Electronic Medical Record (EMR) -

VEIN PROVIDERS –WHAT YOU MAY NOT KNOW ABOUT E/M DOCUMENTATION May 2012

One of the advantages of utilizing an EMR to document E/M services is that it allows you to easily incorporate legible vital information into the patient’s record. But due to the ease of entering information into the record, there is a risk of having a false-sense of security in thinking that with all this information, certainly the documentation requirements have been met.

To help safe-guard your records in the event of an audit and to streamline your documentation, it is imperative that you have a clear understanding of what is required. This article was written to familiarize you with commonly misunderstood areas and to provide you with quick and easy-to-follow solutions.

ARE YOU USING A SCRIBE? Using a scribe is permitted but there are rules that have to be followed. Medicare defines a scribe as a “living recorder,” documenting in real time the actions and words of the provider as they are done. If this is done any other way, it is inappropriate. If using a scribe, the following statement or one similar has to be included in the patient’s medical record and both the scribe and provider need to sign the notes:

Scribe:

“Written by ________, acting as scribe for Dr. _________ .

Provider:

“This note accurately reflects the work and decisions made by me, Dr. ___________.”

CAN CERTAIN COMPONENTS OF THE E/M BE UPDATED BY MY MEDICAL STAFF? Yes, E/M services are comprised of three key components: history, exam, and medical decision making. For the history component, other medical staff can document the Past Medical or Family/Social History section, the Review of Systems (ROS), or both. But in order to use this information to determine the level of E/M service, you must document that you reviewed and addressed the information obtained.

IS YOUR CHIEF COMPLAINT “FOLLOW-UP” WITHOUT IDENTIFYING THE PROBLEM(S)?

Do not limit the chief complaint to “follow-up” without identifying the problem(s) being followed.

Not acceptable: Clinical Indications: Follow-up

Acceptable:

Clinical Indications: Follow-up chronic venous insufficiency with edema of the right lower extremity

DOES MEDICAL NECESSITY DETERMINE YOUR LEVEL OF SERVICE? Just like the vein treatments you perform, E/M services must also be medically necessary. But unlike treatments that have a defined list of payable diagnosis codes, E/M services do not. A defined list does not exist because E/M services cover a wide-range of specialties. The “burden of proof’ has to be found in your documentation.

Recommendation:

Incorporate in your documentation the clinical indications that made you modify or contribute to the patient’s current visit.

Caution:

Do not record unnecessary information solely to meet requirements of a high-level service when the nature of the visit dictates a low-level service is medically appropriate.

Keep in mind that in order to meet requirements of a high-level service when the nature of the visit dictates a low-level service to have been medically appropriate.

CREATING AND THE MEDICAL RECORD – WHY IS IT THE PROVIDER’S RESPONSIBILITY? With the implementation of the EMR, it has become very easy for an authorized individual such as a scribe to write notes in the medical record on your behalf. Keep in mind that it is not enough to follow behind and sign the note. It is imperative that you review it to make sure it is an accurate reflection of what you did and why you did it. Documentation that has not been substantiated by you is an obvious risk to the patient’s health. In addition, it can lead to coding and billing errors which could also trigger an audit. Keep in mind that reimbursement for services and procedures you perform is based on Relative Value Units (RVUs). The value of the RVU reflects the time spent prior to a service, performing the service, and time spent following the service, which includes charting. In other words, you get paid to document the service/procedure you performed.

IN CONCLUSION: Take the time to find out what the documentation requirements are for E/M services. Often, simply by including a certain statement or even just a specific word is all it takes to make your documentation compliant and/or billable. Medicare pays for medically necessary and reasonable services, and expects the person receiving payment to be the one responsible for delivering the services as well as creating the record. Before signing, review the record to ensure the documentation accurately depicts the service you performed because in the end, you are responsible for the record and the codes submitted.

Wendy Block, CPC, RCC, CIRCC Sr. Coding Advisor wblock@prcmedical.com 3333 S. Arlington Road | Akron, Ohio 44312 Phone: 330.564.2618

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ESTABLISHED PATIENT – DOCUMENTATION OF ALL THREE KEY COMPONENTS June 2012 Behind just about every CPT code and description are additional CPT and governmental guidelines that have to be followed.

It is not enough to select a code based on the CPT code description alone and Evaluation and Management (E/M) services are no exception.

The descriptors for the levels of E/M recognize seven components, six of which are used in defining the levels of E/M services. The levels are: history, examination, medical decision making, counseling, coordination of care, nature of presenting problem, and time. The focus of this particular article is on the 3 key components.

The goal is to eliminate any misconceptions regarding the three key components that determine the level of E/M service for an established patient. The selection of the level of service is based on your documentation of each of these components.

Don’t get penalized because you simply don’t understand the rules.

THE BASICS – THREE KEY COMPONENTS Three key components qualify the service as an E/M and are also used to determine the level: • • •

History Exam Medical decision making

CPT CODE DESCRIPTIONS Based on the CPT code descriptions alone: •

New patient – requires 3 key components o 99202 - Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components

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Established patient – requires 2 of the 3 key components o 99212 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components

WHAT YOU NEED TO KNOW: •

CPT guidelines state “…all of the key components, ie, history, examination, and medical decision making must meet or exceed the stated requirements to qualify for a particular level of E/M service.”

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CMS has clarified in the above citation, “…the requirements are ‘two of three requirements must meet or exceed’; meaning the components must all be present but one may be below the requirement described in the level of description.”

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SUMMARY To qualify as an E/M service: All 3 key components have to be documented.

To determine the level of E/M service: •

New patients - 3 key components determine the level

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Established patients - 2 of the 3 key components determine the level

No matter whether the patient is new or established, all 3 key components are required in order for the encounter to be considered an E/M service.

References:

Wendy Block, CPC, RCC, CIRCC Sr. Coding Advisor wblock@prcmedical.com 3333 S. Arlington Road | Akron, Ohio 44312 Phone: 330.564.2618

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2012 CPT Professional Edition, E/M Service Guidelines Medicare Evaluation and Management Services (E&M)

DOCUMENTATION REQUIREMENTS FOR EXTREMITY VEINS DUPLEX SCANS July 2012

Documentation is a fundamental part of your practice as it provides a means to communicate (to coders, billers and insurance companies) what you did and why you did it. Not only is the information vital to diagnosing and treating the patient, it serves as evidence for auditing and reimbursement purposes.

When it comes to documenting Extremity Veins Duplex Scans, there are certain documentation requirements that need to be included in the interpretation of these studies. This article’s purpose is to clearly identify documentation that must be included for auditing and reimbursement purposes.

CPT codes, Work RVUs and descriptions: CPT Code 93970 93971

Work RVU 0.68 0.45

Brief Description Duplex scan of extremity veins; complete bilateral study Duplex scan of extremity veins; unilateral or limited study

CPT 93970 is used for bilateral venous duplex scanning. In the lower extremity this includes the common femoral, superficial femoral, proximal deep femoral, greater saphenous, and popliteal vein. Calf veins may also be evaluated. In the upper extremity the evaluation includes the subclavian, jugular, auxiliary, brachial, basilica, and cephalic veins. Forearm veins may also be evaluated.

CPT 93971 is used for limited bilateral or unilateral venous duplex evaluation, or follow-up studies that are otherwise not complete bilateral studies.

If an iliac duplex Doppler is performed, the CPT code reported is 93978 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts, complete study or 93979 unilateral or limited study.

The use of any Doppler device that produces a record that does not permit analysis of bidirectional vascular flow, or that does not provide a hard copy printout, is part of the physical exam of the vascular system and is not separately reported.

IMPORTANT DOCUMENTATION TIPS FOR EXTREMITY VEINS DUPLEX SCANS: 1) Include in your documentation that both color and spectral Doppler were used in the evaluation.

Reason: What sets the Duplex scan apart from a nonvascular ultrasound of the extremity is the fact that both color and spectral analysis were performed. Turning on the color for a “quick-look-see” does not equate to a Duplex scan, but rather a nonvascular ultrasound.

2)

Identify whether the exam was unilateral, bilateral, or limited.

Reason: This information is critical in the CPT code selection. Bilateral studies are coded with CPT 93970 and

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unilateral or limited studies are coded with CPT 93971.

3) Name of the vessels evaluated as well as the outcome of that evaluation.

Reason: The specific findings of the study will potentially impact the clinical course of treatment for the patient and will aid in proof of medical necessity for the next treatment performed. Not only does naming the vessels help in the accurate selection of the CPT code, it is also valuable when a payer requires a copy of the report for proof of medical necessity.

4) Proof of medical necessity.

Reason: Proof of medical necessity should be determined before any diagnostic procedure is performed. Always include the signs and/or symptoms, or the known disease, which prompted the need for the study. This information is crucial in determining medical necessity and whether you will get paid.

Wendy Block, CPC, RCC, CIRCC Sr. Coding Advisor wblock@prcmedical.com 3333 S. Arlington Road | Akron, Ohio 44312 Phone: 330.564.2618

SEQUENCING MULTIPLE MODIFIER ASSIGNMENTS

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August 2012 CPT codes provide a means of communicating the service or procedure performed in a uniform way. Coding rules require a perfect match between the code description and what was actually performed. But in the event that a service or procedure has to be altered, a modifier may be assigned. When a CPT code and modifier are assigned, the CPT code is reported first, followed by the modifier. For example: 99213-25 The purpose of CPT codes, modifiers, and ICD-9-CM codes is to communicate what was performed and why it was performed. In other words, these codes are used as a means of telling a story of what happened between the patient and the provider. And because some stories are more complex than others, multiple modifiers may need to be assigned. This article was written to provide guidance on sequencing multiple modifier assignments.

Not all modifiers have the same job: some identify an anatomical site, some are used for statistical purposes, some identify eligibility, and some alter payments. Here are just a few examples: LOCATION STATISTICAL ELIGIBILITY PAYMENT ALTERING

LT-left, TA-left foot, great toe, F1-left hand, second digit, RT-right, T5-right foot, great toe 76-repeat same physician, 77-repeat by another physician, Q6-locum tenens physician 24-unrelated EM, 59-distinct procedure, 58-staged or planned, 79-unrelated procedure during post-op 26-professional component, 52-reduced, 53-discontinued, 22-increased work, 62-co-surgeon

When documentation dictates multiple modifier assignments for a single CPT code, there is a general hierarchy that should be followed: • • • •

Payment altering modifiers are listed before eligibility, statistical, and location modifiers Eligibility modifiers are listed before statistical and location modifiers Statistical modifiers are listed before location modifiers Location modifiers are always listed last

Some exceptions: • •

Modifier 26 is always the first modifier When the patient is in a global period, payment eligibility modifiers such as 78, 79, and 58 would be assigned before other modifiers.

It is important to note that even though most payers do follow Medicare guidelines, not all do. It is recommended that you check with the specific payer for instructions on modifier assignments.

Although the current CPT manual specifies that CPT modifier 99 may be used when it is necessary to indicate more than 2 modifiers on a single detail line or service, Medicare allows for use of up to four modifiers. If four or more modifiers are required, place modifiers with major importance in the first three positions, then modifier 99 in the fourth. Place the additional modifiers in the comment field.

EXAMPLE: On July 1st, stab phlebectomy was performed on the patient’s left lower extremity because of varicose veins, and 15 stab incisions were made. The patient then returned to the office on August 10 th because the patient was now experiencing

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symptoms in the right lower extremity. A problem-focused evaluation and management service was performed and a duplex scan of the right lower extremity was also ordered and performed. Then on August 13 th, the patient returned to the office for an EVLA of the right saphenous vein.

Date of Service

CPT

Mod 1

7/1/2012

37765

LT

99212

24

25

79

RT

8/10/2012 8/13/2012

Mod 2

93971 36478

Explanation: Modifier LT was assigned to 37765 because the *MPFS allows for a LT/RT designation.

Modifier 24 was assigned to 99212 because the E/M was performed in a 90-day global period and was unrelated to 37765.

Modifier 25 was also assigned to 99212 because 93971 was a distinct procedure.

Modifier 79 was assigned to 36478 because it was performed in a 90-day global period unrelated to 37765 No modifiers were assigned to 93971 because according to the *MPFS, there is no LT/RT designation. In addition, because this is a diagnostic test, it is not considered to be part of the global surgical package.

Again, it is important to note that even though most payers do follow Medicare guidelines, not all do. It is recommended that you check with the specific payer for instructions on modifier assignments. *MPFS = Medicare Physician Fee Schedule, see: Medicare Physician Fee Schedule Search

Wendy Block, CPC, RCC, CIRCC Sr. Coding Advisor wblock@prcmedical.com 3333 S. Arlington Road | Akron, Ohio 44312 Phone: 330.564.2618

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It’s (Now) Documented, But Did It Happen?

September 2012 Documentation should accurately reflect the services and procedures performed. Not only is this important for appropriate patient care, it also determines procedure and diagnosis code assignments. These codes communicate to a payer if they should pay and how much to pay.

In the not too distant past, insufficient coding documentation was commonplace. Providers had to be reminded often that in addition to conveying information to other colleagues, there were other audiences to consider consisting of coders, auditors, payers, and even sometimes a legal team. But the stringent verbiage needed to support coding documentation was not intuitive to the provider and, because of that, it was often left out and revenue was lost. For the most part, documentation would meet clinical requirements but would fail to include specific phraseology needed for coding assignments. Because coding can only be based on what is documented rather than what is generally understood, the mantra soon became “if it wasn’t documented, it didn’t happen.”

But with the advent of the EHR, labor-intensive, insufficient documentation is no longer a problem. Legible, concise templates can be utilized to include all the required information. Important bullet points that have the potential to raise the level of service are just clicks away! It is easy to point and click—maybe too easy. The risk is now over-reporting what was actually done. In fact, the problem of insufficient documentation has been replaced with excessive information. The new question auditors and payers will be asking is “it’s documented, but was it actually done?”

Reduce your risk of an unfavorable audit: •

Documentation should be concise and not excessive.

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The level of service billed has to be justified.

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Notes should be cohesive. There shouldn’t be conflicting information, such as, “patient denies headache” and “patient complains of headache” documented for the same encounter.

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If you use stock templates, only use them when there is an exact match to what you did.

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Because the EHR is so easy to use and is a time-saver, be sure to take your time when clicking through the record as it is far too easy to select items not actually performed.

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Be specific, your patient records shouldn’t all look identical.

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Don’t ever add documentation in order to support a higher level of service when it wasn’t medically necessary. CMS defines medical necessity as “…the overarching criterion for payment in addition to the individual requirements of a CPT code.”

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Be aware that you have resources available for coding and documentation education. Begin by contacting your coder.

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If you haven’t already done so, select an EHR that has the ability to be specialty-specific.

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Before signing the note, make sure you are in agreement with the story being told.

In summary, the majority of the past problems associated with medical record documentation have been alleviated with the EHR. No longer is the documentation labor-intensive and the provider isn’t left wondering if his/her clinical documentation is enough to meet the coding requirements. It is now very easy to point-and-click your way through the record. But with this added convenience comes added responsibility. Before you pointand-click your way through the record, make sure what you selected was actually done. The mantra has changed from “If it wasn’t documented, it didn’t happen” to “It’s documented, but was it actually done?”

Wendy Block, CPC, RCC, CIRCC Sr. Coding Advisor wblock@prcmedical.com 3333 S. Arlington Road | Akron, Ohio 44312 Phone: 330.564.2618

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Can I Have Your Autograph?

October 2012

Can I get your autograph? Please sign! Your signature is needed! Autograph, please!

Yes, I am talking to YOU! You may not realize this, but like an autographed snapshot of a popular author, a famous musician, a professional athlete, or even a movie star, your autograph is also sought after. But in this case, the snapshot is the medical record and your autograph is your signature authenticating the record.

When it comes to medicine, each piece of the process is signature dependent, from sharing the patient’s record with another provider to releasing the claim for payment. Without your signature, all things come to a halt.

Why? Because documentation that has not been authenticated cannot be coded, billed or even more importantly, used to promote the patient’s continuity of care among providers. Your signature on the medical record is what everyone is waiting for as it is the “green light” that enables the communication to begin.

Consider the following: •

As you are already aware, you are not the only one that can enter information into the medical record.

As an example, someone from your staff can obtain and enter the Review of Systems and the Past, Family, and Social History for an E/M service. Even though the signature of each contributor is retained, it is your signature that finalizes the entire document. Be sure to monitor what is being said and look for inconsistencies. Other contributors to the medical record may have a limited scope regarding the patient’s condition. So, it is imperative that you review the entire record for that encounter before signing.

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Remember, the medical record can be used for litigation purposes, so make sure you review and sign the record and in a timely manner. Avoid time lapses. An unsigned record is at risk of needless or .

inappropriate revisions by anyone who has access. But once you sign it, the information is locked-in. If changes are needed after the record is signed, a formal addendum by you would be required. Consider a signed, but poorly documented record has the potential to lead to a poor defense. There will be no defense if the record isn’t signed at all.

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Don’t amplify what was actually performed. Avoid carrying forward information that is not relevant to the current encounter. The documentation is a written record for that encounter, not all past encounters. Remember it is not a movie, but a snapshot. Keep in mind that what you say and how you say it translates into billable codes for reimbursement purposes.

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The Centers for Medicare and Medicaid Services (CMS) Interpretive Guidelines 482.24(c)(1), states “All entries in the medical record must be dated, timed, and authenticated, in written or electronic form, by the person responsible for providing or evaluating the service performed.” In other words, if you provided the service, you are the one that is responsible for signing the record. Never bill for a procedure or service before it gets signed.

In summary: Review the record. Before signing, make sure you are in agreement with the story being told. Look for conflicts between information entered by office staff and your assessment of the patient’s condition. Make sure the record is clearly stated and the information entered was relevant to that encounter.

Don’t delay signing the record. Lock in the information. Keep in mind an unsigned record offers no defense.

Get it signed as soon as possible. Also remember that procedure code and diagnosis code assignments are based on the signed medical record. Signing the record late delays coding which leads to delayed reimbursement.

Autograph your snapshot!

Do you have a topic that you would like to see covered in the newsletter? If so, call or email Wendy Block at 330-564-2618

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or by email at wblock@prcmedical.com.

Wendy Block, CPC, RCC, CIRCC Sr. Coding Advisor wblock@prcmedical.com 3333 S. Arlington Road | Akron, Ohio 44312 Phone: 330.564.2618

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