E&M documentation: What’s new and what’s what

New evaluation and management documentation guidelines have not been published since 1997, and no replacement guidelines are scheduled in the near future. However, the Centers for Medicare & Medicaid Services has added some clarifying language to the CMS Manual System (Pub. 100-04 Medicare Claims Processing).

The new language, stressing medical necessity, replaces some erroneously deleted instructions. The good news is that no significant changes were made to the way the guidelines have been previously interpreted.

According to a recent CMS update (Transmittal 178, published May 14, 2004): “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of services is billed. Documentation should support the level of service reported.”

My interpretation is very simple. Do not do more work than is medically necessary for each encounter. To charge a level, you must not only document all of the elements required for that level, but also be sure that the work was medically necessary. Just because you do the work and document a level 5 established patient visit does not mean you should charge that level.

‘Medically necessary?’ A blatant example of abuse is the established patient who is asymptomatic and returns for a scheduled visit after a minor illness. A complete history and physical is performed and documented. In the absence of a significant medical problem, I think most of us would agree that a complete history and physical was not medically necessary even though a legitimate, documented level 5 established patient visit was performed.

Unfortunately, if a patient had a significant problem that fully justified a level 5 code but the documentation requirements required by a fifth-level code are not fulfilled, only the level that you have completely documented should be billed.

The bottom line is, charge to the level of medical necessity. Also be sure that you have completed the work and have documented all requirements for the level charged.

Occasionally I am asked the question, “Should a urologist ever charge a level 5 visit?” Absolutely. By all means, charge a level 5 if the patient has a significant problem and the work in your documentation justifies a level 5.

For urologists, the most common scenario that justifies a level 5 established patient code is the individual who returns to the office for discussions of treatment after a positive prostate biopsy. In order to charge a level 5 established patient code, a physician must spend at minimum of 33 minutes face to face with the patient, in which over 50% of the time is counseling. However, don’t forget the critically ill patient or the patient who requires a complete history and physical for surgery.

When a non-physician participates

The new language also clarifies billing for an E&M service in which the physician and a non-physician practitioner (nurse practitioner, physician’s assistant, certified nurse specialist, or certified nurse midwife) participated in the care the patient. It should be billed in the following manner, depending on where the care takes place.

If the visit is in the hospital inpatient/outpatient/emergency department setting:

If there was face-to-face time with the physician at any time during the day, then that day’s encounter can be charged by the physician.

If there was no face-to-face time by the physician, even if the physician reviews and signs the record, then the encounter must be charged by the non-physician practitioner.

As most urologists know, one cannot charge “incident to” services outside the office even if the criteria is met.

If the visit is in the office setting:

If the non-physician practitioner performs part of the E&M encounter and the physician performs the rest, and the “incident to” requirements are met, then the physician reports the service.

If the “incident to” requirements are not met, the service is reported by the non-physician practitioner.

In charging for time, the regulations state that the time has to be face to face with the physician only. Counseling by other staff is not considered part of the face-to-face physician-patient encounter time. The regulations do not specifically address time spent by a non-physician practitioner. However, I would not charge for the additional time spent by the non-physician practitioner if the physician has spent time counseling the patient.

If the non-physician practitioner spends time counseling, he/she should report the appropriate level of service under his/her unique physician identification number.

Stay tuned for more developments, and look for a discussion of the requirements for a level 5 consult in a future issue of Urology Times.

Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook

Mark Painter is CEO of PRS Urology SC in Denver.

Disclaimer:

The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written.  However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.