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Medical Economics JournalMedical Economics August 2021
Volume 98
Issue 08

Focus on coding compliance to safeguard practice revenue

The reimbursement side of medicine is filled with the potential for denials on every claim you submit. Each payer has its own policy, and rules change frequently. Then, of course, there are post-payment audits. Just when you think you are in the clear, a payer decides to recoup that money. It all depends on the codes you assign and whether your documentation supports them.

E/M coding

Office visit evaluation and management (E/M) coding saw some big changes this year, namely new E/M guidelines that took effect Jan. 1, 2021. Experts say it is important for physicians to review this information because they may be over- or undercoding without realizing it. Experts provide these tips to ensure accurate revenue capture.

Tip #1: Familiarize yourself with new time thresholds.

One of the most common mistakes physicians make is that they try to bill 99214 when they spend 25 minutes with an established patient, says Toni Elhoms, CCS, CPC, chief executive officer of Alpha Coding Experts, LLC, in Orlando, Florida. However, beginning in 2021, they should bill 99213 instead. Elhoms urges physicians to review the new thresholds below and update their billing practices accordingly.

Equally important is knowing when to bill based on time, says Deborah Grider, CDIP, CPC, senior consultant at KarenZupko & Associates, Inc., in Chicago. “You don’t want to bill everything by time because, in some cases, you might be getting less revenue than if you had billed based on the complexity of the problems addressed, amount of complexity of data reviewed or analyzed, and risk of morbidity and mortality (i.e., medical decision-making [MDM]).

Tip #2: Document all assessments you perform.

Physicians can easily under- or overcode because they do not accurately document their MDM — specifically the number and complexity of problems addressed, says Joe Rivet, Esq., CCS-P, CPC, CHPC, CHC, CAC, founder andhealth care attorney and arbitrator at Rivet Health Law, PLC, in Norton Shores, Michigan. For example, they might briefly assess a chronic problem or think about the impact of that condition on the current presenting problem but do not document that thought process in the medical record.

“If you do any type of assessment or evaluation around those diagnoses — no matter how slight they may be — then that can factor into the overall (MDM),” says Rivet. “Physicians should document this so they can get appropriate credit in the E/M. It adds to the complexity, and they’re doing work they should be compensated for.” However, simply documenting that another professional is managing the problem does not count toward the E/M, he adds.

Be sure to document the complexity of the problem addressed, says Grider. This includes using terms such as acute, systemic, chronic worsening, exacerbating, severely worsening, and threat to life or body function, she adds.

Tip #3: Know what labs and tests count toward the MDM.

Ordering and/or reviewing unique labs or tests is another area rife with compliance vulnerabilities for over- and undercoding, says Rivet. A unique test is defined as one with its own CPT code, and physicians must understand whether and how the ordering and reviewing of these labs or tests can be used as a data element toward the overall MDM.

Here are three examples to consider:

A physician orders a complete blood cell count (CBC) with differential. This test includes hemoglobin, CBC without differential, and platelet count. According to the AMA, single tests with overlapping elements are not unique even when those individual elements each have their own distinct CPT codes. This means ordering a CBC with differential only counts once toward the MDM.

A physician orders a chest X-ray and reports CPT code 71046. They cannot count the ordering of this diagnostic test as a data element in the MDM if the provider performed and billed an interpretation of the X-ray, says Rivet. The same is true for an electrocardiogram when the physician reports CPT code 93000.

A physician orders a dipstick urinalysis and reports CPT code 81001. This is a results-only test, and the AMA has clarified that physicians can count reviewing the results of this test as a data element in the MDM, he adds. The same is true for a quick strep test, CPT code 87880.

Tip #4: Document review of prior external notes.

When physicians review prior notes, they can count this toward the MDM, and notes from each unique source can be counted separately, says Rivet. A unique source is defined as a physician or qualified health care professional in a distinct group or different specialty or subspecialty, or a unique entity.

Tip #5: Document a clinically relevant history and examination.

Although the new E/M guidelines say history and examination do not count toward the E/M level, they are still important from a clinical perspective and to justify medical necessity, says Grider. “Payers will read the entire note,” she adds. “They’re going to look at what brought the patient into your office, past medical history, the exam you performed and what you found — and then, based on these variables, the assessment and plan of care.”

Tip #6: Get credit for social determinants of health (SDOH).

Physicians can count SDOH toward their MDM when those determinants have an impact on the patient’s health, but only when they clearly document that impact, says Rivet. For example, a patient with uncontrolled, worsening diabetes lacks access to safe and reliable transportation, making it difficult for them to refill prescriptions and thus manage their insulin levels. When properly documented, this equates to a level 4 E/M code, he adds.

Tip #7: Use caution with cases related to COVID-19.

Assigning an E/M level for COVID-19 cases can be tricky, says Grider. For example, an asymptomatic patient says they were exposed to COVID-19 and wants to be tested. This is a minimal problem with one unique test ordered, which is a level 2 E/M code. However, if that same patient presents with signs and symptoms — and the physician prescribes an antibiotic — it’s an undiagnosed new problem with prescription drug management, which is a level 4 E/M code.

Tip #8: Update your E/M template, audit your documentation.

“Templates were designed largely around the old E/M guidelines and elements, which means they may no longer be accurate,” says Rivet. “Still, the provider — not the vendor — is ultimately liable on an audit.”

Once you’ve asked your vendor to update the E/M template, select at least 10 records per provider, including a combination of E/M levels 3, 4 and 5, says Grider. Then hire an external consultant to audit those records, she adds.

“This can be done fairly inexpensively,” agrees Rivet. “The cost associated with this is minuscule compared to the upward benefit.”


With post-payment audits of telehealth services on the rise, physicians should pay close attention to telehealth billing, says Elhoms. “There’s a false sense of security during the public health emergency,” she adds. “Providers think they can do whatever they want, and this isn’t the case.”

Elhoms provides several tips to ensure compliance.

Tip #1: Pay attention to audio-only
versus audiovisual requirements.

During the current public health emergency that was renewed on April 21, 2021, Medicare requires the use of audiovisual technology for certain telehealth services and permits audio-only for others, says Elhoms. For example, physicians can render a telehealth visit for an annual wellness visit using audio only, but they must use audiovisual technology for all E/M levels of new and established patient office visits. Note that commercial payers may have specific telehealth requirements.

Best practice is to document the technology used and whether the encounter included audiovisual communication with the patient, says Elhoms. “In the absence of this documentation, the payer will say you can’t prove you did this through a compliant technology, and thus you can’t support the service,” she adds.

Tip #2: Know your place
of service (POS) codes, modifiers.

Use POS code 11 and modifier-95 when billing Medicare, says Elhoms. Note that commercial payers may require a different POS code (e.g., POS 2 or POS “other”) and modifier.

Tip #3: Document patient consent.

“It seems really simple, but it’s important,” says Elhoms, adding that payers look at utilization patterns and are quick to audit providers whose utilization spikes suddenly or steadily increase over time. Having consent is key to proving that these visits took place. Some providers, for example, may not realize that their practice management system automatically bills appointments even if the encounters do not ultimately occur (e.g., because the patient is a no-show).

Tip #4: Beware of incident-to billing for telehealth.

Does documentation clearly indicate that a supervising physician is immediately available? For example, does the physician’s schedule show that they are supervising during the hours in which incident-to visits are billed? Payers may request this information to validate services rendered, says Elhoms.

Remote patient monitoring

Remote patient monitoring (RPM) helps physicians keep patients healthy; however, it is not without its own unique reimbursement challenges, especially in light of more specific RPM guidance published in January. “The OIG (Office of Inspector General) is just now starting to audit practices that are using RPM for compliance with this rule,” says Kaitlyn O’Connor, J.D., senior counsel at Nixon Gwilt Law in Richmond, Virginia, who works with more than 80 RPM providers and vendors.

However, these audits should not necessarily scare providers away from offering RPM, says O’Connor. The startup costs associated with RPM (i.e., purchasing devices) should not either. “Most vendors will wrap the cost of devices into a flat monthly fee rather than requiring practices to purchase devices outright,” she says. “Now that we’ve been through COVID-19, I think a lot of practices are starting to integrate RPM. If you’re not doing it, you may start to lose patients to practices that are.”

Consider the following relevant RPM codes.


Initial device setup and patient education for RPM that includes at least 16 days’ worth of data (billable only once per episode of care*)



Rental fee for devices that supply daily recordings or programmed alert transmissions for at least 16 days’ worth of data (billable once every 30 days)



RPM treatment management service by clinical staff, physicians, or other qualified health care professionals requiring 20 minutes of live, interactive communication with the patient or caregiver during a 30-day period



[Each additional 20 minutes]



Collection and interpretation of physiologic data digitally stored and transferred, requiring a minimum of 30 minutes of analysis by a physician or other qualified health care professional during a 30-day period**



Self-measured blood pressure using a device validated for clinical accuracy (including patient education/training and device calibration)



Collect and review separate self-measurements of two readings one minute apart, twice daily over a 30-day period (minimum of 12 readings), and communicate a treatment plan as well as average systolic and diastolic pressures to the patient



Continuous glucose monitoring requiring a minimum of 72 hours, billable once every 30 days


Common denial: The RPM device doesn’t meet federal requirements.

How to avoid it: Use a medical device, as defined by the United States Food and Drug Administration, that provides automatic data upload and transmission, says Charles C. Dunham IV, J.D., business and health care attorney at Greenberg Traurig in Houston. Dunham says he encounters physicians who bill RPM when patients manually input their weight and other physiologic data into an app and then manually upload that data to the practice. “If at any point your patient needs to enter information, that’s not the type of device the government is willing to cover,” he says.

If physicians are working with a vendor to supply RPM devices and manage the RPM program, Dunham says, they should include a provision in the vendor agreement that the vendor is supplying the practice with a device that meets functionality requirements for RPM under the Medicare Part B program and that it will indemnify the practice for any damages or overpayment recoupment.

Common denial: There’s no medical necessity for RPM.

How to avoid it: Only use RPM for patients with an acute or chronic condition that must be monitored, says Dunham, adding that documentation should clearly reflect how remotely monitoring the patient supports the care plan and period of use. Also, if the RPM is for an acute condition, Medicare’s expectation is that the RPM will cease at some point in the short-term when it no longer becomes medically necessary, he adds.

Common denial: The RPM doesn’t include 16 days’ worth of RPM data.

How to avoid it: Physicians may use multiple devices or a single device that captures more than one type of physiological data, says Dunham. “You can pull data from multiple devices to meet the 16-day requirement,” he adds. One important caveat: Physicians can only bill 99453 once per episode of care and 99454 once every 30 days regardless of how many devices the patient uses.

That does not preclude physicians from billing more specific codes when possible, adds Dunham. Examples include 95250 for continuous glucose monitoring as well as 99473 and 99474 for self-measured blood pressure monitoring.

It can also be helpful to work with a vendor that helps manage your RPM program because the vendor typically reminds patients when to take their readings, which can help with adherence, says O’Connor. Some vendors may also use devices that incorporate software that automatically reminds patients to take their readings, she adds.

Common denial: Provider submits a date range for RPM services.

How to avoid it: Only submit one date of service for CPT codes 99453 and 99454 even though the codes require at least 16 days of data, says O’Connor. Practices usually use the first or last day of the month, for example.

Common denial: Medicare Administrative Contractor (MAC) doesn’t apply RPM rules correctly.

How to avoid it: Although these denials can be frustrating, the good news is that practices can often simply point out the error and ask the MAC to adjust the denial, says O’Connor. For example, some MACs have denied RPM claims in the past, stating the service can only be used for cardiology. “Because RPM originated in the cardiology space, there’s a misconception that it can only be used for cardiology patients, which is not accurate,” she adds.

Managing denials and appeals

It is the part of running a medical practice that no physician wants to spend time addressing: Denials…and then appealing them. However, experts agree that a few simple steps can go a long way in terms of improving cashflow. Consider the following tips.

Tip #1: Run daily reports.

What is the denial rate by payer and reason code? “A lot of practices will just sit on denials,” says Rozmin Bapat, CCS-P, CPC, CPCO, CPMA, founder and CEO of
CodeRite Healthcare Consulting in Allen, Texas. “If there’s a denial, they need to work on it right away.”

Tammy Tipton, owner of Appeal Solutions Inc. in Oklahoma City, agrees. “So few practices have a good handle on their denial rate and appeal success rate,” she says. “It’s very important to know this information and to look at it on a payer-by-payer basis.”

If a practice outsources its coding and/or denial and appeal management, it’s paramount to work collaboratively with the vendor to keep tabs on accounts receivable, says Tipton. The vendor can be an excellent source of input regarding recurring issues and opportunities for focused training, she adds.

Tip #2: Use technology to your advantage.

For example, coordination of benefit (COB) denials can be easily addressed by requiring staff to use payer portals to check insurance eligibility. Staff might also be able to check eligibility from within the practice’s billing software. Another strategy is to put edits in place to catch front-end errors. For example, practices could create an edit that would, for example, prohibit staff from entering a Blue Cross Blue Shield ID that isn’t typed in an alphanumeric format.

Tip #3: Provide ongoing education for staff.

For example, certified medical coders require ongoing education and training to maintain their certification and to help ensure revenue integrity. A reasonable budget for this type of education is approximately $350 per coder annually, says Bapat.

Training staff on the Employee Retirement Income Security Act of 1974, known as ERISA, the Affordable Care Act, and state-specific laws regarding legal protections related to insurance benefits is also important, says Tipton.

Tip #4: Use the right forms.

Each payer has its own appeal guidelines and forms, and appeals may be rejected if providers don’t follow the rules, says Bapat.

Tip #5: Involve patients in clinical appeals related to the application of policy benefits.

That is because patients can often provide helpful policy language, says Tipton. “A broad appeal letter that’s not specific to the claim ends up sacrificing some effectiveness,” she adds.

In some cases, patients may be able to handle the appeal themselves, says Tipton. “If you’ve got a motivated, well-educated patient, it’s probably better to let them handle it. To the payer, it can be more persuasive coming from the patient,” she adds.

Tip #6: Negotiate payer contracts that include additional appeal protections.

For example, practices can negotiate longer time frames for appealing denials or require payers to disclose the clinical information and guidelines it used to determine the denial, says Tipton.

Tip #7: Correlate denials with patient satisfaction.

“With high deductible plans and greater out-of-pocket patient responsibility, patients are being very vigilant,” says Bapat. “They’re going online looking at their explanation of benefits and questioning things.”

Tipton says everyone within the practice should understand how their role fits into the bigger picture of helping patients avoid inaccurate bills and unnecessary frustration. For example, patient access staff can file pretreatment benefit clarification requests and pretreatment appeals when authorizations are denied. Patient financial staff can review claims that fail on front-end edits. Clinical staff can file clinical denials, work with payers to understand reasons for denials, and review managed care contracts annually for problematic terms that impact quality of care. “Everybody can really play a part in reducing denials,” she adds.

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