and Kickbacks

Waiving coinsurance and deductibles can be trouble too, particularly with Medicare and Medicaid. You might intend it as a good deed, but the Centers for Medicare & Medicaid Services (CMS) will see it as an inducement or kickback, especially if you do it routinely, and similar to private carriers, they will consider the discounted fee your new customary fee. The CMS has no problem with an occasional waiver, especially “after determining in good faith that the individual is in financial need,” according to the Office of Inspector General,⁷ but thorough documentation is necessary in such cases.

Waiving co-pays for privately insured patients can be equally problematic. Nearly all insurers impose a contractual duty on providers to make a reasonable effort to collect applicable co-pays and/or deductibles. They view the routine waiver of patient payments as a breach of contract, and litigation may occur against providers who flout this requirement.⁸ As with the CMS, accommodating patients with individually documented financial limitations is acceptable, but if there is a pattern of routine waivers and a paucity of documentation, you will have difficulty defending it.

Antidiscrimination Laws

In addition to kickback laws, some states also have antidiscrimination laws that forbid lower charges to any subset of insurance payers or to direct payers.⁴ Some states make specific exceptions for legitimate discounts, such as individual cases of financial hardship, or if you pass along your lower billing and collection expenditures to patients who pay immediately, but other states do not.

Determining Discount Amounts

The discount amount depends on the physician’s situation and deserves careful consideration. If the amount or percentage that you choose to offer as a discount is completely out of proportion with the administrative costs of submitting paperwork as well as the hassles associated with waiting for third-party payments, you could be accused of running a discount policy that is in effect a de facto increase to insurance carriers, which also could result in charges of fraud.²

In cases of legitimate financial hardship, the most effective and least problematic strategy may be to offer a sliding scale. Many large clinics and community agencies as well as all hospitals have written policies for this system, often based on federal poverty guidelines. To avoid any potential issues, contact your local social service agencies and welfare clinics, learn the community standard in your area, and formulate a written policy with guidelines for determining a patient’s indigence.

Final Thoughts

Consistency of administration, objectivity in policies, and documentation of individual eligibility will ensure that the discounts you offer patients are in line with legal and payer regulations. Before you establish a discount policy, be sure to check your state’s applicable laws, and as always, run everything by your attorney.

• Continue to educate physicians on proper billing for E/M services;
• Encourage its contractors to review physicians’ billing for E/M services; and
• Review physicians who bill higher level E/M codes for appropriate action.¹

When documenting patient history, physicians must be aware of the common discrepancies that occur. Although the physician becomes familiar with the patient as he/she provides care throughout the hospitalization, the auditor must acquaint himself or herself with the patient using only the limited information provided in the progress note.

When documentation is requested by the payer for a specific service date, only the documentation from that service date is considered. Be sure that the information is adequate to support both clinical care and the reported service level.

Patient History Requirements

Chief complaint. The chief complaint (CC) is the reason for the visit as stated in the patient’s own words. Every encounter, regardless of visit type, must include a CC. The physician must personally document and/or validate the CC with reference to a specific condition or symptom (e.g. patient complains of abdominal pain).

• Incomplete CC example: “Follow-up”;
• Better CC example: “Follow-up for severe abdominal cramping.”

History of present illness. The history of present illness (HPI) describes the development or progression of the patient’s current problem(s). The traditional HPI elements recognized in the 1995 documentation guidelines are location, quality, severity, duration, timing, context, modifying factors, and associated signs/symptoms.^2,3

The physician must obtain and personally document the HPI. He/she also has the option to link to the HPI documented by residents (i.e., residents, fellows, interns) in compliance with the teaching physician rules or nonphysician practitioners (i.e., nurse practitioners and physician assistants) as defined by the split-shared billing rules. An auditor will not accept HPI information if the physician attempts to link to any other individual, even if that person may be qualified to obtain this (e.g. registered nurse, medical assistant) or is a student (e.g. medical students, nurse practitioner students).

Because auditors recognize both 1995 and 1997 documentation guidelines, they must also recognize the HPI differences. The 1997 HPI format promotes the status of the patient’s chronic or inactive conditions.⁴ The physician receives one credit for each chronic condition that is noted, along with documentation of what has occurred since the last physician encounter as it relates to the chronic condition (e.g. “patient has a history of chronic obstructive bronchitis without acute exacerbation in past six months”).

Physicians may utilize either style of HPI documentation, and auditors must review provider records against each set of guidelines. The final audited result reflects the highest visit level supported by either set of guidelines. For example, if physician documentation yields an “extended” HPI when 1995 guidelines are used but only a “brief” HPI (see Table 2) when 1997 guidelines are reviewed, the auditor awards the physician credit for the “extended” HPI.

• 1995 example: “The patient has intermittent (duration), sharp (quality) pain in the right upper quadrant (location) without associated nausea, vomiting, or diarrhea (associated signs/symptoms).”
• 1997 example: “Diabetes controlled by oral medication; hyperlipidemia stable on simvastatin with increased dietary efforts; hypertension stable with pressures ranging from 130-140/80-90 overnight” (status of three chronic conditions).

Review of systems. A review of systems (ROS) is a series of questions inquiring about additional signs, symptoms, or problems currently or previously experienced by the patient as related to the CC or presenting problem. The recognized systems are constitutional; eyes; ears, nose, mouth, throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary (including skin and/or breast); neurological; psychiatric; endocrine; hematologic/lymphatic; and allergic/immunologic.^2,3

The physician may choose to document the ROS by making a notation for individual systems: “no fever/chills (constitutional) or blurred vision (eyes); no chest pain (cardiovascular) or shortness of breath (respiratory); intermittent nausea (gastrointestinal) and occasional runny nose (ears, nose, mouth, throat).” Alternatively, the physician may inquire about all of the systems but only document the positive and pertinent negative findings related to the CC, along with an additional comment that “all other systems are negative.” Most Medicare audit contractors currently accept this method as long as all systems were reviewed.^5,6,7,8,9

Be advised that ROS information can be documented by anyone, including the patient. The physician must remember to reference ROS information that is completed by individuals other than residents or nonphysician practitioners (the physician is already required to reference the documentation of the latter individuals under the Teaching Physician Rules or Split-Shared Billing Rules).

Past, family, and social histories. Documentation of past, family, and social histories (PFSH) involves data obtained about the patient’s previous illness or medical conditions/therapies, family occurrences with illness, and relevant patient activities. An auditor credits the physician for a single comment correlated to each history for the PFSH. Using the term “noncontributory” (N/C) with any of the histories can result in downcoding. Many contractors do not allow this statement due to previous misunderstandings over its use.

• Incomplete PFSH example: “Patient is status-post cholecystectomy in August 2013; family history N/C; patient is former smoker” (Note: “family history N/C” is not accepted by most contractors).
• Better PFSH example: “Patient currently on Prilosec 20 mg daily; family history of Barrett’s Esophagus; no tobacco or alcohol use.”

PFSH data can also be documented by anyone, including the patient, and the physician must reference the PFSH information in his own progress note. Re-documenting the PFSH is not necessary unless a revision is required. PFSH documentation is only required for initial care services (i.e., initial hospital care, initial observation care, consultations). It is not required for subsequent care services, unless additional pertinent information that impacts care is obtained during the hospital stay.

Common Problems to Avoid

Information cannot be obtained. Some contractors will not penalize the physician for the inability to ascertain complete historical information as long as there is evidenced documentation of an attempt to obtain the information. When the physician cannot extract historical information from the patient directly and no other source is available, the physician documents that he is “unable to obtain” the history. Additionally, the physician must provide a comment to explain why the information is unobtainable (e.g. patient confused, no caregiver present) along with the available information from the limited resources (e.g. emergency medical technicians, records from previous hospitalizations at the same facility).

Previous information referenced. When referencing items from a previous encounter, be sure to include the referenced information when documentation is requested by the payer. Per CMS guidelines, the ROS and/or PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. The review and update may be documented by either describing any new ROS and/or PFSH information or noting that there has been no change in the information and noting the date and location of the earlier ROS and/or PFSH.²

Pre-op clearance and HPI deficiencies. HPI is typically not as deficient as the ROS or family history elements; however, HPI underdocumentation is mostly associated with encounters for pre-op clearance. The physician may state that “patient requires pre-op clearance for left knee repair.” In the absence of any comorbidities or acute illness, HPI documentation may be missing. The physician should remember to identify the details of the presenting problem: “Patient runs five miles daily. Knee felt unstable after running two weeks ago. Swelling and intermittent sharp pain 7/10. Patient has been taking ibuprofen daily without relief.”

Not medically necessary. Remember not to document any elements for the purpose of “getting paid.” Only document information that is clinically relevant, lends to the quality of care provided, or demonstrates the delivery of healthcare services. This prevents accusations of fraud and abuse, promotes billing compliance, and supports medical necessity for the services provided.

Varying levels of history. E/M services are selected based on the content of the three “key” components: history, exam, and decision-making (or visit time). If counseling and/or coordination of care does not encompass >50% of the physician’s total visit time or the service is not exclusively designated as a time-based service (e.g. critical care and discharge day management), the physician’s service time is not considered.

Documentation for each of the three key components must support the reported visit level when reporting initial hospital care and consultations (for those payers who still recognize consultation codes). Subsequent hospital care (e.g. 99233) only requires supportive documentation from two key components. Medical decision-making should be one of the two supporting components in order to demonstrate the medical necessity and nature of the presenting problem; the other supporting component can be history or exam.

Each visit category (e.g. initial hospital care or subsequent hospital care) and service level (e.g. 99221-99233) identifies corresponding documentation requirements. Failure to document any essential element in a given visit level (e.g. family history required for a comprehensive history when billing for 99222 and 99223) may result in service denial or downcoding (e.g. 99221). Be aware of what an auditor expects when reviewing patient history (see Table 1).

There are four levels of history: problem-focused, expanded problem-focused, detailed, and comprehensive. An auditor determines the number of history elements documented in the progress note (see Table 2). The history level corresponds to the lowest documented element. For example, if physician documentation includes four HPI elements, eight ROS, and a comment in each of the PFSHs, the history level is equivalent to “detailed.” The history would support initial hospital care 99221 or subsequent hospital care 99233.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Levinson DR. Department of Health and Human Services, Office of Inspector General: Coding Trends of Medicare Evaluation and Management Services. May 2012. Available at: oig.hhs.gov/oei/reports/oei-04-10-00180.pdf. Accessed October 4, 2014.
2. Centers for Medicare and Medicaid Services. 1995 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf. Accessed October 4, 2014.
3. Abraham M, Ahlman J, Boudreau A, Connelly J, Levreau-Davis L. CPT 2013 Professional Edition (Current Procedural Terminology). Chicago: American Medical Association Press; 2012:4-10.
4. Centers for Medicare and Medicaid Services. 1997 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf. Accessed October 4, 2014.
5. Noridian Healthcare Solutions. Medicare Part B: Evaluation and Management Workshop Questions and Answers. Available at: www.noridianmedicare.com/cgi-bin/coranto/viewnews.cgi?id=EkZpEVAyylqZyOfqel&tmpl=part_b_viewnews&style=part_ab_viewnews Accessed on October 4, 2014.
6. WPS Medicare Health Insurance. J5 MAC Part B: Documentation (Q&As). Available at: www.wpsmedicare.com/j5macpartb/resources/provider_types/evalmngmntqa.shtml. Accessed October 4, 2014.
7. NHIC, Corp. Building Your Medicare Knowledge: Advanced Building Blocks. Available at: www.medicarenhic.com/providers/pubs/AdvdBuildBlocks061212.pdf.
8. Palmetto GBA. Jurisdiction 11 Part B: History Component. Available at: www.palmettogba.com/Palmetto/Providers.nsf/docsCat/Jurisdiction%2011%20Part%20B~EM%20Help%20Center~General%20Articles~History%20Component?open&Expand=1. Accessed October 4, 2014.
9. Novitas Solutions. Frequently Asked Questions: Evaluation and Management Services (Part B). Available at: https://www.novitas-solutions.com/faq/partb/pet/lpet-evaluation_management_services.html. Accessed October 4, 2014.

• Continue to educate physicians on proper billing for E/M services;
• Encourage its contractors to review physicians’ billing for E/M services; and
• Review physicians who bill higher level E/M codes for appropriate action.¹

When documenting patient history, physicians must be aware of the common discrepancies that occur. Although the physician becomes familiar with the patient as he/she provides care throughout the hospitalization, the auditor must acquaint himself or herself with the patient using only the limited information provided in the progress note.

When documentation is requested by the payer for a specific service date, only the documentation from that service date is considered. Be sure that the information is adequate to support both clinical care and the reported service level.

Patient History Requirements

Chief complaint. The chief complaint (CC) is the reason for the visit as stated in the patient’s own words. Every encounter, regardless of visit type, must include a CC. The physician must personally document and/or validate the CC with reference to a specific condition or symptom (e.g. patient complains of abdominal pain).

• Incomplete CC example: “Follow-up”;
• Better CC example: “Follow-up for severe abdominal cramping.”

History of present illness. The history of present illness (HPI) describes the development or progression of the patient’s current problem(s). The traditional HPI elements recognized in the 1995 documentation guidelines are location, quality, severity, duration, timing, context, modifying factors, and associated signs/symptoms.^2,3

The physician must obtain and personally document the HPI. He/she also has the option to link to the HPI documented by residents (i.e., residents, fellows, interns) in compliance with the teaching physician rules or nonphysician practitioners (i.e., nurse practitioners and physician assistants) as defined by the split-shared billing rules. An auditor will not accept HPI information if the physician attempts to link to any other individual, even if that person may be qualified to obtain this (e.g. registered nurse, medical assistant) or is a student (e.g. medical students, nurse practitioner students).

Because auditors recognize both 1995 and 1997 documentation guidelines, they must also recognize the HPI differences. The 1997 HPI format promotes the status of the patient’s chronic or inactive conditions.⁴ The physician receives one credit for each chronic condition that is noted, along with documentation of what has occurred since the last physician encounter as it relates to the chronic condition (e.g. “patient has a history of chronic obstructive bronchitis without acute exacerbation in past six months”).

Physicians may utilize either style of HPI documentation, and auditors must review provider records against each set of guidelines. The final audited result reflects the highest visit level supported by either set of guidelines. For example, if physician documentation yields an “extended” HPI when 1995 guidelines are used but only a “brief” HPI (see Table 2) when 1997 guidelines are reviewed, the auditor awards the physician credit for the “extended” HPI.

• 1995 example: “The patient has intermittent (duration), sharp (quality) pain in the right upper quadrant (location) without associated nausea, vomiting, or diarrhea (associated signs/symptoms).”
• 1997 example: “Diabetes controlled by oral medication; hyperlipidemia stable on simvastatin with increased dietary efforts; hypertension stable with pressures ranging from 130-140/80-90 overnight” (status of three chronic conditions).

Review of systems. A review of systems (ROS) is a series of questions inquiring about additional signs, symptoms, or problems currently or previously experienced by the patient as related to the CC or presenting problem. The recognized systems are constitutional; eyes; ears, nose, mouth, throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary (including skin and/or breast); neurological; psychiatric; endocrine; hematologic/lymphatic; and allergic/immunologic.^2,3

The physician may choose to document the ROS by making a notation for individual systems: “no fever/chills (constitutional) or blurred vision (eyes); no chest pain (cardiovascular) or shortness of breath (respiratory); intermittent nausea (gastrointestinal) and occasional runny nose (ears, nose, mouth, throat).” Alternatively, the physician may inquire about all of the systems but only document the positive and pertinent negative findings related to the CC, along with an additional comment that “all other systems are negative.” Most Medicare audit contractors currently accept this method as long as all systems were reviewed.^5,6,7,8,9

Be advised that ROS information can be documented by anyone, including the patient. The physician must remember to reference ROS information that is completed by individuals other than residents or nonphysician practitioners (the physician is already required to reference the documentation of the latter individuals under the Teaching Physician Rules or Split-Shared Billing Rules).

Past, family, and social histories. Documentation of past, family, and social histories (PFSH) involves data obtained about the patient’s previous illness or medical conditions/therapies, family occurrences with illness, and relevant patient activities. An auditor credits the physician for a single comment correlated to each history for the PFSH. Using the term “noncontributory” (N/C) with any of the histories can result in downcoding. Many contractors do not allow this statement due to previous misunderstandings over its use.

• Incomplete PFSH example: “Patient is status-post cholecystectomy in August 2013; family history N/C; patient is former smoker” (Note: “family history N/C” is not accepted by most contractors).
• Better PFSH example: “Patient currently on Prilosec 20 mg daily; family history of Barrett’s Esophagus; no tobacco or alcohol use.”

PFSH data can also be documented by anyone, including the patient, and the physician must reference the PFSH information in his own progress note. Re-documenting the PFSH is not necessary unless a revision is required. PFSH documentation is only required for initial care services (i.e., initial hospital care, initial observation care, consultations). It is not required for subsequent care services, unless additional pertinent information that impacts care is obtained during the hospital stay.

Common Problems to Avoid

Information cannot be obtained. Some contractors will not penalize the physician for the inability to ascertain complete historical information as long as there is evidenced documentation of an attempt to obtain the information. When the physician cannot extract historical information from the patient directly and no other source is available, the physician documents that he is “unable to obtain” the history. Additionally, the physician must provide a comment to explain why the information is unobtainable (e.g. patient confused, no caregiver present) along with the available information from the limited resources (e.g. emergency medical technicians, records from previous hospitalizations at the same facility).

Previous information referenced. When referencing items from a previous encounter, be sure to include the referenced information when documentation is requested by the payer. Per CMS guidelines, the ROS and/or PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. The review and update may be documented by either describing any new ROS and/or PFSH information or noting that there has been no change in the information and noting the date and location of the earlier ROS and/or PFSH.²

Pre-op clearance and HPI deficiencies. HPI is typically not as deficient as the ROS or family history elements; however, HPI underdocumentation is mostly associated with encounters for pre-op clearance. The physician may state that “patient requires pre-op clearance for left knee repair.” In the absence of any comorbidities or acute illness, HPI documentation may be missing. The physician should remember to identify the details of the presenting problem: “Patient runs five miles daily. Knee felt unstable after running two weeks ago. Swelling and intermittent sharp pain 7/10. Patient has been taking ibuprofen daily without relief.”

Not medically necessary. Remember not to document any elements for the purpose of “getting paid.” Only document information that is clinically relevant, lends to the quality of care provided, or demonstrates the delivery of healthcare services. This prevents accusations of fraud and abuse, promotes billing compliance, and supports medical necessity for the services provided.

Varying levels of history. E/M services are selected based on the content of the three “key” components: history, exam, and decision-making (or visit time). If counseling and/or coordination of care does not encompass >50% of the physician’s total visit time or the service is not exclusively designated as a time-based service (e.g. critical care and discharge day management), the physician’s service time is not considered.

Documentation for each of the three key components must support the reported visit level when reporting initial hospital care and consultations (for those payers who still recognize consultation codes). Subsequent hospital care (e.g. 99233) only requires supportive documentation from two key components. Medical decision-making should be one of the two supporting components in order to demonstrate the medical necessity and nature of the presenting problem; the other supporting component can be history or exam.

Each visit category (e.g. initial hospital care or subsequent hospital care) and service level (e.g. 99221-99233) identifies corresponding documentation requirements. Failure to document any essential element in a given visit level (e.g. family history required for a comprehensive history when billing for 99222 and 99223) may result in service denial or downcoding (e.g. 99221). Be aware of what an auditor expects when reviewing patient history (see Table 1).

There are four levels of history: problem-focused, expanded problem-focused, detailed, and comprehensive. An auditor determines the number of history elements documented in the progress note (see Table 2). The history level corresponds to the lowest documented element. For example, if physician documentation includes four HPI elements, eight ROS, and a comment in each of the PFSHs, the history level is equivalent to “detailed.” The history would support initial hospital care 99221 or subsequent hospital care 99233.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Levinson DR. Department of Health and Human Services, Office of Inspector General: Coding Trends of Medicare Evaluation and Management Services. May 2012. Available at: oig.hhs.gov/oei/reports/oei-04-10-00180.pdf. Accessed October 4, 2014.
2. Centers for Medicare and Medicaid Services. 1995 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf. Accessed October 4, 2014.
3. Abraham M, Ahlman J, Boudreau A, Connelly J, Levreau-Davis L. CPT 2013 Professional Edition (Current Procedural Terminology). Chicago: American Medical Association Press; 2012:4-10.
4. Centers for Medicare and Medicaid Services. 1997 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf. Accessed October 4, 2014.
5. Noridian Healthcare Solutions. Medicare Part B: Evaluation and Management Workshop Questions and Answers. Available at: www.noridianmedicare.com/cgi-bin/coranto/viewnews.cgi?id=EkZpEVAyylqZyOfqel&tmpl=part_b_viewnews&style=part_ab_viewnews Accessed on October 4, 2014.
6. WPS Medicare Health Insurance. J5 MAC Part B: Documentation (Q&As). Available at: www.wpsmedicare.com/j5macpartb/resources/provider_types/evalmngmntqa.shtml. Accessed October 4, 2014.
7. NHIC, Corp. Building Your Medicare Knowledge: Advanced Building Blocks. Available at: www.medicarenhic.com/providers/pubs/AdvdBuildBlocks061212.pdf.
8. Palmetto GBA. Jurisdiction 11 Part B: History Component. Available at: www.palmettogba.com/Palmetto/Providers.nsf/docsCat/Jurisdiction%2011%20Part%20B~EM%20Help%20Center~General%20Articles~History%20Component?open&Expand=1. Accessed October 4, 2014.
9. Novitas Solutions. Frequently Asked Questions: Evaluation and Management Services (Part B). Available at: https://www.novitas-solutions.com/faq/partb/pet/lpet-evaluation_management_services.html. Accessed October 4, 2014.

• Continue to educate physicians on proper billing for E/M services;
• Encourage its contractors to review physicians’ billing for E/M services; and
• Review physicians who bill higher level E/M codes for appropriate action.¹

When documenting patient history, physicians must be aware of the common discrepancies that occur. Although the physician becomes familiar with the patient as he/she provides care throughout the hospitalization, the auditor must acquaint himself or herself with the patient using only the limited information provided in the progress note.

When documentation is requested by the payer for a specific service date, only the documentation from that service date is considered. Be sure that the information is adequate to support both clinical care and the reported service level.

Patient History Requirements

Chief complaint. The chief complaint (CC) is the reason for the visit as stated in the patient’s own words. Every encounter, regardless of visit type, must include a CC. The physician must personally document and/or validate the CC with reference to a specific condition or symptom (e.g. patient complains of abdominal pain).

• Incomplete CC example: “Follow-up”;
• Better CC example: “Follow-up for severe abdominal cramping.”

History of present illness. The history of present illness (HPI) describes the development or progression of the patient’s current problem(s). The traditional HPI elements recognized in the 1995 documentation guidelines are location, quality, severity, duration, timing, context, modifying factors, and associated signs/symptoms.^2,3

The physician must obtain and personally document the HPI. He/she also has the option to link to the HPI documented by residents (i.e., residents, fellows, interns) in compliance with the teaching physician rules or nonphysician practitioners (i.e., nurse practitioners and physician assistants) as defined by the split-shared billing rules. An auditor will not accept HPI information if the physician attempts to link to any other individual, even if that person may be qualified to obtain this (e.g. registered nurse, medical assistant) or is a student (e.g. medical students, nurse practitioner students).

Because auditors recognize both 1995 and 1997 documentation guidelines, they must also recognize the HPI differences. The 1997 HPI format promotes the status of the patient’s chronic or inactive conditions.⁴ The physician receives one credit for each chronic condition that is noted, along with documentation of what has occurred since the last physician encounter as it relates to the chronic condition (e.g. “patient has a history of chronic obstructive bronchitis without acute exacerbation in past six months”).

Physicians may utilize either style of HPI documentation, and auditors must review provider records against each set of guidelines. The final audited result reflects the highest visit level supported by either set of guidelines. For example, if physician documentation yields an “extended” HPI when 1995 guidelines are used but only a “brief” HPI (see Table 2) when 1997 guidelines are reviewed, the auditor awards the physician credit for the “extended” HPI.

• 1995 example: “The patient has intermittent (duration), sharp (quality) pain in the right upper quadrant (location) without associated nausea, vomiting, or diarrhea (associated signs/symptoms).”
• 1997 example: “Diabetes controlled by oral medication; hyperlipidemia stable on simvastatin with increased dietary efforts; hypertension stable with pressures ranging from 130-140/80-90 overnight” (status of three chronic conditions).

Review of systems. A review of systems (ROS) is a series of questions inquiring about additional signs, symptoms, or problems currently or previously experienced by the patient as related to the CC or presenting problem. The recognized systems are constitutional; eyes; ears, nose, mouth, throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary (including skin and/or breast); neurological; psychiatric; endocrine; hematologic/lymphatic; and allergic/immunologic.^2,3

The physician may choose to document the ROS by making a notation for individual systems: “no fever/chills (constitutional) or blurred vision (eyes); no chest pain (cardiovascular) or shortness of breath (respiratory); intermittent nausea (gastrointestinal) and occasional runny nose (ears, nose, mouth, throat).” Alternatively, the physician may inquire about all of the systems but only document the positive and pertinent negative findings related to the CC, along with an additional comment that “all other systems are negative.” Most Medicare audit contractors currently accept this method as long as all systems were reviewed.^5,6,7,8,9

Be advised that ROS information can be documented by anyone, including the patient. The physician must remember to reference ROS information that is completed by individuals other than residents or nonphysician practitioners (the physician is already required to reference the documentation of the latter individuals under the Teaching Physician Rules or Split-Shared Billing Rules).

Past, family, and social histories. Documentation of past, family, and social histories (PFSH) involves data obtained about the patient’s previous illness or medical conditions/therapies, family occurrences with illness, and relevant patient activities. An auditor credits the physician for a single comment correlated to each history for the PFSH. Using the term “noncontributory” (N/C) with any of the histories can result in downcoding. Many contractors do not allow this statement due to previous misunderstandings over its use.

• Incomplete PFSH example: “Patient is status-post cholecystectomy in August 2013; family history N/C; patient is former smoker” (Note: “family history N/C” is not accepted by most contractors).
• Better PFSH example: “Patient currently on Prilosec 20 mg daily; family history of Barrett’s Esophagus; no tobacco or alcohol use.”

PFSH data can also be documented by anyone, including the patient, and the physician must reference the PFSH information in his own progress note. Re-documenting the PFSH is not necessary unless a revision is required. PFSH documentation is only required for initial care services (i.e., initial hospital care, initial observation care, consultations). It is not required for subsequent care services, unless additional pertinent information that impacts care is obtained during the hospital stay.

Common Problems to Avoid

Information cannot be obtained. Some contractors will not penalize the physician for the inability to ascertain complete historical information as long as there is evidenced documentation of an attempt to obtain the information. When the physician cannot extract historical information from the patient directly and no other source is available, the physician documents that he is “unable to obtain” the history. Additionally, the physician must provide a comment to explain why the information is unobtainable (e.g. patient confused, no caregiver present) along with the available information from the limited resources (e.g. emergency medical technicians, records from previous hospitalizations at the same facility).

Previous information referenced. When referencing items from a previous encounter, be sure to include the referenced information when documentation is requested by the payer. Per CMS guidelines, the ROS and/or PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. The review and update may be documented by either describing any new ROS and/or PFSH information or noting that there has been no change in the information and noting the date and location of the earlier ROS and/or PFSH.²

Pre-op clearance and HPI deficiencies. HPI is typically not as deficient as the ROS or family history elements; however, HPI underdocumentation is mostly associated with encounters for pre-op clearance. The physician may state that “patient requires pre-op clearance for left knee repair.” In the absence of any comorbidities or acute illness, HPI documentation may be missing. The physician should remember to identify the details of the presenting problem: “Patient runs five miles daily. Knee felt unstable after running two weeks ago. Swelling and intermittent sharp pain 7/10. Patient has been taking ibuprofen daily without relief.”

Not medically necessary. Remember not to document any elements for the purpose of “getting paid.” Only document information that is clinically relevant, lends to the quality of care provided, or demonstrates the delivery of healthcare services. This prevents accusations of fraud and abuse, promotes billing compliance, and supports medical necessity for the services provided.

Varying levels of history. E/M services are selected based on the content of the three “key” components: history, exam, and decision-making (or visit time). If counseling and/or coordination of care does not encompass >50% of the physician’s total visit time or the service is not exclusively designated as a time-based service (e.g. critical care and discharge day management), the physician’s service time is not considered.

Documentation for each of the three key components must support the reported visit level when reporting initial hospital care and consultations (for those payers who still recognize consultation codes). Subsequent hospital care (e.g. 99233) only requires supportive documentation from two key components. Medical decision-making should be one of the two supporting components in order to demonstrate the medical necessity and nature of the presenting problem; the other supporting component can be history or exam.

Each visit category (e.g. initial hospital care or subsequent hospital care) and service level (e.g. 99221-99233) identifies corresponding documentation requirements. Failure to document any essential element in a given visit level (e.g. family history required for a comprehensive history when billing for 99222 and 99223) may result in service denial or downcoding (e.g. 99221). Be aware of what an auditor expects when reviewing patient history (see Table 1).

There are four levels of history: problem-focused, expanded problem-focused, detailed, and comprehensive. An auditor determines the number of history elements documented in the progress note (see Table 2). The history level corresponds to the lowest documented element. For example, if physician documentation includes four HPI elements, eight ROS, and a comment in each of the PFSHs, the history level is equivalent to “detailed.” The history would support initial hospital care 99221 or subsequent hospital care 99233.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Levinson DR. Department of Health and Human Services, Office of Inspector General: Coding Trends of Medicare Evaluation and Management Services. May 2012. Available at: oig.hhs.gov/oei/reports/oei-04-10-00180.pdf. Accessed October 4, 2014.
2. Centers for Medicare and Medicaid Services. 1995 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf. Accessed October 4, 2014.
3. Abraham M, Ahlman J, Boudreau A, Connelly J, Levreau-Davis L. CPT 2013 Professional Edition (Current Procedural Terminology). Chicago: American Medical Association Press; 2012:4-10.
4. Centers for Medicare and Medicaid Services. 1997 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf. Accessed October 4, 2014.
5. Noridian Healthcare Solutions. Medicare Part B: Evaluation and Management Workshop Questions and Answers. Available at: www.noridianmedicare.com/cgi-bin/coranto/viewnews.cgi?id=EkZpEVAyylqZyOfqel&tmpl=part_b_viewnews&style=part_ab_viewnews Accessed on October 4, 2014.
6. WPS Medicare Health Insurance. J5 MAC Part B: Documentation (Q&As). Available at: www.wpsmedicare.com/j5macpartb/resources/provider_types/evalmngmntqa.shtml. Accessed October 4, 2014.
7. NHIC, Corp. Building Your Medicare Knowledge: Advanced Building Blocks. Available at: www.medicarenhic.com/providers/pubs/AdvdBuildBlocks061212.pdf.
8. Palmetto GBA. Jurisdiction 11 Part B: History Component. Available at: www.palmettogba.com/Palmetto/Providers.nsf/docsCat/Jurisdiction%2011%20Part%20B~EM%20Help%20Center~General%20Articles~History%20Component?open&Expand=1. Accessed October 4, 2014.
9. Novitas Solutions. Frequently Asked Questions: Evaluation and Management Services (Part B). Available at: https://www.novitas-solutions.com/faq/partb/pet/lpet-evaluation_management_services.html. Accessed October 4, 2014.

As I have mentioned in prior columns, the key to success with International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) coding will be additional specificity, which will come in the form of more characters to communicate with payors and statisticians regarding the services that have been provided during the office visit. The addition of characters will permit more information about the visit to be delivered in the code.

Some of these additional characters will be required to submit the code for processing. Specifically look out for codes that communicate accidents or injury. Some common circumstances for dermatologists will be lacerations, abrasions, laceration repairs, and burns. The structure of the ICD-10-CM codes is outlined below to explain circumstances in which the increased number of characters will be most important for dermatologists.

The ICD-10-CM codes will be 3 to 7 characters long.¹ The first 3 characters are the general categories. For example, L70 is the 3-character category for acne and L40 is the category for psoriasis. The next 3 characters (ie, characters 4–6) correspond to the related etiology (ie, the cause, set of causes, manner of causation of a disease or condition), anatomic site, severity, and other vital clinical details.¹

Take the case of a burn on the hand. With the International Classification of Diseases, Ninth Revision, a first-degree burn on the back of the hand is coded with 5 characters (944.16).² According to the ICD-10-CM coding system, the code for an initial visit for a first-degree burn on the back of the hand would include 7 characters (T23.169A).¹ There will be times when the sixth character may not be necessary; in these instances, an X must be placed in this position as a placeholder, but the absence of a sixth character does not negate the need for a seventh. Thankfully, the seventh character can only be 1 of 3 letters. As illustrated above in the code for a first-degree burn on the back of the hand, the A designates an initial encounter; a D would designate a follow-up visit for this burn, and an S would represent a sequela from the initial burn, such as a postinflammatory change, which would have its own code.¹

Conclusion

To be reimbursed, appropriate ICD-10-CM codes must be used. Be sure to master the structure of these codes before the October 1, 2015, compliance deadline; plan now for a training and testing period.

As I have mentioned in prior columns, the key to success with International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) coding will be additional specificity, which will come in the form of more characters to communicate with payors and statisticians regarding the services that have been provided during the office visit. The addition of characters will permit more information about the visit to be delivered in the code.

Some of these additional characters will be required to submit the code for processing. Specifically look out for codes that communicate accidents or injury. Some common circumstances for dermatologists will be lacerations, abrasions, laceration repairs, and burns. The structure of the ICD-10-CM codes is outlined below to explain circumstances in which the increased number of characters will be most important for dermatologists.

The ICD-10-CM codes will be 3 to 7 characters long.¹ The first 3 characters are the general categories. For example, L70 is the 3-character category for acne and L40 is the category for psoriasis. The next 3 characters (ie, characters 4–6) correspond to the related etiology (ie, the cause, set of causes, manner of causation of a disease or condition), anatomic site, severity, and other vital clinical details.¹

Take the case of a burn on the hand. With the International Classification of Diseases, Ninth Revision, a first-degree burn on the back of the hand is coded with 5 characters (944.16).² According to the ICD-10-CM coding system, the code for an initial visit for a first-degree burn on the back of the hand would include 7 characters (T23.169A).¹ There will be times when the sixth character may not be necessary; in these instances, an X must be placed in this position as a placeholder, but the absence of a sixth character does not negate the need for a seventh. Thankfully, the seventh character can only be 1 of 3 letters. As illustrated above in the code for a first-degree burn on the back of the hand, the A designates an initial encounter; a D would designate a follow-up visit for this burn, and an S would represent a sequela from the initial burn, such as a postinflammatory change, which would have its own code.¹

Conclusion

To be reimbursed, appropriate ICD-10-CM codes must be used. Be sure to master the structure of these codes before the October 1, 2015, compliance deadline; plan now for a training and testing period.

As I have mentioned in prior columns, the key to success with International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) coding will be additional specificity, which will come in the form of more characters to communicate with payors and statisticians regarding the services that have been provided during the office visit. The addition of characters will permit more information about the visit to be delivered in the code.

Some of these additional characters will be required to submit the code for processing. Specifically look out for codes that communicate accidents or injury. Some common circumstances for dermatologists will be lacerations, abrasions, laceration repairs, and burns. The structure of the ICD-10-CM codes is outlined below to explain circumstances in which the increased number of characters will be most important for dermatologists.

The ICD-10-CM codes will be 3 to 7 characters long.¹ The first 3 characters are the general categories. For example, L70 is the 3-character category for acne and L40 is the category for psoriasis. The next 3 characters (ie, characters 4–6) correspond to the related etiology (ie, the cause, set of causes, manner of causation of a disease or condition), anatomic site, severity, and other vital clinical details.¹

Take the case of a burn on the hand. With the International Classification of Diseases, Ninth Revision, a first-degree burn on the back of the hand is coded with 5 characters (944.16).² According to the ICD-10-CM coding system, the code for an initial visit for a first-degree burn on the back of the hand would include 7 characters (T23.169A).¹ There will be times when the sixth character may not be necessary; in these instances, an X must be placed in this position as a placeholder, but the absence of a sixth character does not negate the need for a seventh. Thankfully, the seventh character can only be 1 of 3 letters. As illustrated above in the code for a first-degree burn on the back of the hand, the A designates an initial encounter; a D would designate a follow-up visit for this burn, and an S would represent a sequela from the initial burn, such as a postinflammatory change, which would have its own code.¹

Conclusion

To be reimbursed, appropriate ICD-10-CM codes must be used. Be sure to master the structure of these codes before the October 1, 2015, compliance deadline; plan now for a training and testing period.

For many years I have advised physicians that aggressive management of accounts receivable is the key to financial health for any private practice. In the current health care reform climate, it has become more important than ever. A crucial step toward proper management of accounts receivable in the age of the Patient Protection and Affordable Care Act is minimization, if not outright elimination, of patient billing, which is a hallowed yet obsolete tradition in private practice. Billing, in effect, is extending free credit to patients, and independent physicians can no longer afford it.

Some physicians of a traditional bent cling to the idea that accepting credit cards or even asking for payment at the time of service smacks of “storekeeping.” They feel more comfortable billing patients for outstanding balances but complain that their bills often are ignored; with each passing day following treatment in your office, the likelihood decreases that a patient will pay the bill.

Patient billing also is expensive. When you total the costs of materials, postage, and staff labor, each bill can cost anywhere from $2 to $10 or more. Every minute the office staff spends producing and mailing bills is time not spent on more productive work. Billing services are an alternative, but they also are expensive, and those bills get ignored too. Requiring immediate payment may seem distasteful to some physicians, but for physicians who wish to keep their office private and independent, it is rapidly becoming the only viable option.

Health Savings Accounts

Private practices will need to become increasingly flexible in how they accept payments as the population continues to age. This flexibility becomes increasingly important as more and more patients rely on health savings accounts (HSAs). Enrollment in these specialized, tax-deductible, tax-free accounts has increased 10-fold over the last decade.¹ Private practice physicians will want to accommodate for HSAs as much as possible.

A few credit companies are already promoting cards to finance HSAs and other private-pay portions of health care expenses, such as The HELPcard (www.helpcard.com). Major credit card companies also have begun to appreciate this largely untapped segment of potential business for them. Soon you may begin receiving help from them in setting up creative payment plans for your patients. Some financial institutions have even begun creating medical credit and debit cards called health benefit cards that are designed specifically for use at physicians’ offices.²

Credit and Debit Cards

Credit and debit cards eliminate many of the problems associated with patient billing. They allow you to collect more fees at the time of service while you still have the patient’s attention and the service you provided is still appreciated.

Charging to a credit or debit card also reduces the chances of a balance owed falling through the cracks, getting lost in the mail, or getting embezzled, and it cannot bounce so it is better than a check. Card payments also can improve your practice’s cash flow, which is always a welcome benefit. Additionally, if a patient is delinquent in paying a credit card bill, it is the credit card company’s problem, not yours.

Credit cards also offer more payment flexibility for patients. In the case of a large balance, offer your patient the option of charging all of the services to a credit card, which he/she can then pay off in affordable monthly installments. Your practice will get reimbursed in full, even as the patient is paying it off slowly, and the patient is able to pay off the debt at a pace that makes sense for his/her finances.

Payment Policies

Beyond simply accepting credit cards, the next step is one that every hotel, rental car agency, and many other businesses have used for years: Retain a card number in each patient’s file, and bill balances as they come in.

Every new patient in my office receives a letter at his/her first visit explaining our policy: We will keep a credit card number on file and use it to bill any outstanding balances after third parties pay their portion. At the bottom of the letter is a brief statement of consent for the patient to sign, along with a place to write the credit card number and expiration date. This policy also comes in handy for patients who claim to have come to the office without cash, a checkbook, credit cards, or any other method of payment. In such situations, my office manager can say, “No problem, we have your credit card information on file!”

Do patients object to this policy? Some do, mostly older patients. But when we explain that we are doing nothing different than hotels do at check-in and that this policy also will work to their advantage by decreasing the number of bills they receive and checks they must write, most come around. Make it an option at first if you wish; then, when everyone is accustomed, you can make it a mandatory policy. My office manager has the authority to make exceptions on a case-by-case basis when necessary.

Do patients worry about confidentiality or unauthorized use? Most individuals do not worry when they use a credit card at a restaurant, hotel, or the Internet. Guard your patients’ financial information as carefully as their medical information. If you have electronic health records, the patient’s credit card number can go in the medical chart. Otherwise use a separate portable filing system that can be locked up each night.

Does this policy work? In only 1 year, my total accounts receivable dropped by nearly 50%; after another year they stabilized at 30% to 35% of prior levels and have remained there ever since, which was a source of consternation for our new accountant who we hired shortly thereafter. “Something must be wrong,” he said nervously after his first look at our books. “Accounts receivable totals are never that low in a medical office with your level of volume.” His eyes widened as I explained our system. “Why doesn’t every private practice do that?” he asked. Why, indeed.

Final Thoughts

The business of health care delivery is currently being rocked at its foundations, as I have been detailing in this column. Without considerable adaptation to these fundamental changes, a private practice can do little more than survive, and even that will take luck. A crucial component of adaptation involves doing more of what we do best, treating patients. Leave the business of extending credit to the banks and credit card companies.

For many years I have advised physicians that aggressive management of accounts receivable is the key to financial health for any private practice. In the current health care reform climate, it has become more important than ever. A crucial step toward proper management of accounts receivable in the age of the Patient Protection and Affordable Care Act is minimization, if not outright elimination, of patient billing, which is a hallowed yet obsolete tradition in private practice. Billing, in effect, is extending free credit to patients, and independent physicians can no longer afford it.

Some physicians of a traditional bent cling to the idea that accepting credit cards or even asking for payment at the time of service smacks of “storekeeping.” They feel more comfortable billing patients for outstanding balances but complain that their bills often are ignored; with each passing day following treatment in your office, the likelihood decreases that a patient will pay the bill.

Patient billing also is expensive. When you total the costs of materials, postage, and staff labor, each bill can cost anywhere from $2 to $10 or more. Every minute the office staff spends producing and mailing bills is time not spent on more productive work. Billing services are an alternative, but they also are expensive, and those bills get ignored too. Requiring immediate payment may seem distasteful to some physicians, but for physicians who wish to keep their office private and independent, it is rapidly becoming the only viable option.

Health Savings Accounts

Private practices will need to become increasingly flexible in how they accept payments as the population continues to age. This flexibility becomes increasingly important as more and more patients rely on health savings accounts (HSAs). Enrollment in these specialized, tax-deductible, tax-free accounts has increased 10-fold over the last decade.¹ Private practice physicians will want to accommodate for HSAs as much as possible.

A few credit companies are already promoting cards to finance HSAs and other private-pay portions of health care expenses, such as The HELPcard (www.helpcard.com). Major credit card companies also have begun to appreciate this largely untapped segment of potential business for them. Soon you may begin receiving help from them in setting up creative payment plans for your patients. Some financial institutions have even begun creating medical credit and debit cards called health benefit cards that are designed specifically for use at physicians’ offices.²

Credit and Debit Cards

Credit and debit cards eliminate many of the problems associated with patient billing. They allow you to collect more fees at the time of service while you still have the patient’s attention and the service you provided is still appreciated.

Charging to a credit or debit card also reduces the chances of a balance owed falling through the cracks, getting lost in the mail, or getting embezzled, and it cannot bounce so it is better than a check. Card payments also can improve your practice’s cash flow, which is always a welcome benefit. Additionally, if a patient is delinquent in paying a credit card bill, it is the credit card company’s problem, not yours.

Credit cards also offer more payment flexibility for patients. In the case of a large balance, offer your patient the option of charging all of the services to a credit card, which he/she can then pay off in affordable monthly installments. Your practice will get reimbursed in full, even as the patient is paying it off slowly, and the patient is able to pay off the debt at a pace that makes sense for his/her finances.

Payment Policies

Beyond simply accepting credit cards, the next step is one that every hotel, rental car agency, and many other businesses have used for years: Retain a card number in each patient’s file, and bill balances as they come in.

Every new patient in my office receives a letter at his/her first visit explaining our policy: We will keep a credit card number on file and use it to bill any outstanding balances after third parties pay their portion. At the bottom of the letter is a brief statement of consent for the patient to sign, along with a place to write the credit card number and expiration date. This policy also comes in handy for patients who claim to have come to the office without cash, a checkbook, credit cards, or any other method of payment. In such situations, my office manager can say, “No problem, we have your credit card information on file!”

Do patients object to this policy? Some do, mostly older patients. But when we explain that we are doing nothing different than hotels do at check-in and that this policy also will work to their advantage by decreasing the number of bills they receive and checks they must write, most come around. Make it an option at first if you wish; then, when everyone is accustomed, you can make it a mandatory policy. My office manager has the authority to make exceptions on a case-by-case basis when necessary.

Do patients worry about confidentiality or unauthorized use? Most individuals do not worry when they use a credit card at a restaurant, hotel, or the Internet. Guard your patients’ financial information as carefully as their medical information. If you have electronic health records, the patient’s credit card number can go in the medical chart. Otherwise use a separate portable filing system that can be locked up each night.

Does this policy work? In only 1 year, my total accounts receivable dropped by nearly 50%; after another year they stabilized at 30% to 35% of prior levels and have remained there ever since, which was a source of consternation for our new accountant who we hired shortly thereafter. “Something must be wrong,” he said nervously after his first look at our books. “Accounts receivable totals are never that low in a medical office with your level of volume.” His eyes widened as I explained our system. “Why doesn’t every private practice do that?” he asked. Why, indeed.

Final Thoughts

The business of health care delivery is currently being rocked at its foundations, as I have been detailing in this column. Without considerable adaptation to these fundamental changes, a private practice can do little more than survive, and even that will take luck. A crucial component of adaptation involves doing more of what we do best, treating patients. Leave the business of extending credit to the banks and credit card companies.

For many years I have advised physicians that aggressive management of accounts receivable is the key to financial health for any private practice. In the current health care reform climate, it has become more important than ever. A crucial step toward proper management of accounts receivable in the age of the Patient Protection and Affordable Care Act is minimization, if not outright elimination, of patient billing, which is a hallowed yet obsolete tradition in private practice. Billing, in effect, is extending free credit to patients, and independent physicians can no longer afford it.

Some physicians of a traditional bent cling to the idea that accepting credit cards or even asking for payment at the time of service smacks of “storekeeping.” They feel more comfortable billing patients for outstanding balances but complain that their bills often are ignored; with each passing day following treatment in your office, the likelihood decreases that a patient will pay the bill.

Patient billing also is expensive. When you total the costs of materials, postage, and staff labor, each bill can cost anywhere from $2 to $10 or more. Every minute the office staff spends producing and mailing bills is time not spent on more productive work. Billing services are an alternative, but they also are expensive, and those bills get ignored too. Requiring immediate payment may seem distasteful to some physicians, but for physicians who wish to keep their office private and independent, it is rapidly becoming the only viable option.

Health Savings Accounts

Private practices will need to become increasingly flexible in how they accept payments as the population continues to age. This flexibility becomes increasingly important as more and more patients rely on health savings accounts (HSAs). Enrollment in these specialized, tax-deductible, tax-free accounts has increased 10-fold over the last decade.¹ Private practice physicians will want to accommodate for HSAs as much as possible.

A few credit companies are already promoting cards to finance HSAs and other private-pay portions of health care expenses, such as The HELPcard (www.helpcard.com). Major credit card companies also have begun to appreciate this largely untapped segment of potential business for them. Soon you may begin receiving help from them in setting up creative payment plans for your patients. Some financial institutions have even begun creating medical credit and debit cards called health benefit cards that are designed specifically for use at physicians’ offices.²

Credit and Debit Cards

Credit and debit cards eliminate many of the problems associated with patient billing. They allow you to collect more fees at the time of service while you still have the patient’s attention and the service you provided is still appreciated.

Charging to a credit or debit card also reduces the chances of a balance owed falling through the cracks, getting lost in the mail, or getting embezzled, and it cannot bounce so it is better than a check. Card payments also can improve your practice’s cash flow, which is always a welcome benefit. Additionally, if a patient is delinquent in paying a credit card bill, it is the credit card company’s problem, not yours.

Credit cards also offer more payment flexibility for patients. In the case of a large balance, offer your patient the option of charging all of the services to a credit card, which he/she can then pay off in affordable monthly installments. Your practice will get reimbursed in full, even as the patient is paying it off slowly, and the patient is able to pay off the debt at a pace that makes sense for his/her finances.

Payment Policies

Beyond simply accepting credit cards, the next step is one that every hotel, rental car agency, and many other businesses have used for years: Retain a card number in each patient’s file, and bill balances as they come in.

Every new patient in my office receives a letter at his/her first visit explaining our policy: We will keep a credit card number on file and use it to bill any outstanding balances after third parties pay their portion. At the bottom of the letter is a brief statement of consent for the patient to sign, along with a place to write the credit card number and expiration date. This policy also comes in handy for patients who claim to have come to the office without cash, a checkbook, credit cards, or any other method of payment. In such situations, my office manager can say, “No problem, we have your credit card information on file!”

Do patients object to this policy? Some do, mostly older patients. But when we explain that we are doing nothing different than hotels do at check-in and that this policy also will work to their advantage by decreasing the number of bills they receive and checks they must write, most come around. Make it an option at first if you wish; then, when everyone is accustomed, you can make it a mandatory policy. My office manager has the authority to make exceptions on a case-by-case basis when necessary.

Do patients worry about confidentiality or unauthorized use? Most individuals do not worry when they use a credit card at a restaurant, hotel, or the Internet. Guard your patients’ financial information as carefully as their medical information. If you have electronic health records, the patient’s credit card number can go in the medical chart. Otherwise use a separate portable filing system that can be locked up each night.

Does this policy work? In only 1 year, my total accounts receivable dropped by nearly 50%; after another year they stabilized at 30% to 35% of prior levels and have remained there ever since, which was a source of consternation for our new accountant who we hired shortly thereafter. “Something must be wrong,” he said nervously after his first look at our books. “Accounts receivable totals are never that low in a medical office with your level of volume.” His eyes widened as I explained our system. “Why doesn’t every private practice do that?” he asked. Why, indeed.

Final Thoughts

The business of health care delivery is currently being rocked at its foundations, as I have been detailing in this column. Without considerable adaptation to these fundamental changes, a private practice can do little more than survive, and even that will take luck. A crucial component of adaptation involves doing more of what we do best, treating patients. Leave the business of extending credit to the banks and credit card companies.

Dr. Hospitalist

I just read your article regarding billing. My supervising physician is a surgeon. She and I are both employed by the same hospital. Can she have me dictate the discharge summary before she signs off on it? Or does she have to dictate it because it is in the global post-op period and she is paid for the surgery? If she has me perform an inpatient consult one afternoon/evening, but she doesn't lay eyes on the patient until the following morning, can she bill for the initial consult? Or does she bill for the first subsequent consult? Where is the information to back up your responses, please?

—Concerned with Coding

Dr. Hospitalist responds:

You don’t say so, but I’m assuming you work as a physician assistant (PA) or a nurse practitioner (NP). Since you and your supervising physician are employed by the same hospital, I also assume your fees are assigned to the hospital and you are both considered members of the same “surgical group.”

Just so we’re all on the same page, let’s further define “global surgical” period. Even though there are three types of global surgical packages, they are all based on the number of expected post-operative days. In general, there are the zero- and 10-day post-op periods (for minor procedures) and the 90-day post-op period (for most major procedures). Almost all services, supplies, wound management, and follow-up visits related to the procedure are included in the global surgery payment.

The discharge summary also is part of the global surgery package. When your supervising physician co-signs and validates your note, she can bill as though she did the note herself as defined in the scope of practice and credentialing process at your hospital.

If allowed by your state and sanctioned by your hospital, you can bill separately; however, the global surgery payment would be decreased as per the Medicare Claims Processing Manual (Chapter 12, Sections 40 and 40.1-Physician/Nonphysician Practitioners), which states that “when a NP, PA, or CNS furnish services to a patient during a global surgical period, contractors shall determine the level of NP [nurse practitioner], PA [physician assistant], or CNS [clinical nurse specialist] involvement in furnishing part of the surgeon’s global surgical package consistent with their current practice of processing such claims.” The manual goes on to say that those NP, PA, or CNS services furnished are paid at 80% of the lesser of the actual charge or 85% of what a physician is paid under the Medicare Physician Fee Schedule.

Now you see why it’s more lucrative for the physician to bill than the NP/PA, especially if the extender is working under the “supervision” of the physician.

As I’m sure you’re aware, effective Jan. 1, 2010, the consultation codes were no longer recognized for Medicare Part B payment. Practitioners are directed to code patient evaluation and management (E/M) visits with E/M codes that represent where the visit occurs and identify the complexity of the visit performed.

Medicare directives are pretty clear that in order to bill for a visit, the physician or clinician must have a “face-to-face” encounter with the patient on the day of service billed. There is an opportunity for the physician and NP/PA from the same group practice to bill a split/shared E/M code under either unique physician identification number (UPIN), but the physician must still have a face-to-face encounter on the day of service or the bill must be submitted using the NP/PA’s UPIN (Medicare Claims Processing Manual, Chapter 12 – Physician/Nonphysician Practitioners. Section 30.6.1-Selection of Level of Evaluation and Management Service. Implemented: 01-04-10).

Therefore, in the situation that you describe, the supervising physician must bill for a subsequent visit E/M code.

Occasionally, teaching institutions with residents have formalized agreements with insurers that allow residents to see patients one day, with the attending physician allowed to bill for that day without seeing the patient. You should check with your group’s billing specialist to see if such arrangements have been made for your group.

After taking all this into consideration, however, I perceive the bigger issue as underlying tension or mistrust between you and the supervising physician. I suggest sitting down and having a conversation about scope of practice and expectations, and then you can better determine if you are the right person for that position.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

Dr. Hospitalist

I just read your article regarding billing. My supervising physician is a surgeon. She and I are both employed by the same hospital. Can she have me dictate the discharge summary before she signs off on it? Or does she have to dictate it because it is in the global post-op period and she is paid for the surgery? If she has me perform an inpatient consult one afternoon/evening, but she doesn't lay eyes on the patient until the following morning, can she bill for the initial consult? Or does she bill for the first subsequent consult? Where is the information to back up your responses, please?

—Concerned with Coding

Dr. Hospitalist responds:

You don’t say so, but I’m assuming you work as a physician assistant (PA) or a nurse practitioner (NP). Since you and your supervising physician are employed by the same hospital, I also assume your fees are assigned to the hospital and you are both considered members of the same “surgical group.”

Just so we’re all on the same page, let’s further define “global surgical” period. Even though there are three types of global surgical packages, they are all based on the number of expected post-operative days. In general, there are the zero- and 10-day post-op periods (for minor procedures) and the 90-day post-op period (for most major procedures). Almost all services, supplies, wound management, and follow-up visits related to the procedure are included in the global surgery payment.

The discharge summary also is part of the global surgery package. When your supervising physician co-signs and validates your note, she can bill as though she did the note herself as defined in the scope of practice and credentialing process at your hospital.

If allowed by your state and sanctioned by your hospital, you can bill separately; however, the global surgery payment would be decreased as per the Medicare Claims Processing Manual (Chapter 12, Sections 40 and 40.1-Physician/Nonphysician Practitioners), which states that “when a NP, PA, or CNS furnish services to a patient during a global surgical period, contractors shall determine the level of NP [nurse practitioner], PA [physician assistant], or CNS [clinical nurse specialist] involvement in furnishing part of the surgeon’s global surgical package consistent with their current practice of processing such claims.” The manual goes on to say that those NP, PA, or CNS services furnished are paid at 80% of the lesser of the actual charge or 85% of what a physician is paid under the Medicare Physician Fee Schedule.

Now you see why it’s more lucrative for the physician to bill than the NP/PA, especially if the extender is working under the “supervision” of the physician.

As I’m sure you’re aware, effective Jan. 1, 2010, the consultation codes were no longer recognized for Medicare Part B payment. Practitioners are directed to code patient evaluation and management (E/M) visits with E/M codes that represent where the visit occurs and identify the complexity of the visit performed.

Medicare directives are pretty clear that in order to bill for a visit, the physician or clinician must have a “face-to-face” encounter with the patient on the day of service billed. There is an opportunity for the physician and NP/PA from the same group practice to bill a split/shared E/M code under either unique physician identification number (UPIN), but the physician must still have a face-to-face encounter on the day of service or the bill must be submitted using the NP/PA’s UPIN (Medicare Claims Processing Manual, Chapter 12 – Physician/Nonphysician Practitioners. Section 30.6.1-Selection of Level of Evaluation and Management Service. Implemented: 01-04-10).

Therefore, in the situation that you describe, the supervising physician must bill for a subsequent visit E/M code.

Occasionally, teaching institutions with residents have formalized agreements with insurers that allow residents to see patients one day, with the attending physician allowed to bill for that day without seeing the patient. You should check with your group’s billing specialist to see if such arrangements have been made for your group.

After taking all this into consideration, however, I perceive the bigger issue as underlying tension or mistrust between you and the supervising physician. I suggest sitting down and having a conversation about scope of practice and expectations, and then you can better determine if you are the right person for that position.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

Dr. Hospitalist

I just read your article regarding billing. My supervising physician is a surgeon. She and I are both employed by the same hospital. Can she have me dictate the discharge summary before she signs off on it? Or does she have to dictate it because it is in the global post-op period and she is paid for the surgery? If she has me perform an inpatient consult one afternoon/evening, but she doesn't lay eyes on the patient until the following morning, can she bill for the initial consult? Or does she bill for the first subsequent consult? Where is the information to back up your responses, please?

—Concerned with Coding

Dr. Hospitalist responds:

You don’t say so, but I’m assuming you work as a physician assistant (PA) or a nurse practitioner (NP). Since you and your supervising physician are employed by the same hospital, I also assume your fees are assigned to the hospital and you are both considered members of the same “surgical group.”

Just so we’re all on the same page, let’s further define “global surgical” period. Even though there are three types of global surgical packages, they are all based on the number of expected post-operative days. In general, there are the zero- and 10-day post-op periods (for minor procedures) and the 90-day post-op period (for most major procedures). Almost all services, supplies, wound management, and follow-up visits related to the procedure are included in the global surgery payment.

The discharge summary also is part of the global surgery package. When your supervising physician co-signs and validates your note, she can bill as though she did the note herself as defined in the scope of practice and credentialing process at your hospital.

If allowed by your state and sanctioned by your hospital, you can bill separately; however, the global surgery payment would be decreased as per the Medicare Claims Processing Manual (Chapter 12, Sections 40 and 40.1-Physician/Nonphysician Practitioners), which states that “when a NP, PA, or CNS furnish services to a patient during a global surgical period, contractors shall determine the level of NP [nurse practitioner], PA [physician assistant], or CNS [clinical nurse specialist] involvement in furnishing part of the surgeon’s global surgical package consistent with their current practice of processing such claims.” The manual goes on to say that those NP, PA, or CNS services furnished are paid at 80% of the lesser of the actual charge or 85% of what a physician is paid under the Medicare Physician Fee Schedule.

Now you see why it’s more lucrative for the physician to bill than the NP/PA, especially if the extender is working under the “supervision” of the physician.

As I’m sure you’re aware, effective Jan. 1, 2010, the consultation codes were no longer recognized for Medicare Part B payment. Practitioners are directed to code patient evaluation and management (E/M) visits with E/M codes that represent where the visit occurs and identify the complexity of the visit performed.

Medicare directives are pretty clear that in order to bill for a visit, the physician or clinician must have a “face-to-face” encounter with the patient on the day of service billed. There is an opportunity for the physician and NP/PA from the same group practice to bill a split/shared E/M code under either unique physician identification number (UPIN), but the physician must still have a face-to-face encounter on the day of service or the bill must be submitted using the NP/PA’s UPIN (Medicare Claims Processing Manual, Chapter 12 – Physician/Nonphysician Practitioners. Section 30.6.1-Selection of Level of Evaluation and Management Service. Implemented: 01-04-10).

Therefore, in the situation that you describe, the supervising physician must bill for a subsequent visit E/M code.

Occasionally, teaching institutions with residents have formalized agreements with insurers that allow residents to see patients one day, with the attending physician allowed to bill for that day without seeing the patient. You should check with your group’s billing specialist to see if such arrangements have been made for your group.

After taking all this into consideration, however, I perceive the bigger issue as underlying tension or mistrust between you and the supervising physician. I suggest sitting down and having a conversation about scope of practice and expectations, and then you can better determine if you are the right person for that position.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

In recent months, numerous articles have come out targeting high-billing physicians—looking for smoking guns in recently released 2012 Medicare fee-for-service physician claims data. These data include both the amount each individual physician billed and the amount Medicare paid on average for services performed by all physicians treating Medicare beneficiaries.

Many physician groups, including the AMA, criticized the data release as having significant limitations, including clinical and billing practice realities that confound the layperson’s understanding of the data’s implications. Still, there is much physicians can learn by exploring this information, particularly those in a still-growing field like hospital medicine (HM).

There is no clear method to identify hospitalists within these data. Hospitalists are dispersed throughout their respective board certifications—internal medicine, family practice, pediatrics. The designations come directly from the Medicare specialty billing code; the code associated with the largest number of services becomes that provider’s de facto specialty. For the majority of providers, this will correspond with their board certification and their professional identity. A hospitalist’s unique practice is lost within these general identifiers.

However, the contours of that unique practice may provide some tools to identify hospitalists, albeit roughly, within the data and in the absence of a specialty billing code. Things like practice location and commonly billed Healthcare Common Procedure Coding System (HCPCS) codes can help sketch the boundaries of the field. Certainly, any classification methodology will have its share of imperfections and may exclude individuals who would otherwise identify as hospitalists. Regardless, such an exercise could identify trends in hospital medicine while providing a better understanding of the field as a whole.

HM does not have the traditional hallmark signifiers—board certification and Medicare specialty billing code—used by many specialties and subspecialties to frame their fields and to classify and compare physicians. The Medicare specialty billing code is a unique code applied to Medicare billing claims that tells Medicare exactly how the provider would like to be identified.

Because of its relative specificity and ready accessibility, the Centers for Medicare and Medicaid Services (CMS) uses the specialty billing code to create specialty comparison groups in pay-for-performance programs. Under the value-based payment modifier, hospitalists are compared against outpatient internal medicine or family medicine physicians, which makes them seem all the more expensive and less efficient.

SHM has been attuned to this particular issue since the early days of the physician value-based payment modifier. For nearly two years, SHM has repeatedly admonished CMS to compare hospitalists against other hospitalists in order for a pay-for-performance scheme to fairly and reasonably evaluate quality and efficiency. CMS acknowledged that many specialties and subspecialties may be masked within the current listing of Medicare specialty billing codes but yielded only so far as to say that aggrieved specialties can apply for their own code. SHM, for its part, applied for a specialty billing code for hospitalists in May 2014.

SHM has been actively exploring the data and looking at ways to identify hospitalists within this Medicare data. There’s an inherent value to this sort of self-reflection—it explains who we are and where we have been.

More importantly, it helps inform where we are going.

Joshua Lapps is SHM’s government relations manager.

In recent months, numerous articles have come out targeting high-billing physicians—looking for smoking guns in recently released 2012 Medicare fee-for-service physician claims data. These data include both the amount each individual physician billed and the amount Medicare paid on average for services performed by all physicians treating Medicare beneficiaries.

Many physician groups, including the AMA, criticized the data release as having significant limitations, including clinical and billing practice realities that confound the layperson’s understanding of the data’s implications. Still, there is much physicians can learn by exploring this information, particularly those in a still-growing field like hospital medicine (HM).

There is no clear method to identify hospitalists within these data. Hospitalists are dispersed throughout their respective board certifications—internal medicine, family practice, pediatrics. The designations come directly from the Medicare specialty billing code; the code associated with the largest number of services becomes that provider’s de facto specialty. For the majority of providers, this will correspond with their board certification and their professional identity. A hospitalist’s unique practice is lost within these general identifiers.

However, the contours of that unique practice may provide some tools to identify hospitalists, albeit roughly, within the data and in the absence of a specialty billing code. Things like practice location and commonly billed Healthcare Common Procedure Coding System (HCPCS) codes can help sketch the boundaries of the field. Certainly, any classification methodology will have its share of imperfections and may exclude individuals who would otherwise identify as hospitalists. Regardless, such an exercise could identify trends in hospital medicine while providing a better understanding of the field as a whole.

HM does not have the traditional hallmark signifiers—board certification and Medicare specialty billing code—used by many specialties and subspecialties to frame their fields and to classify and compare physicians. The Medicare specialty billing code is a unique code applied to Medicare billing claims that tells Medicare exactly how the provider would like to be identified.

Because of its relative specificity and ready accessibility, the Centers for Medicare and Medicaid Services (CMS) uses the specialty billing code to create specialty comparison groups in pay-for-performance programs. Under the value-based payment modifier, hospitalists are compared against outpatient internal medicine or family medicine physicians, which makes them seem all the more expensive and less efficient.

SHM has been attuned to this particular issue since the early days of the physician value-based payment modifier. For nearly two years, SHM has repeatedly admonished CMS to compare hospitalists against other hospitalists in order for a pay-for-performance scheme to fairly and reasonably evaluate quality and efficiency. CMS acknowledged that many specialties and subspecialties may be masked within the current listing of Medicare specialty billing codes but yielded only so far as to say that aggrieved specialties can apply for their own code. SHM, for its part, applied for a specialty billing code for hospitalists in May 2014.

SHM has been actively exploring the data and looking at ways to identify hospitalists within this Medicare data. There’s an inherent value to this sort of self-reflection—it explains who we are and where we have been.

More importantly, it helps inform where we are going.

Joshua Lapps is SHM’s government relations manager.

In recent months, numerous articles have come out targeting high-billing physicians—looking for smoking guns in recently released 2012 Medicare fee-for-service physician claims data. These data include both the amount each individual physician billed and the amount Medicare paid on average for services performed by all physicians treating Medicare beneficiaries.

Many physician groups, including the AMA, criticized the data release as having significant limitations, including clinical and billing practice realities that confound the layperson’s understanding of the data’s implications. Still, there is much physicians can learn by exploring this information, particularly those in a still-growing field like hospital medicine (HM).

There is no clear method to identify hospitalists within these data. Hospitalists are dispersed throughout their respective board certifications—internal medicine, family practice, pediatrics. The designations come directly from the Medicare specialty billing code; the code associated with the largest number of services becomes that provider’s de facto specialty. For the majority of providers, this will correspond with their board certification and their professional identity. A hospitalist’s unique practice is lost within these general identifiers.

However, the contours of that unique practice may provide some tools to identify hospitalists, albeit roughly, within the data and in the absence of a specialty billing code. Things like practice location and commonly billed Healthcare Common Procedure Coding System (HCPCS) codes can help sketch the boundaries of the field. Certainly, any classification methodology will have its share of imperfections and may exclude individuals who would otherwise identify as hospitalists. Regardless, such an exercise could identify trends in hospital medicine while providing a better understanding of the field as a whole.

HM does not have the traditional hallmark signifiers—board certification and Medicare specialty billing code—used by many specialties and subspecialties to frame their fields and to classify and compare physicians. The Medicare specialty billing code is a unique code applied to Medicare billing claims that tells Medicare exactly how the provider would like to be identified.

Because of its relative specificity and ready accessibility, the Centers for Medicare and Medicaid Services (CMS) uses the specialty billing code to create specialty comparison groups in pay-for-performance programs. Under the value-based payment modifier, hospitalists are compared against outpatient internal medicine or family medicine physicians, which makes them seem all the more expensive and less efficient.

SHM has been attuned to this particular issue since the early days of the physician value-based payment modifier. For nearly two years, SHM has repeatedly admonished CMS to compare hospitalists against other hospitalists in order for a pay-for-performance scheme to fairly and reasonably evaluate quality and efficiency. CMS acknowledged that many specialties and subspecialties may be masked within the current listing of Medicare specialty billing codes but yielded only so far as to say that aggrieved specialties can apply for their own code. SHM, for its part, applied for a specialty billing code for hospitalists in May 2014.

SHM has been actively exploring the data and looking at ways to identify hospitalists within this Medicare data. There’s an inherent value to this sort of self-reflection—it explains who we are and where we have been.

More importantly, it helps inform where we are going.

Joshua Lapps is SHM’s government relations manager.

Have you ever worried about which billing code is appropriate? Worried that your coding decisions could be called into question, but reading up on the topic only left you more confused?

SHM’s new, first-of-its-kind online educational tool can help.

CODE-H Interactive—short for “Coding Optimally for Documenting Effectively for Hospitalists”—gives hospitalists an online guided tour through six different coding scenarios, enabling them to choose the codes they believe are appropriate. Then, SHM’s coding expert highlights the correct codes and offers rationales for each.

HM groups can enroll multiple team members using a single subscription, making educating entire teams easy. Each participant receives a certificate documenting his or her participation in the program.

CODE-H Interactive is available today at www.hospitalmedicine.org/codehi.

Have you ever worried about which billing code is appropriate? Worried that your coding decisions could be called into question, but reading up on the topic only left you more confused?

SHM’s new, first-of-its-kind online educational tool can help.

CODE-H Interactive—short for “Coding Optimally for Documenting Effectively for Hospitalists”—gives hospitalists an online guided tour through six different coding scenarios, enabling them to choose the codes they believe are appropriate. Then, SHM’s coding expert highlights the correct codes and offers rationales for each.

HM groups can enroll multiple team members using a single subscription, making educating entire teams easy. Each participant receives a certificate documenting his or her participation in the program.

CODE-H Interactive is available today at www.hospitalmedicine.org/codehi.

Have you ever worried about which billing code is appropriate? Worried that your coding decisions could be called into question, but reading up on the topic only left you more confused?

SHM’s new, first-of-its-kind online educational tool can help.

CODE-H Interactive—short for “Coding Optimally for Documenting Effectively for Hospitalists”—gives hospitalists an online guided tour through six different coding scenarios, enabling them to choose the codes they believe are appropriate. Then, SHM’s coding expert highlights the correct codes and offers rationales for each.

HM groups can enroll multiple team members using a single subscription, making educating entire teams easy. Each participant receives a certificate documenting his or her participation in the program.

CODE-H Interactive is available today at www.hospitalmedicine.org/codehi.

It is important that dermatologists do not overlook the changes associated with the transition to International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). Some physicians believe that providing this level of specificity is not important because at the end of the day, who is watching? You will see with several of the codes highlighted in this column that specificity may be required before a claim can be submitted to the payor for processing. In addition, some older catchall codes will go away, forcing us to provide additional specificity.¹

Scabies coding is a good example of an added specificity requirement. Currently, with the International Classification of Diseases, Ninth Revision (ICD-9), we have a code for scabies but no code to address the postscabetic pruritus that patients often develop. The ICD-9 code 133.0 applies to scabies, and if we would like to code for the itch, we must enter a second code for unspecified pruritic disorder (698.9).² With ICD-10-CM, we can be more specific and actually code for the cause of the itch. We will be able to mark the initial visit as B86 (scabies), but subsequent visits for the itch related to scabies can be coded as pruritus using the primary code L29.8 (other pruritus) and a new sequelae or late effect code of B94 (sequelae of other and unspecified infectious and parasitic diseases).³ You will still be able to submit the second visit with scabies as the primary diagnosis, but this practice should be avoided to prevent claim rejection on the backend. In addition, there will be codes to allow for evaluation of a family member or close contact for this condition. Although coding these patients as an initial visit for scabies may be easier, for epidemiologic purposes a more complete code to provide would be the ICD-10-CM code of Z11.8 (encounter for screening for other infectious and parasitic diseases), particularly if they are not found to have scabies.³ This code also would be useful when screening for head lice when a close contact is not found to have it. What do we currently code when someone comes for screening of head lice because a classmate or sibling has it? With ICD-10-CM we will have a more accurate way to communicate with the payor.

The increase in the number of codes with ICD-10-CM permits us to give a description on a situation or circumstance when a person who may not be sick comes into the office for a specific reason or when circumstances influence a person’s health status but those circumstances are not an actual illness or injury. It is frustrating that I currently am not able to code for a skin examination appropriately using ICD-9. Let me be clear, I am not saying that this new code will be reimbursable. We will have to wait and see how we are reimbursed for all of these codes, but at least we will have the option of coding for the reason the patient presents to me, which is often a skin examination, and then the secondary code could be benign nevi or seborrheic keratosis. The code Z12.83 (encounter for screening for malignant neoplasm of skin) will now be the best code for these purposes.³ In addition, codes that address postoperative nursing visits have not been available. With ICD-10-CM we will have a new code for encounter for surgical aftercare following surgery on the skin and subcutaneous tissue that does not include a standard suture removal but is a necessary visit (Z48.817). In addition, we will have a specific code to document encounters for allergy testing (Z01.82).³ With ICD-9, rash not otherwise specified or eczema would have to be the primary code (782.1) and you were forced to place a code for the patient’s allergy, regardless of whether or not the allergy was known.

The reimbursement of these codes has not been addressed, so ideally during the testing period there can be a head-to-head comparison. By adhering to some of the new rules, hopefully we will be able to more completely communicate about what is occurring during the patient visit.

It is important that dermatologists do not overlook the changes associated with the transition to International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). Some physicians believe that providing this level of specificity is not important because at the end of the day, who is watching? You will see with several of the codes highlighted in this column that specificity may be required before a claim can be submitted to the payor for processing. In addition, some older catchall codes will go away, forcing us to provide additional specificity.¹

Scabies coding is a good example of an added specificity requirement. Currently, with the International Classification of Diseases, Ninth Revision (ICD-9), we have a code for scabies but no code to address the postscabetic pruritus that patients often develop. The ICD-9 code 133.0 applies to scabies, and if we would like to code for the itch, we must enter a second code for unspecified pruritic disorder (698.9).² With ICD-10-CM, we can be more specific and actually code for the cause of the itch. We will be able to mark the initial visit as B86 (scabies), but subsequent visits for the itch related to scabies can be coded as pruritus using the primary code L29.8 (other pruritus) and a new sequelae or late effect code of B94 (sequelae of other and unspecified infectious and parasitic diseases).³ You will still be able to submit the second visit with scabies as the primary diagnosis, but this practice should be avoided to prevent claim rejection on the backend. In addition, there will be codes to allow for evaluation of a family member or close contact for this condition. Although coding these patients as an initial visit for scabies may be easier, for epidemiologic purposes a more complete code to provide would be the ICD-10-CM code of Z11.8 (encounter for screening for other infectious and parasitic diseases), particularly if they are not found to have scabies.³ This code also would be useful when screening for head lice when a close contact is not found to have it. What do we currently code when someone comes for screening of head lice because a classmate or sibling has it? With ICD-10-CM we will have a more accurate way to communicate with the payor.

The increase in the number of codes with ICD-10-CM permits us to give a description on a situation or circumstance when a person who may not be sick comes into the office for a specific reason or when circumstances influence a person’s health status but those circumstances are not an actual illness or injury. It is frustrating that I currently am not able to code for a skin examination appropriately using ICD-9. Let me be clear, I am not saying that this new code will be reimbursable. We will have to wait and see how we are reimbursed for all of these codes, but at least we will have the option of coding for the reason the patient presents to me, which is often a skin examination, and then the secondary code could be benign nevi or seborrheic keratosis. The code Z12.83 (encounter for screening for malignant neoplasm of skin) will now be the best code for these purposes.³ In addition, codes that address postoperative nursing visits have not been available. With ICD-10-CM we will have a new code for encounter for surgical aftercare following surgery on the skin and subcutaneous tissue that does not include a standard suture removal but is a necessary visit (Z48.817). In addition, we will have a specific code to document encounters for allergy testing (Z01.82).³ With ICD-9, rash not otherwise specified or eczema would have to be the primary code (782.1) and you were forced to place a code for the patient’s allergy, regardless of whether or not the allergy was known.

The reimbursement of these codes has not been addressed, so ideally during the testing period there can be a head-to-head comparison. By adhering to some of the new rules, hopefully we will be able to more completely communicate about what is occurring during the patient visit.

It is important that dermatologists do not overlook the changes associated with the transition to International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). Some physicians believe that providing this level of specificity is not important because at the end of the day, who is watching? You will see with several of the codes highlighted in this column that specificity may be required before a claim can be submitted to the payor for processing. In addition, some older catchall codes will go away, forcing us to provide additional specificity.¹

Scabies coding is a good example of an added specificity requirement. Currently, with the International Classification of Diseases, Ninth Revision (ICD-9), we have a code for scabies but no code to address the postscabetic pruritus that patients often develop. The ICD-9 code 133.0 applies to scabies, and if we would like to code for the itch, we must enter a second code for unspecified pruritic disorder (698.9).² With ICD-10-CM, we can be more specific and actually code for the cause of the itch. We will be able to mark the initial visit as B86 (scabies), but subsequent visits for the itch related to scabies can be coded as pruritus using the primary code L29.8 (other pruritus) and a new sequelae or late effect code of B94 (sequelae of other and unspecified infectious and parasitic diseases).³ You will still be able to submit the second visit with scabies as the primary diagnosis, but this practice should be avoided to prevent claim rejection on the backend. In addition, there will be codes to allow for evaluation of a family member or close contact for this condition. Although coding these patients as an initial visit for scabies may be easier, for epidemiologic purposes a more complete code to provide would be the ICD-10-CM code of Z11.8 (encounter for screening for other infectious and parasitic diseases), particularly if they are not found to have scabies.³ This code also would be useful when screening for head lice when a close contact is not found to have it. What do we currently code when someone comes for screening of head lice because a classmate or sibling has it? With ICD-10-CM we will have a more accurate way to communicate with the payor.

The increase in the number of codes with ICD-10-CM permits us to give a description on a situation or circumstance when a person who may not be sick comes into the office for a specific reason or when circumstances influence a person’s health status but those circumstances are not an actual illness or injury. It is frustrating that I currently am not able to code for a skin examination appropriately using ICD-9. Let me be clear, I am not saying that this new code will be reimbursable. We will have to wait and see how we are reimbursed for all of these codes, but at least we will have the option of coding for the reason the patient presents to me, which is often a skin examination, and then the secondary code could be benign nevi or seborrheic keratosis. The code Z12.83 (encounter for screening for malignant neoplasm of skin) will now be the best code for these purposes.³ In addition, codes that address postoperative nursing visits have not been available. With ICD-10-CM we will have a new code for encounter for surgical aftercare following surgery on the skin and subcutaneous tissue that does not include a standard suture removal but is a necessary visit (Z48.817). In addition, we will have a specific code to document encounters for allergy testing (Z01.82).³ With ICD-9, rash not otherwise specified or eczema would have to be the primary code (782.1) and you were forced to place a code for the patient’s allergy, regardless of whether or not the allergy was known.

The reimbursement of these codes has not been addressed, so ideally during the testing period there can be a head-to-head comparison. By adhering to some of the new rules, hopefully we will be able to more completely communicate about what is occurring during the patient visit.

click for large version

Medical decision-making (MDM) mistakes are common. Here are the coding and documentation mistakes hospitalists make most often, along with some tips on how to avoid them.

Listing the problem without a plan. Healthcare professionals are able to infer the acuity and severity of a case without superfluous or redundant documentation, but auditors may not have this ability. Adequate documentation for every service date helps to convey patient complexity during a medical record review. Although the problem list may not change dramatically from day to day during a hospitalization, the auditor only reviews the service date in question, not the entire medical record.

Hospitalists should be sure to formulate a complete and accurate description of the patient’s condition with an analogous plan of care for each encounter. Listing problems without a corresponding plan of care does not corroborate physician management of that problem and could cause a downgrade of complexity. Listing problems with a brief, generalized comment (e.g. “DM, CKD, CHF: Continue current treatment plan”) equally diminishes the complexity and effort put forth by the physician.

Clearly document the plan. The care plan represents problems the physician personally manages, along with those that must also be considered when he or she formulates the management options, even if another physician is primarily managing the problem. For example, the hospitalist can monitor the patient’s diabetic management while the nephrologist oversees the chronic kidney disease (CKD). Since the CKD impacts the hospitalist’s diabetic care plan, the hospitalist may also receive credit for any CKD consideration if the documentation supports a hospitalist-related care plan, or comment about CKD that does not overlap or replicate the nephrologist’s plan. In other words, there must be some “value-added” input by the hospitalist.

Credit is given for the quantity of problems addressed as well as the quality. For inpatient care, an established problem is defined as one in which a care plan has been generated by the physician (or same specialty group practice member) during the current hospitalization. Established problems are less complex than new problems, for which a diagnosis, prognosis, or care plan has not been developed. Severity of the problem also influences complexity. A “worsening” problem is considered more complex than an “improving” problem, since the worsening problem likely requires revisions to the current care plan and, thus, more physician effort. Physician documentation should always:

• Identify all problems managed or addressed during each encounter;
• Identify problems as stable or progressing, when appropriate;
• Indicate differential diagnoses when the problem remains undefined;
• Indicate the management/treatment option(s) for each problem; and
• Note management options to be continued somewhere in the progress note for that encounter (e.g. medication list) when documentation indicates a continuation of current management options (e.g. “continue meds”).

Considering relevant data. “Data” is organized as pathology/laboratory testing, radiology, and medicine-based diagnostic testing that contributes to diagnosing or managing patient problems. Pertinent orders or results may appear in the medical record, but most of the background interactions and communications involving testing are undetected when reviewing the progress note. To receive credit:

• Specify tests ordered and rationale in the physician’s progress note, or make an entry that refers to another auditor-accessible location for ordered tests and studies; however, this latter option jeopardizes a medical record review due to potential lack of awareness of the need to submit this extraneous information during a payer record request or appeal.
• Document test review by including a brief entry in the progress note (e.g. “elevated glucose levels” or “CXR shows RLL infiltrates”); credit is not given for entries lacking a comment on the findings (e.g. “CXR reviewed”).
• Summarize key points when reviewing old records or obtaining history from someone other than the patient, as necessary; be sure to identify the increased efforts of reviewing the considerable number of old records by stating, “OSH (outside hospital) records reviewed and shows…” or “Records from previous hospitalization(s) reveal….”
• Indicate when images, tracings, or specimens are “personally reviewed,” or the auditor will assume the physician merely reviewed the written report; be sure to include a comment on the findings.
• Summarize any discussions of unexpected or contradictory test results with the physician performing the procedure or diagnostic study.

click for large version

Data credit may be more substantial during the initial investigative phase of the hospitalization, before diagnoses or treatment options have been confirmed. Routine monitoring of the stabilized patient may not yield as many “points.”

Undervaluing the patient’s complexity. A general lack of understanding of the MDM component of the documentation guidelines often results in physicians undervaluing their services. Some physicians may consider a case “low complexity” simply because of the frequency with which they encounter the case type. The speed with which the care plan is developed should have no bearing on how complex the patient’s condition really is. Hospitalists need to better identify the risk involved for the patient.

Patient risk is categorized as minimal, low, moderate, or high based on pre-assigned items pertaining to the presenting problem, diagnostic procedures ordered, and management options selected. The single highest-rated item detected on the Table of Risk determines the overall patient risk for an encounter.¹ Chronic conditions with exacerbations and invasive procedures offer more patient risk than acute, uncomplicated illnesses or noninvasive procedures. Stable or improving problems are considered “less risky” than progressing problems; conditions that pose a threat to life/bodily function outweigh undiagnosed problems where it is difficult to determine the patient’s prognosis; and medication risk varies with the administration (e.g. oral vs. parenteral), type, and potential for adverse effects. Medication risk for a particular drug is invariable whether the dosage is increased, decreased, or continued without change. Physicians should:

1. Provide status for all problems in the plan of care and identify them as stable, worsening, or progressing (mild or severe), when applicable; don’t assume that the auditor can infer this from the documentation details.
2. Document all diagnostic or therapeutic procedures considered.
3. Identify surgical risk factors involving co-morbid conditions that place the patient at greater risk than the average patient, when appropriate.
4. Associate the labs ordered to monitor for medication toxicity with the corresponding medication; don’t assume that the auditor knows which labs are used to check for toxicity.

Varying levels of complexity. Remember that decision-making is just one of three components in evaluation and management (E&M) services, along with history and exam. MDM is identical for both the 1995 and 1997 guidelines, rooted in the complexity of the patient’s problem(s) addressed during a given encounter.^1,2 Complexity is categorized as straightforward, low, moderate, or high, and directly correlates to the content of physician documentation.

Each visit level represents a particular level of complexity (see Table 1). Auditors only consider the care plan for a given service date when reviewing MDM. More specifically, the auditor reviews three areas of MDM for each encounter (see Table 2), and the physician receives credit for: a) the number of diagnoses and/or treatment options; b) the amount and/or complexity of data ordered/reviewed; c) the risk of complications/morbidity/mortality.

To determine MDM complexity, each MDM category is assigned a point level. Complexity correlates to the second-highest MDM category. For example, if the auditor assigns “multiple” diagnoses/treatment options, “minimal” data, and “high” risk, the physician attains moderate complexity decision-making (see Table 3).

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Centers for Medicare and Medicaid Services. 1995 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf. Accessed July 7, 2014.
2. Centers for Medicare and Medicaid Services. 1997 Documentation Guidelines for Evaluation and Management Services. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf. Accessed July 7, 2014.
3. American Medical Association. Current Procedural Terminology: 2014 Professional Edition. Chicago: American Medical Association; 2013:14-21.
4. Novitas Solutions. Novitas Solutions documentation worksheet. Available at: www.novitas-solutions.com/webcenter/content/conn/UCM_Repository/uuid/dDocName:00004966. Accessed July 7, 2014.

click for large version

Medical decision-making (MDM) mistakes are common. Here are the coding and documentation mistakes hospitalists make most often, along with some tips on how to avoid them.

Listing the problem without a plan. Healthcare professionals are able to infer the acuity and severity of a case without superfluous or redundant documentation, but auditors may not have this ability. Adequate documentation for every service date helps to convey patient complexity during a medical record review. Although the problem list may not change dramatically from day to day during a hospitalization, the auditor only reviews the service date in question, not the entire medical record.

Hospitalists should be sure to formulate a complete and accurate description of the patient’s condition with an analogous plan of care for each encounter. Listing problems without a corresponding plan of care does not corroborate physician management of that problem and could cause a downgrade of complexity. Listing problems with a brief, generalized comment (e.g. “DM, CKD, CHF: Continue current treatment plan”) equally diminishes the complexity and effort put forth by the physician.

Clearly document the plan. The care plan represents problems the physician personally manages, along with those that must also be considered when he or she formulates the management options, even if another physician is primarily managing the problem. For example, the hospitalist can monitor the patient’s diabetic management while the nephrologist oversees the chronic kidney disease (CKD). Since the CKD impacts the hospitalist’s diabetic care plan, the hospitalist may also receive credit for any CKD consideration if the documentation supports a hospitalist-related care plan, or comment about CKD that does not overlap or replicate the nephrologist’s plan. In other words, there must be some “value-added” input by the hospitalist.

Credit is given for the quantity of problems addressed as well as the quality. For inpatient care, an established problem is defined as one in which a care plan has been generated by the physician (or same specialty group practice member) during the current hospitalization. Established problems are less complex than new problems, for which a diagnosis, prognosis, or care plan has not been developed. Severity of the problem also influences complexity. A “worsening” problem is considered more complex than an “improving” problem, since the worsening problem likely requires revisions to the current care plan and, thus, more physician effort. Physician documentation should always:

• Identify all problems managed or addressed during each encounter;
• Identify problems as stable or progressing, when appropriate;
• Indicate differential diagnoses when the problem remains undefined;
• Indicate the management/treatment option(s) for each problem; and
• Note management options to be continued somewhere in the progress note for that encounter (e.g. medication list) when documentation indicates a continuation of current management options (e.g. “continue meds”).

Considering relevant data. “Data” is organized as pathology/laboratory testing, radiology, and medicine-based diagnostic testing that contributes to diagnosing or managing patient problems. Pertinent orders or results may appear in the medical record, but most of the background interactions and communications involving testing are undetected when reviewing the progress note. To receive credit:

• Specify tests ordered and rationale in the physician’s progress note, or make an entry that refers to another auditor-accessible location for ordered tests and studies; however, this latter option jeopardizes a medical record review due to potential lack of awareness of the need to submit this extraneous information during a payer record request or appeal.
• Document test review by including a brief entry in the progress note (e.g. “elevated glucose levels” or “CXR shows RLL infiltrates”); credit is not given for entries lacking a comment on the findings (e.g. “CXR reviewed”).
• Summarize key points when reviewing old records or obtaining history from someone other than the patient, as necessary; be sure to identify the increased efforts of reviewing the considerable number of old records by stating, “OSH (outside hospital) records reviewed and shows…” or “Records from previous hospitalization(s) reveal….”
• Indicate when images, tracings, or specimens are “personally reviewed,” or the auditor will assume the physician merely reviewed the written report; be sure to include a comment on the findings.
• Summarize any discussions of unexpected or contradictory test results with the physician performing the procedure or diagnostic study.

click for large version

Data credit may be more substantial during the initial investigative phase of the hospitalization, before diagnoses or treatment options have been confirmed. Routine monitoring of the stabilized patient may not yield as many “points.”

Undervaluing the patient’s complexity. A general lack of understanding of the MDM component of the documentation guidelines often results in physicians undervaluing their services. Some physicians may consider a case “low complexity” simply because of the frequency with which they encounter the case type. The speed with which the care plan is developed should have no bearing on how complex the patient’s condition really is. Hospitalists need to better identify the risk involved for the patient.

Patient risk is categorized as minimal, low, moderate, or high based on pre-assigned items pertaining to the presenting problem, diagnostic procedures ordered, and management options selected. The single highest-rated item detected on the Table of Risk determines the overall patient risk for an encounter.¹ Chronic conditions with exacerbations and invasive procedures offer more patient risk than acute, uncomplicated illnesses or noninvasive procedures. Stable or improving problems are considered “less risky” than progressing problems; conditions that pose a threat to life/bodily function outweigh undiagnosed problems where it is difficult to determine the patient’s prognosis; and medication risk varies with the administration (e.g. oral vs. parenteral), type, and potential for adverse effects. Medication risk for a particular drug is invariable whether the dosage is increased, decreased, or continued without change. Physicians should:

1. Provide status for all problems in the plan of care and identify them as stable, worsening, or progressing (mild or severe), when applicable; don’t assume that the auditor can infer this from the documentation details.
2. Document all diagnostic or therapeutic procedures considered.
3. Identify surgical risk factors involving co-morbid conditions that place the patient at greater risk than the average patient, when appropriate.
4. Associate the labs ordered to monitor for medication toxicity with the corresponding medication; don’t assume that the auditor knows which labs are used to check for toxicity.

Varying levels of complexity. Remember that decision-making is just one of three components in evaluation and management (E&M) services, along with history and exam. MDM is identical for both the 1995 and 1997 guidelines, rooted in the complexity of the patient’s problem(s) addressed during a given encounter.^1,2 Complexity is categorized as straightforward, low, moderate, or high, and directly correlates to the content of physician documentation.

Each visit level represents a particular level of complexity (see Table 1). Auditors only consider the care plan for a given service date when reviewing MDM. More specifically, the auditor reviews three areas of MDM for each encounter (see Table 2), and the physician receives credit for: a) the number of diagnoses and/or treatment options; b) the amount and/or complexity of data ordered/reviewed; c) the risk of complications/morbidity/mortality.

To determine MDM complexity, each MDM category is assigned a point level. Complexity correlates to the second-highest MDM category. For example, if the auditor assigns “multiple” diagnoses/treatment options, “minimal” data, and “high” risk, the physician attains moderate complexity decision-making (see Table 3).

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Centers for Medicare and Medicaid Services. 1995 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf. Accessed July 7, 2014.
2. Centers for Medicare and Medicaid Services. 1997 Documentation Guidelines for Evaluation and Management Services. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf. Accessed July 7, 2014.
3. American Medical Association. Current Procedural Terminology: 2014 Professional Edition. Chicago: American Medical Association; 2013:14-21.
4. Novitas Solutions. Novitas Solutions documentation worksheet. Available at: www.novitas-solutions.com/webcenter/content/conn/UCM_Repository/uuid/dDocName:00004966. Accessed July 7, 2014.

click for large version

Medical decision-making (MDM) mistakes are common. Here are the coding and documentation mistakes hospitalists make most often, along with some tips on how to avoid them.

Listing the problem without a plan. Healthcare professionals are able to infer the acuity and severity of a case without superfluous or redundant documentation, but auditors may not have this ability. Adequate documentation for every service date helps to convey patient complexity during a medical record review. Although the problem list may not change dramatically from day to day during a hospitalization, the auditor only reviews the service date in question, not the entire medical record.

Hospitalists should be sure to formulate a complete and accurate description of the patient’s condition with an analogous plan of care for each encounter. Listing problems without a corresponding plan of care does not corroborate physician management of that problem and could cause a downgrade of complexity. Listing problems with a brief, generalized comment (e.g. “DM, CKD, CHF: Continue current treatment plan”) equally diminishes the complexity and effort put forth by the physician.

Clearly document the plan. The care plan represents problems the physician personally manages, along with those that must also be considered when he or she formulates the management options, even if another physician is primarily managing the problem. For example, the hospitalist can monitor the patient’s diabetic management while the nephrologist oversees the chronic kidney disease (CKD). Since the CKD impacts the hospitalist’s diabetic care plan, the hospitalist may also receive credit for any CKD consideration if the documentation supports a hospitalist-related care plan, or comment about CKD that does not overlap or replicate the nephrologist’s plan. In other words, there must be some “value-added” input by the hospitalist.

Credit is given for the quantity of problems addressed as well as the quality. For inpatient care, an established problem is defined as one in which a care plan has been generated by the physician (or same specialty group practice member) during the current hospitalization. Established problems are less complex than new problems, for which a diagnosis, prognosis, or care plan has not been developed. Severity of the problem also influences complexity. A “worsening” problem is considered more complex than an “improving” problem, since the worsening problem likely requires revisions to the current care plan and, thus, more physician effort. Physician documentation should always:

• Identify all problems managed or addressed during each encounter;
• Identify problems as stable or progressing, when appropriate;
• Indicate differential diagnoses when the problem remains undefined;
• Indicate the management/treatment option(s) for each problem; and
• Note management options to be continued somewhere in the progress note for that encounter (e.g. medication list) when documentation indicates a continuation of current management options (e.g. “continue meds”).

Considering relevant data. “Data” is organized as pathology/laboratory testing, radiology, and medicine-based diagnostic testing that contributes to diagnosing or managing patient problems. Pertinent orders or results may appear in the medical record, but most of the background interactions and communications involving testing are undetected when reviewing the progress note. To receive credit:

• Specify tests ordered and rationale in the physician’s progress note, or make an entry that refers to another auditor-accessible location for ordered tests and studies; however, this latter option jeopardizes a medical record review due to potential lack of awareness of the need to submit this extraneous information during a payer record request or appeal.
• Document test review by including a brief entry in the progress note (e.g. “elevated glucose levels” or “CXR shows RLL infiltrates”); credit is not given for entries lacking a comment on the findings (e.g. “CXR reviewed”).
• Summarize key points when reviewing old records or obtaining history from someone other than the patient, as necessary; be sure to identify the increased efforts of reviewing the considerable number of old records by stating, “OSH (outside hospital) records reviewed and shows…” or “Records from previous hospitalization(s) reveal….”
• Indicate when images, tracings, or specimens are “personally reviewed,” or the auditor will assume the physician merely reviewed the written report; be sure to include a comment on the findings.
• Summarize any discussions of unexpected or contradictory test results with the physician performing the procedure or diagnostic study.

click for large version

Data credit may be more substantial during the initial investigative phase of the hospitalization, before diagnoses or treatment options have been confirmed. Routine monitoring of the stabilized patient may not yield as many “points.”

Undervaluing the patient’s complexity. A general lack of understanding of the MDM component of the documentation guidelines often results in physicians undervaluing their services. Some physicians may consider a case “low complexity” simply because of the frequency with which they encounter the case type. The speed with which the care plan is developed should have no bearing on how complex the patient’s condition really is. Hospitalists need to better identify the risk involved for the patient.

Patient risk is categorized as minimal, low, moderate, or high based on pre-assigned items pertaining to the presenting problem, diagnostic procedures ordered, and management options selected. The single highest-rated item detected on the Table of Risk determines the overall patient risk for an encounter.¹ Chronic conditions with exacerbations and invasive procedures offer more patient risk than acute, uncomplicated illnesses or noninvasive procedures. Stable or improving problems are considered “less risky” than progressing problems; conditions that pose a threat to life/bodily function outweigh undiagnosed problems where it is difficult to determine the patient’s prognosis; and medication risk varies with the administration (e.g. oral vs. parenteral), type, and potential for adverse effects. Medication risk for a particular drug is invariable whether the dosage is increased, decreased, or continued without change. Physicians should:

1. Provide status for all problems in the plan of care and identify them as stable, worsening, or progressing (mild or severe), when applicable; don’t assume that the auditor can infer this from the documentation details.
2. Document all diagnostic or therapeutic procedures considered.
3. Identify surgical risk factors involving co-morbid conditions that place the patient at greater risk than the average patient, when appropriate.
4. Associate the labs ordered to monitor for medication toxicity with the corresponding medication; don’t assume that the auditor knows which labs are used to check for toxicity.

Varying levels of complexity. Remember that decision-making is just one of three components in evaluation and management (E&M) services, along with history and exam. MDM is identical for both the 1995 and 1997 guidelines, rooted in the complexity of the patient’s problem(s) addressed during a given encounter.^1,2 Complexity is categorized as straightforward, low, moderate, or high, and directly correlates to the content of physician documentation.

Each visit level represents a particular level of complexity (see Table 1). Auditors only consider the care plan for a given service date when reviewing MDM. More specifically, the auditor reviews three areas of MDM for each encounter (see Table 2), and the physician receives credit for: a) the number of diagnoses and/or treatment options; b) the amount and/or complexity of data ordered/reviewed; c) the risk of complications/morbidity/mortality.

To determine MDM complexity, each MDM category is assigned a point level. Complexity correlates to the second-highest MDM category. For example, if the auditor assigns “multiple” diagnoses/treatment options, “minimal” data, and “high” risk, the physician attains moderate complexity decision-making (see Table 3).

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Centers for Medicare and Medicaid Services. 1995 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf. Accessed July 7, 2014.
2. Centers for Medicare and Medicaid Services. 1997 Documentation Guidelines for Evaluation and Management Services. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf. Accessed July 7, 2014.
3. American Medical Association. Current Procedural Terminology: 2014 Professional Edition. Chicago: American Medical Association; 2013:14-21.
4. Novitas Solutions. Novitas Solutions documentation worksheet. Available at: www.novitas-solutions.com/webcenter/content/conn/UCM_Repository/uuid/dDocName:00004966. Accessed July 7, 2014.

SHM’s coding education program, CODE-H, now has an interactive component through the SHM Learning Portal. CODE-H originally was developed as a series of live and on-demand webinars complemented by online forums; today, CODE-H Interactive brings the same expertise to an interactive platform ideal for new hospitalists learning the nuances of coding, hospital medicine groups assessing the coding skills of their caregivers, or even coders using it as a training tool for conducting audits of hospital medicine groups.

To learn more about CODE-H and CODE-H Interactive, visit www.hospitalmedicine.org/codeh.

SHM’s coding education program, CODE-H, now has an interactive component through the SHM Learning Portal. CODE-H originally was developed as a series of live and on-demand webinars complemented by online forums; today, CODE-H Interactive brings the same expertise to an interactive platform ideal for new hospitalists learning the nuances of coding, hospital medicine groups assessing the coding skills of their caregivers, or even coders using it as a training tool for conducting audits of hospital medicine groups.

To learn more about CODE-H and CODE-H Interactive, visit www.hospitalmedicine.org/codeh.

SHM’s coding education program, CODE-H, now has an interactive component through the SHM Learning Portal. CODE-H originally was developed as a series of live and on-demand webinars complemented by online forums; today, CODE-H Interactive brings the same expertise to an interactive platform ideal for new hospitalists learning the nuances of coding, hospital medicine groups assessing the coding skills of their caregivers, or even coders using it as a training tool for conducting audits of hospital medicine groups.

To learn more about CODE-H and CODE-H Interactive, visit www.hospitalmedicine.org/codeh.