Physicians Practice - March 2008 - (Page 38)

BILLING AND COLLECTIONS BETTER E&M CODING E&M visits account for more than 50 percent of revenue in most primarycare practices. And Medicare reimbursements for E&M visits across specialties added up to around $30 billion in recent years — more than 1 percent of the entire federal budget. So you better believe Medicare carriers are paying attention to how you are using these codes. But most physicians are rather uncomfortable with them. “Physicians don’t clearly understand the requirements for each level of service, so they can end up upcoding and undercoding,” says La Verne Jones, director of evaluation and management services for The Coding Network. Jones performs chart audits for physician practices and regularly sees upcoding for level four and five visits. Here’s a quickie primer: • Level four visits require a moderate level of medical decision-making. • Level ﬁve visits require a high level of medical decision-making (see chart below for an extended explanation). • Both level four and level ﬁve visits require a comprehensive history. That means including: H H H A history of the chief complaint; An extended history of the present illness; A review of relevant systems plus a review of other systems following either the 1995 or 1997 guidelines; Complete past, family, and social histories. (This is the part Jones often ﬁnds left off. “It may be true that family history isn’t relevant to some specialties, say in orthopedics with a fracture,” she admits. But if you think the level of care is a four or ﬁve, you are required to have a family history.) and may also translate into more revenue, especially if you routinely undercode now. In truth, there’s no way to avoid taking the time to learn the basics. CONSULT OR NEW-PATIENT VISIT? H Still confused? Many practices have templates for physicians to follow — either on paper or through an EMR — to make sure they cover what’s needed. For some samples, visit the tools section of www.PhysiciansPractice.com. Here’s another great idea: Have a coder visit your practice, audit your charts, and show you what is specifically missing from your documentation. That can be more efﬁcient than abstract education, although it might also be worthwhile to invest a day studying E&M documentation alongside an expert. Getting it right reduces the risk of a Medicare audit going south Picking the right code level is the big issue in E&M, but practices also make mistakes when determining whether an encounter is a consult or a newpatient visit, says Jones. Consults pay better, so it’s worth getting right. What’s the difference? “The focus has to be on the intent of the visit — whether another provider is requesting advice on the patient or if the physician has already determined that care needs to be transferred to the specialist,” Jones explains. In short, if another physician just wants your opinion, it’s a consult. If he is actually transferring care to you, it’s a new-patient visit (or established patient if you or anyone in your practice in the same specialty has seen this patient in the past three years). For a consult, make sure to document the “Three Rs”: • The Reason for the consult; • The Requesting physician’s name; and • The Report back to the requesting physician. HOW TO ASSESS YOUR DECISION-MAKING E&M VISIT PRESENTING PROBLEM I 3+ self-limited problems I 1+ chronic illnesses or self-limited problem with mild exacerbation I 2 or 3 stable chronic illnesses I Undiagnosed new illness, injury, or problem with uncertain prognosis I Acute illness with systemic symptoms I 1+ chronic illnesses w/severe exacerbation I 4+ stable chronic illnesses I Acute complicated injury I Acute/chronic illness or injury posing threat to life or bodily function I An abrupt change in bodily function SAMPLE TREATMENT OPTIONS I Referrals requiring detailed discussion I Management of medications with moderate risk I Hospitalization for noncritical illness/injury I Initiation of total parenteral nutrition I Referral for comprehensive pain management rehabilitation LEVEL 4: MODERATE MEDICAL DECISION-MAKING LEVEL 5: HIGH MEDICAL DECISION-MAKING I Emergency hospitalization I Medications requiring intensive monitoring I Surgery or procedure with ASA 2* or higher risk status I Decision not to resuscitate or to de-escalate care because of poor prognosis I Mechanical ventilator management (Source: Bill Dacey, CPC, MBA, MHA, principal in the Dacey Group. Original source AMA 1999 revised Table of Risk) 38 | PHYSICIANS PRACTICE | MARCH 2008 WWW.PHYSICIANSPRACTICE.COM http://www.PhysiciansPractice.com http://WWW.PHYSICIANSPRACTICE.COM

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Physicians Practice - March 2008 Contents The Bigger Picture: Try a Little Tenderness Second Opinion Letters Physicians Practice Pearls: The Value of First Impressions Noteworthy Cover Story: Your Complete Guide to Patient Service Billings & Collections: Rules to Code By The Administrators Desk: Selecting an EMR Technology: Learn to Love Your Nerd Ask The Experts Coding The Guide The Tech Doctor: All About Blogs The Great Practice Makeover: When Bad Things Happen to Good Practices Start It Up - NEW! The Law: Audits 101 In Practice: Do As I Say... Pretty Please? Healthonomics: Handling the Changes Wrought by Medicare D Classifieds Advertiser Index

Physicians Practice - March 2008

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