Ask an Auditor Series: Auditing When There Are Conflicts of Interest

We received a lot of great questions during our Conflicts of Interest Webinar.

Webinar Details >>

Unfortunately, we weren’t able to get to all of them during the the webinar. But, it’s important to us to answer all of your questions so we made sure to save each and everyone one of them so we can answer them here in this series. Don’t see your question below? Stay tuned for Part 2, or, go ahead and put your question in the comment section below and we’ll get to it as soon as possible.

Q1. For all new patients, is a provider always to do a Physical Exam?

A1. For Office or Other Outpatient Services New Patient E/M codes 99201-99205, all new patients need to receive a physical exam per CPT guidelines as three out of three of the key components of history, examination, and medical decision making must be met.

Q2. Are most external auditors looking at multiple records per patient in order to determine cloning?

A2. Since a majority of healthcare providers all utilize an electronic medical record (EMR), auditors are able to view multiple dates of service per patient if cloning of information is suspected during an audit.

Q3. How do you determine what is "above and beyond" when deciding whether or not to bill an E/M same day as procedure? For example, our doctors are asked to consult a patient in the hospital for possible food impaction. He sees the patient and then performs a procedure to remove the foreign body. Is a separate E/M warranted in this case?

A3. One of the items in the Fact Sheet by CMS states: “The initial evaluation for minor surgical procedures and endoscopies is always included in the global surgery package. Visits by the same physician on the same day as a minor surgery or endoscopy are included in the global package, unless a significant, separately identifiable service is also performed. Modifier -25 is used to bill a separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure."

We recommend reviewing the following resources:

Q4. What are some elements and practices a coder could use from an auditor, especially with Neurology Inp Services?

A4. Some audit and documentation tips might be:

  • Always document the diagnosis(es) that is the reason for admission, rather than just the presenting symptoms, as soon as it is determined
  • Document diagnoses, rather than descriptors (e.g. “metabolic encephalopathy”, not “altered mental status”)
  • Indicate acuity/severity of all diagnoses: acute, chronic, acute on chronic, or exacerbation.
  • Link all diseases /diagnoses to their underlying causes if known. This is more important than ever under ICD10. (For example, “TIA symptoms due to hypertensive encephalopathy”)
  • Indicate “suspected,” “possible,” or “likely,” when treating a condition empirically, such as a gram negative pneumonia. Coding guidelines require that uncertain diagnoses are documented as such at the time of discharge.
  • Use supporting documentation from dietary and wound care specialists to accurately document nutritional disorders and pressure ulcers.
  • Clarify what is present on admission (POA)
  • Clearly indicate what has been ruled out (e.g., “post-op infection: ruled out”)
  • Avoid use of temporal indicators, unless they are pertinent and are intended to describe complications rather than expected events.
  • Consider documenting if systemic inflammatory response syndrome (SIRS) is present in trauma, burn, and pancreatitis cases when VS and labs support this
  • Avoid use of arrows/symbols (e.g., use hyponatremia instead of ↓Na)
  • Document/notate the site of the CVA (hemisphere, brain stem, cerebellum, intravascular, multiple localized)
  • Document/notate notable points related to the Glasgow Coma Scale
  • For paralytic conditions you need documentation of the type of condition, cause of condition, and duration.
  • Review the ICD10 guidelines for documentation of para- and hemiplegia, epilepsy, and migraines for further needed information to properly code.

Q5. What if you do not use the 1995 guidelines? I am in an area in which several offices have been known to use both 1995 and 1997.

A5. CMS has stated that physicians may utilize whichever set of guidelines benefits them most for each individual patient E/M service. You may use either version of the documentation guidelines, not a combination of the two, for a patient encounter. For reporting services furnished on and after September 10, 2013, to Medicare, you may use the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 documentation guidelines to document an evaluation and management service.

Q6. One of our physician orders labs for Vitamin D and Vitamin B12 when there is no signs or symptoms warranting it. Is that valid. When questioned we were told that there are not usually signs or symptoms?

A6. While there may not be signs or symptoms for ordering diagnostic services there should always be a medically necessary reason for such services being performed. Your physician/provider will need to provide you key information which allows an ICD10 code to be assigned for the reason(s).

Q7. When a physician documents a symptom first followed by a related condition in an emergency center situation, do you have to use the symptom as the principal diagnosis when coding the claim or list the condition first w/symptom second? ie And pain #1 and Ovarian Cyst #2?

A7. There are instances in which two or more interrelated conditions may meet guidelines for assignment as the principal diagnosis, in which case either diagnosis may be assigned as principal. However, we would recommend a thorough review of the ICD-10-CM Official Guidelines for Coding and Reporting FY 2016.

Q8. Is the bill payable without a chief complaint?

A8. According to Medicare’s official Evaluation and Management Documentation Guidelines dated August 2015 a chief complaint (CC) should be documented for each patient encounter. However, the CC is required for all E/M services that require documentation of the history component, which would be new patient E/M services, and other E/M services which require three out of three of the key components of history, examination, and medical decision making. To quote, “While documentation of the CC is required for all levels (of history), the extent of information gathered for the remaining elements related to a patient’s history depends on clinical judgment and the nature of the presenting problem.

While established patient E/M services and others only require two out of the three key components, the history component could be bypassed by the provider. However, CMS apparently still expects a CC to accompany patient encounters. We would recommend consulting your Medicare Administrative Contractor (MAC) for further clarification.

Q9. Regarding the write-off process, outside of the reasonable and customary ceiling of a payer, what else would escape the conflict scenario?

A9. Concerning routine waiver of co-pays, deductibles, and courtesy write offs, we would refer you to OIG fraud and abuse alert found at:

And another reference is a court case involving a physician who violated anti-kickback statutes and is barred from participation with government healthcare for three years, which can be found at:

Stay tuned for Part 2 of this Ask an Auditor Blog Series: Auditing When There Are Conflicts Of Interest.

Questions or Comments?