Coding comments

From: "Stacey Robinson" <srobinson2@tampabay.rr.com>
Mailing-List: list Practiceimprovement1@yahoogroups.com; contact Practiceimprovement1-owner@yahoogroups.com
Date: Wed, 2 Feb 2005 20:51:40 -0500
Subject: Re: [Practiceimprovement1] coding correctly
Reply-To: Practiceimprovement1@yahoogroups.com

I have been solo for almost a year now. I've been to several coding seminars
and feel fairly comfortable with coding. I would say the majority of mine
are 214 and 203. The 3/3 on the new patient visit usually discourages me
from coding a 204 on a fairly healthy patient when I meet the history and
physical exam portion for a 204 but feel that the MDM is fairly simple. I
have templates for most of my visit types and my templates are structured so
that I can get what I deserve by documenting appropriately. I think I have
submitted215 maybe twice and was not questioned. I did get a request for
documentation on a cervical strain that I coded a 214. I got lazy and really
should have been a 213. They down-coded it to a 213 but paid for my 214
charge because it was an auto insurance claim with no "allowable" $$. I'm
not sure what you mean by "self-audit". I do all my own coding and don't
have anyone review it.

From: Kathleen delaCruz <kellydlc@yahoo.com>
Mailing-List: list Practiceimprovement1@yahoogroups.com; contact Practiceimprovement1-owner@yahoogroups.com
Date: Thu, 3 Feb 2005 04:59:39 -0800 (PST)
Subject: RE: [Practiceimprovement1] medicare audit
Reply-To: Practiceimprovement1@yahoogroups.com

I'm the one who went through the medicare audit and I've been too busy seeing patients and enduring the endless monotony of paperwork to write - and keeping up with all of these conversations is very difficult for me.

Anyway. Medicare audited 20 encounter from Jan-April 2004. This was a time period during which I was not using eMDs coder and most(70%) of my charges were 202s or 214s. After an auditor reviewed the charts she sent me a very nice, allbeit, bureaucratic response that indicated she believed medicare overpayed me the amount of $142.66. (I disagree but I'm not going to fight the madness.) She said medicare would send a bill to me but I haven't seen it yet. The reason for the review "was conducted because of random data analysis of new providers (sic) billing practices" althouth I've been a doctor with medicare in North Carolina since 1999. The charts were reviewed by the Carrier Medical Director, Registered Nurses and Certified Professional Carriers.

The Nurse Reviewer's comments were sent to me. She explained that she used the 1995 guidelines to "score" the records and that "those tools are actually slanted toward the physician." The review included criteria as follows: medical necessity, appropriate billing of CPT and ICD-9 codes, medicare published guidelines, adherence to the Social Security Act and the CMS Online Manual System.

I sent a cover letter which she appreciated very much and actually helped while she was evaluating the charts. I explained that I had just started with EMR and that, although, information was comprehensive it was fragmented in that, initially, each chart had electronic and handwritten information. When I combined the information in order to send her the records the newly input data from each visit (like vital signs) were given the date on which I input them not the date I acquired them. She accepted that explanation but said it would have been a bugaboo for Medicare had I not explained that.

The most interesting thing she said was that EMR essentially lets us get away with upcooding by "cloning" past visits because we probably don't actually review social/family history each visit. The gist was that we shouldn't allow use of EMR to help us abuse the Medicare System. She admonished me to compare "the volume of documentation vs. medical necessity." I guess that means if they have a cold don't ask if Dad;s had a heart attack lately. The official statement is as follows:

The availability of electronic records provides a tendency to "overdocument" and consequently to select and bill for a higher level E?M code than is medically reasonable and necessary and the practice should be avoided.

She also says that a statement regarding the level of or time devote to counseling should not be made with every visit. (But she didn't count it against me.) Sorry for being thoroughandncatching disease processes early before they get really expensive for medicare.

She made no mention of curves and outliers and overpayment of us physicians in general.

My error rate was "low" and the overall error rate for the nation is 13% but Medicare wants us to get educated and reduce the rate to under 5%.

By the way, since I've started using eMDs coder, my codes have largely been 214s and 203s. I occassionally code down and virtually never code up.

Hope this helps.

Kathleen Meehan-de la Cruz MD

Grace Family Medicine

Hendersonville, NC