Lisa Eramo, MA, is a contributing author for Medical Economics.
Address coding vulnerabilities to protect practice revenue.
There’s nothing more frustrating than rendering a service and not being paid. Sometimes the problem comes down to a single code.
Nuanced coding rules are difficult to understand, and physicians aren’t taught this information in medical school. Still, health care is a business. As business owners, physicians need to know how they’re paid, including what codes to use, what modifiers to append and what details to document. Brushing up on common coding mistakes helps avoid costly recoupments and denials. We asked several experts, all certified professional coders, for their best advice on how physicians can maintain compliance and collect all the revenue to which they’re entitled.
Office visit evaluation and management (E/M) coding is the bread and butter for practices nationwide. Yet experts say physicians continue to make mistakes that cost them thousands or even hundreds of thousands of dollars annually.
It all goes back to the three critical components of an E/M code: history, exam and medical decision-making (MDM), says Deborah Grider, senior health care consultant at KarenZupko & Associates Inc. in Chicago. Every office visit E/M code has its own requirements for each component, with medical necessity being the ultimate deciding factor for which E/M level to assign.
Physicians often oversimplify E/M coding, Grider says, making them easy targets for post-payment audits. For example, they incorrectly assign 99213 (established patient level three office visit) if a patient has three diagnoses and 99214 (level four) for four diagnoses. “That’s not the way it works,” she says, emphasizing the need to follow Common Procedural Terminology (CPT) guidelines that dictate specific requirements.
Consider these three common reasons for post-payment recoupments and advice on how to maintain compliance.
Post-payment audit: The reason for the visit doesn’t support the level of E/M code assigned. In other words, the service wasn’t medically necessary.
How to avoid it: “I always tell doctors to take a step back and look at their documentation,” Grider says. “Does the level make sense given the problem they’re addressing and managing?”
For example, physicians should not assign 99214 for a patient with allergic rhinitis. However, if they see an obstruction in the nose and recommend an MRI to make sure it isn’t a tumor, 99214 may be warranted. To report 99214, physicians must perform and document a detailed history, examination and moderate complexity MDM.
Angela Jordan, senior clinical documentation improvement consultant at Trusted i10, agrees. For example, physicians shouldn’t bill a level four or five E/M service for a patient with stable chronic conditions that don’t warrant testing or medication changes. “An E/M leveling tool may map it to a 99214, but if you know in your gut that it’s not a level four, then don’t go with it. Your gut instinct is probably right,” she says.
Physicians who rely on the E/M calculator in their electronic health record (EHR) should ask a certified coder or external consultant to vet the tool and determine its accuracy, according to Jordan. “I don’t want to make a blanket statement that all these tools are bad, because they’re not,” she says. “However, an audit of the tool will tell you what it does well and what could pose problems.”
Post-payment audit: History doesn’t support a higher-level E/M service.
How to avoid it: Ensure that documentation reflects the detailed conversation with the patient, says Sonal Patel, a health care coder and compliance consultant with Nexsen Pruet LLC, a business law firm in Charleston, South Carolina.
For example, when billing a level four or five E/M service for a new patient or a level five E/M service for an established patient, physicians need to document a comprehensive history. This includes a chief complaint, an extended history of present illness (HPI) and a complete review of systems, including those directly related to the problem identified in the HPI, as well as all additional body systems and a complete past, family and social history.
When billing a level four E/M service for an established patient, a detailed history must be documented, including the chief complaint, an extended HPI, an extendedreview of systems and a pertinent past, family and/or social history directly related to the problem.
Typically, each of these scenarios lacks the extended HPI — either the status of three chronic conditions or four or more of the following elements: quality, location, duration, severity, timing, context, modifying factors and associated signs/symptoms.
“You can easily get four elements in the HPI just by hearing the patient talk about their pain or the particular problem that brought them in,” Patel says. “We know that the physician is touching the patient and talking with them, but if it’s not being documented, an auditor can’t score it.”
Post-payment audit: Documentation doesn’t support time-based billing.
How to avoid it: Document the specific details of counseling and coordination of care that dominated at least 50% of the visit, says Patel, noting what you discuss and with whom. “An auditor wants to see why this extra time was spent. What was the greater purpose?” she adds.
Experts say chronic care management (CCM) — care coordination services given to patients with two or more chronic conditions that are expected to last at least 12 months and place the patient at significant risk of death, acute exacerbation/decompensation or functional decline — can help improve patient outcomes and generate revenue for the practice.
“As we’re ramping back up from COVID-19, I’m telling practices to think about CCM,” says Sandy Giangreco Brown,director of coding and revenue integrity at CliftonLarsonAllen LLP in Loveland, Colorado. “It’s totally feasible, and you can provide better care for your patients.”
Consider the following CCM codes and average Medicare payments:
99490 CCM provided by clinical staff directed by a physician or other qualified health care professional
20 minutes per calendar month
G2058* CCM provided by clinical staff directed by a physician or other qualified health care professional
Each additional 20 minutes per calendar month (may be billed twice a month)
99491 CCM provided personally by a physician or other qualified health care professional
30 minutes per calendar month
99487 Complex CCM provided by a physician, other qualified health care professional or clinical staff under the direction of a physician or other qualified health care professional
60 minutes per calendar month
99489 Complex CCM provided by a physician, other qualified health care professional or clinical staff under the direction of a physician or other qualified health care professional
Each additional 30 minutes per calendar month
Not sure about return on investment? Think again, says Brown. A physician who bills 99491 for 250 patients every month for a year could generate $252,270 annually. That can more than cover the salary of a nurse whose sole responsibility is to communicate with the patient, assess for medication adherence, identify community and health resources, facilitate access to care, and more, she adds.
However, experts say CCM can also pose compliance risk when physicians don’t code and document it correctly. Consider the following four reasons for denial and how to avoid them:
Reason for denial: There is no separate documentation of CCM services.
How to avoid it: Create a separate note tracking the provider’s work related to CCM, says Manny Oliverez,CEO of Capture Billing & Consulting Inc. in Leesburg, Virginia. Don’t add this information to an existing note, he adds.
Physicians can also work with their EHR vendor to create a CCM template that includes documentation requirements and helps physicians and their staff track time spent rendering CCM services, Brown says.
Reason for denial: Another provider already billed CCM.
How to avoid it: “Only one provider per month can be reimbursed for CCM,” Oliverez says. He provides the example of a patient with end-stage renal disease in a skilled nursing facility who is managed by the facility’s medical director, a primary care physician and a nephrologist. Each provider can technically bill CCM; however, to avoid denials and costly rework, they should agree on who will bill it. The billing provider should be the one who ultimately performs all or a majority of the care management activities, including addressing the patient’s psychosocial needs, Oliverez adds.
Reason for denial: The wrong codes, depending on who provided the service, were billed.
How to avoid it: When medical-directed clinical staff perform CCM, report 99490, says Oliverez. When physicians perform it, report 99491.
Reason for denial: Complex CCM was billed when it wasn’t warranted.
How to avoid it: Document specific changes in the care plan, as well as medication or treatment changes, Oliverez says. Physicians or other qualified health care professionals can’t report complex CCM when the care plan is unchanged or requires minimal change (e.g., only a medication is changed or an adjustment in a treatment modality is ordered), he adds.
CPT modifiers communicate important information to payers, and physicians must ensure the message they send is accurate, says Rhonda Buckholtz, CPC, CPMA, owner of Coding and Reimbursement Experts LLC in Pittsburgh, Pennsylvania. Consider the following:
25: The physician performed a significant and separately identifiable E/M service on the same day as another procedure or service.
Pay for both services because the E/M service went above and beyond the usual pre- and post-operative work.
59: A distinct procedural service was done.
Pay for two or more procedures/services because they were performed during different sessions or on different anatomical sites, organ systems or lesions or for different injuries.
Sending the wrong message could lead to costly post-payment audits and recoupments, Buckholtz says. Consider these myths and truths about modifiers 25 and 59, commonly used in primary care/internal medicine:
Myth: Physicians should automatically report an E/M code with modifier 25 in addition to a procedure when the physician documents a history, an exam and an MDM.
Truth: Report modifier 25 only when the E/M service goes above and beyond the usual pre- and post-operative work associated with a procedure that has a global fee period, Grider says. For example, an otherwise healthy patient with knee pain presents for a second routine injection in a series of three injections; physicians can’t bill a separate E/M with modifier 25 because the physician didn’t perform additional workup. “That E/M service should be part of the preevaluation workup and not billed separately,” she adds.
Buckholtz agrees. When the decision to perform the procedure has already been made and the patient presents for that scheduled procedure, physicians can’t bill a separate E/M service, she adds.
Grider offers this example of when an E/M service with modifier 25 may be warranted: A patient with diabetes and knee pain presents for a joint injection, and the physician changes the patient’s insulin regimen based on blood sugar levels.
The same is true for a patient who presents for an immunization but also complains of headaches, Buckholtz says. When the physician performs and documents a history, an exam and an MDM related to the headaches, they may be able to bill an E/M code with modifier 25 in addition to the joint injection. “This modifier is always heavily scrutinized by payers,” she says. “It must be clearly documented that the E/M service isn’t what the patient originally came in for.”
Myth: Physicians need two different diagnoses to report a procedure in addition to an E/M service with modifier 25.
Truth: The diagnoses for the procedure and the E/M service may be the same. Buckholtz’s example: A patient presents with knee pain; the physician performs a workup to determine that a cortisone injection is necessary and administers the injection. When the decision to perform the procedure is made the same day it is done, the physician can bill both the procedure and the E/M service with modifier 25. The diagnosis code for each service is knee pain.
Myth: When payers deny a service, practices should automatically submit the service with modifier 59 to bypass payer edits.
Truth: Modifier 59 should be a last resort because it’s likely that a different modifier is more appropriate, Buckholtz says. Other options: RT (right), LT (left) or 50 (bilateral procedure). Payers may also accept modifiers XE (separate encounter), XS (separate organ or structure), XU (unusual nonoverlapping service) or XP (separate practitioner). Each payer policy will dictate what modifiers it requires in each circumstance. An encoder that includes payer-specific policies can help practices maintain compliance, she adds.
Myth: Once published, payer policies for modifier 59 remain largely unchanged.
Truth: Payer policies change frequently, and these revisions are often communicated via electronic remittance advice, Buckholtz says. For example, a payer may add and delete codes for which modifier 59 is appropriate. “If nobody is paying attention to these remittance advice communications, that’s when you get into trouble, because you’re billing per an old policy,” she says.
She shares these tips to help practices stay on top of policy changes: