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Use self-audits to uncover, correct coding issues


This month's question focuses on what to do when you receive analyses from your payers. Find out the answer to this pressing coding question.

Q: I recently received a letter from one of my third-party payers regarding its use of level 4 and level 5 evaluation and management (E/M) codes compared with other doctors in my specialty. What do I do now?

A: This type of analysis is happening more frequently with many payers. It’s called data mining, and payers are using the level of service claims you submit and comparing them with those submitted by doctors in your area with the same specialty. Sometimes payers make a list of patients you billed for a level 4 or level 5 office visit, or the number of times you billed at such levels during a specific period.

Education is an important part of auditing. If you do not comply with the federal government’s guidelines, you must learn to provide the medically necessary information for the level of service billed. Otherwise, you must report at a lower level.

Conduct a self-audit to uncover and correct any issues. Here’s how.

1. Print the codes from your practice management system for the levels in question. Compare them with those sent by the payer. If the numbers do not match, and if no list of beneficiaries exists from which the data were abstracted, then request the patient list. Check the names on this list to be certain the patients are yours and assigned to a doctor in your practice.

2. Review your charts. Is the coding and billing in compliance with the payer’s requirements? Are the services performed medically reasonable and necessary? Is the necessary documentation for the specific level of E/M services included?

3. Correct the mistakes you find in your charts. Let’s look at some common issues and how you can fix them.

  • Insufficient information. An E/M service consists of history, examination, and medical decision-making. A common omission in the history portion is a clearly stated chief complaint. Although it frequently can be found in the history of present illness, many times recheck or follow-up is listed as the chief complaint. You need more documentation than that for an appropriate chief complaint, however. You may refer to past medical, social, and family history as previously documented, but sometimes this information has not been updated in several years and therefore is invalid.

  • Include medically indicated details of the physical examination. Comorbid conditions may affect medical necessity, but the use of electronic health records makes it easy to bring forward past notations in future documentation.

  • Add information with an addendum that includes the date and time you added it. For example, if a lab or pathology report was missing from the chart, you can include it. Each encounter must be complete to code properly.

  • Meet the criteria that determine whether an encounter was reported properly. Incident-to billings may involve additional investigation.

  • Sign your charts electronically or manually, but not with a stamp. The federal government focuses on signatures, and although guidelines primarily are for Medicare requirements, most other third-party payers will soon follow. Your name is on the claim, and you are responsible for billing that service.

4. Appeal a penalty by contacting the third-party payer if you find after your self-audit that your levels of service are correct.

Because it is easy to slip back into old habits, every practice should conduct a self-audit on a regular basis. The complexity of coding and billing will not be simplified; it will increase significantly with the International Classification of Diseases and Related Health Problems, 10th Revision, and the Physician Quality Reporting System.

The author is president of Medical Coding & Reimbursement in Cincinnati, Ohio. Do you have a primary care-related coding question you would like to have our experts answer in this column? Send it to medec@advanstar.com. Also engage at www.twitter.com/MedEconomics and www.facebook.com/MedicalEconomics.


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