Be sure the services and documentation you provide support the levels you are charging
Q I recently received a letter from my Medicare carrier indicating that I am charging more high-level evaluation and management (E&M) codes than the average urologist. The carrier did not ask for any charts, nor did it ask me to pay any money. What will happen next? What should I do?
A The government has contracted with a number of different companies (eg, recovery audit contractors, zone program integrity contractors, and Medicare contractors) to look at all Medicare payments and try to detect billing patterns that are outside the norm. A number of practices have received similar letters. These letters represent “a shot across the bow.” In other words, it is nothing more than a warning that your billing pattern does not match that of the average urologist.
What will happen next? Chances are, the contractor will continue to monitor your charges and if it does not see a pattern of change, will audit some of your charts to confirm that you are reporting only the work that your documentation supports.
What should you do? First, audit your charts to be sure that the work you’re providing and your documentation support the levels you charge. Second, consider an “external” audit to confirm that you and your internal audit team have appropriately determined the correct level to charge for each documented service. (Full disclosure: We perform off-site audits for many practices; however, there are many other consultants who perform in-house and off-site audits.)
You should not simply change your billing pattern to try and match the curve. We still strongly recommend that you provide the services you feel are medically necessary, document what you do, and charge what is documented.
This latest set of letters raise a few areas of concern:
Medicare is using average charges for all urologists. Unfortunately, many urologists are not charging for the work they perform as defined by the documentation guidelines. Therefore, the statistics that Medicare is referencing in the letters are skewed lower. We are also seeing a shift in the coding pattern for those practices using electronic health records. While we expect the coding curve to shift, the timing of the shift will leave many outside the norm and on the list for letters and audits.
The letters also question whether the work being done is justified by the severity of the problem being addressed. This response is related to the changes seen in billing as a result of EHRs. It is apparent that Medicare contractors are looking at “medical necessity.” In our seminars, we have always taught that medical necessity is an over-arching measure for all services. If you read any local coverage determination (LCD) or the Medicare payment manuals, you will find a statement explaining that Medicare will pay for services deemed reasonable and necessary. Typically, reasonable and necessary guidance from Medicare is operationalized in the form of ICD-9 restrictions included in the national coverage determination and LCD. While many of us question the accuracy of these ICD-9 lists, they are ultimately governed by medical necessity.
Payers have used numerous sources to develop guidelines similar to those developed by Medicare. A common source for payers is CPT. Medical necessity as it relates to E&M codes is addressed in the E&M codes and guidelines in CPT. Interpretation of these guidelines will provide the jumping-off point for medical necessity as it relates to E&M codes. We suspect that Medicare will use ICD-9 codes as a filter for audits but will have to use the CPT interpretation as enforcement. The letters from the carriers seem to indicate that higher-level E&M codes are justified only for services provided to those presenting with problems that will result in death or disability before intervention or the next visit. Clearly, this interpretation will have to be refined. We will keep you up to date as we are provided more detail.
Medicare and other payers are struggling with the effect of medical record programs on the billing patterns of all providers. While the rules governing E&M coding levels as published in the documentation guidelines can be programmed, they can also be automatically populated. Templates in the EHR are a necessity for both data entry and retrieval. Time-saving steps for entry of data have been requested by many providers and developed by programmers. Beware of these features, make sure that your documentation truly reflects what you have done, and make certain that your matrix reports the correct codes if you are using an auto calculation tool.
In the end, both payers and providers will have to adapt to the change in medical practice caused by EHRs. From the physician office, you must guard against the quick fix and maintain coding discipline and a compliance culture that will allow you to be paid accurately for the services you provide.
