The information provided here applies to Medicare coding. Be sure to check with your Medicare Administrative Contractor (MAC) for additional information and clarification on these and other items. You should also contact your local insurance carriers to determine if private insurers follow Medicare's lead on all coding matters.
Show Your Work to Assure Proper Payment
I was with a new client recently who wanted training on documentation of Evaluation & Management services (E&M). He had been audited by a major insurance carrier and several of the visits reviewed were down-coded after their analysis. There was no real explanation given to him. The carrier’s only feedback was to reference the carrier manual reject code that indicated “documentation does not meet standards for code billed.”
Upon further review, it was clear that his documentation was deficient. However, it was also clear that the patients were ill and presented complex cases warranting the higher reimbursement. The cases were not over-coded, they were under-documented!
For an auditor, seeing documentation that a patient is ill, moderately ill or severely ill shows the “work” of the physician in the medical decision-making (MDM) process. I believe inclusion of a few words can make all the difference to an auditor in validating that the documentation supports the level of service billed.
Many times I see documentation of a condition and wonder if the condition is new or not. An earache that has been present for only two days seems to represent a new problem. If the documentation states that the patient’s shortness of breath has been increasing, I am not sure if the condition is a new or ongoing issue for a patient with COPD or heart failure. In your final listing of a diagnosis for the patient, be sure to indicate if the condition is new or not. Remember, often when looking at your own charts many things are obvious to you that are not obvious to an auditor who does not have the clinical expertise you do. Clear documentation can be very helpful.
Another tip for reflecting the true status of a patient’s condition is to state whether the condition is an exacerbation or a flare-up. If a diagnosis is listed without qualification, the default is for the condition to be considered stable. A diagnosis of asthma for a patient coming in for a checkup is appropriate. However, your documentation for a patient coming in sick with an exacerbation of their asthma should include “exacerbation” of asthma in the chart with additional notations for the asthma codes ( i.e. mild intermittent, severe persistent). Complete documentation will give you the most specific diagnosis code.
If we look at the MDM, the Table of Risk has a listing of “mild exacerbation” and “severe exacerbation” for the moderate and high level, respectively. If the remainder of the documentation and the medical necessity supports it, inclusion of “severe” would potentially lead to the highest level office visit (new or established patient), or highest level hospital visit (initial or subsequent care days). Without “severe,” documentation of “asthma” alone does not show the severity of the patient’s condition and that same visit could be down-coded several levels by an auditor. Without complete documentation, the severely ill patient looks like a healthy patient coming in for a routine follow-up visit.
Be sure to show the extent of your patient’s illness by including the appropriate descriptors in your documentation. It may not change the diagnosis code, but it might affect the level of the E&M code.