March 20, 2019
An annual review of each provider’s E/M code usage is an essential component of physician practice compliance management. Reviewing documentation can identify coding pattern anomalies, uncover opportunities for physician and staff education, and move your practice toward coding correctly according to federal, state, and payor guidelines.
Here are seven steps for conducting this review.
1. Refresh your knowledge of E/M documentation criteria.
Before you start, be sure staff and physicians understand that for each E/M service, a provider must:
– Create a unique note for each patient encounter. All payors require this.
– Select an E/M code on the basis of the history, exam, and medical decision making (or other contributing components) for that specific encounter.
– Provide documentation to support medical necessity for the level of service reported.
What about time spent with the patient? Although there are some instances where time and counseling may be a contributing component, it’s the level of history, exam, and medical decision making that typically drive the level of E/M service. Beginning in 2019, CMS made changes that relax previous documentation requirements, so it will be important to recognize how this impacts claim reviews: 2018 rules are more stringent.
2. Generate a CPT frequency (usage) report.
This report is standard in most practice management systems (PMSs). It summarizes the number of times each provider billed each CPT code. Here’s how to run this report for your E/M review:
– Select a date range of one full year.
– Run one report for each provider, and one report for all providers combined.
If you aren’t sure how to run the report, contact your PMS vendor.
3. Review your E/M code usage patterns against the CMS data of specialty peers in your state, and nationally.
CMS and other payors review the data this way and you should too. It’s available from CMS and updated annually. Purchase and parse it for your specialty and state to see how your provider patterns stack up against peers. Or save yourself some time by using KZA’s Excel-based, E/M Profile Analyzer. Enter your practice E/M frequency data and the Analyzer displays it in a line graph against CMS’ most recently-published state and national claims database.
Regardless of how you do the comparative analysis, what you are looking for are providers whose patterns fall outside the E/M code usage in your specialty. The ones that stand out as “outliers.” Is being an outlier always bad? Not necessarily. Sub-specialty is something that could drive the pattern difference. For example, a neurotologist’s patterns may be different from a general otolaryngologist’s. Or, an orthopaedic surgeon in an academic medical center may have different utilization patterns than her private practice peers.
Unfortunately, being an outlier can attract a payor’s attention, making a request for records more likely.
4. Review ten notes per provider.
Choose records that include some of the outlier codes identified in the previous step. And try to choose dates of service that include encounters for something other than just the E/M service. For example, visits that include an injection, a procedure or test, or modifier 25.
Once you’ve chosen a date of service, look up the encounter in the PMS to see which E/M code was billed. Review the note to determine whether it supports the billed code, based on E/M documentation guidelines. At the same time, evaluate the accuracy of the diagnosis code.
5. Discuss findings as a group.
Review E/M usage patterns, documentation, and coding rules, and consider actions for improvement. If you have identified discrepancies between the codes selected and the documentation present, engage a healthcare attorney to advise on next steps.
6. Schedule provider education.
Consider this baseline education, targeted toward the compliance risks you identified in the record review. To measure the success of this education, conduct another record review in 90 days after the education, and establish a passing rate. Provide additional coaching for the providers who are still not hitting the mark.
Even if your coding gets an A grade, several staff and physicians should attend annual coding education to keep up with regulatory changes, learn the latest rules and code changes, and reinforce your team’s coding knowledge.
7. Document everything in the compliance plan.
This includes a summary of the methodology used, the results of the review, issues identified, actions being taken, and providers and staff trained. If there was an improvement between the baseline education and the 90 day follow up documentation review, log that too. And, if you’ve engaged a healthcare attorney as part of the review, work with him or her to ensure what you document is thorough and meets risk management standards.
If you lack the time or confidence to complete an annual review like this, engage a reputable third party to conduct an audit. Choose a company with good credentials and deep experience in your specialty. And don’t forget to check references.