Ask an Auditor Series: Common Errors in Evaluation and Management (E/M) Audits Frequently Asked Questions (Part 2)

During our recent webinar, The Five Problem Areas in E/M Audits, many of you posted really interesting questions. Unfortunately, we weren’t able to get to all of them live. So, we’re going to tackle them here in this ongoing blog series that we're calling "Ask an Auditor."

In this series, I will answer your most frequently asked questions related to evaluation and management (E/M) audits. After all, I’m here to support you while you master all things auditing.

If you’re tuning in for the first time, you can find Part 1 here. Otherwise, let’s continue on with Part 2. 

Q1. When a provider decides to order an X-ray, read, and bill it, in addition to the E/M, can they also count 2 points in MDM for independently reviewing in addition to billing for the X-ray CPTcode?

A1. We do not recommend counting an independent review with also billing for a diagnostic procedure. Look to your MAC for guidance. Novitas does not allow a provider that is billing for the interpretation to also get 2 points towards data under MDM: Novitas E/M Documentation Auditor’s Instructions

Q2. Where can we find documentation requirements for new services such as Chronic Care Management? 

A2. For Chronic Care Management (CCM), please refer to the following links:

• MLM Chronic Care Management Services
• CY 2014 Medicare PFS Final Rule (CMS-1600-FC) pages 74414-74427: https://www.gpo.gov/fdsys/pkg/FR-2013-12-10/pdf/2013-28696.pdf 
• CY 2015 Medicare PFS Final Rule (CMS-1612-FC) pages 67715-67730: https://www.gpo.gov/fdsys/pkg/FR-2014-11-13/pdf/2014-26183.pdf

Q3. Where can we find documentation requirements for Advanced Care Planning?

A3. The official instruction for Advanced Care Planning , CR9271, was issued to your MAC regarding this change via two transmittals.

• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9271.pdf 
• The first updates the “Medicare Benefit Policy Manual” and it is available at http://www.cms.hhs.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R216BP.pdf on the CMS website. 
• The second transmittal updates the “Medicare Claims Processing Manual” and it is available at http://www.cms.hhs.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3428CP.pdf on the CMS website.

Q4. When multiple modifiers are reported on a claim such as Pricing, Payment, and Location modifiers, what order should modifiers go in?

A4. We recommend you refer to your MAC for guidance in this area.  For example, WPS has a section on Ranking Modifiers:  Payment Modifier Versus Informational Modifier on their website as follows:

"The CPT coding system includes two-digit modifier codes which are used to report that a service or procedure has been altered or modified by some specific circumstance without altering or modifying the basic definition for the CPT code. Proper use can speed up claim processing and increase reimbursement, while improper use can result in claim delays, rejections, or denials.

Some modifiers are used for "informational" purposes only, and do not affect reimbursement, while other "pricing" or "payment" modifiers, when used, will always affect reimbursement. Understanding which modifiers affect reimbursement and which ones do not is paramount in order to properly submit a claim when more than one modifier is needed to describe a single CPT code.

The Multi-Carrier System (MCS), used for claims processing, requires placement of pricing/payment modifiers in the first modifier position. Some pricing/payment modifiers are not limited to the first position. In such cases, if there is another pricing modifier submitted that is required to be in the first modifier field, these modifiers should be in the second, third or fourth modifier position. To learn which modifiers must be submitted in the first modifier position, please view our Pricing or Payment Modifier Fact Sheet.

When more than four modifiers apply, enter modifier 99 in the first modifier field. In the narrative field (item 19 on the claim form), list all modifiers in the correct ranking order, making sure to identify which detail line or procedure code to which the modifiers apply."

The fact sheet they reference is here: http://wpsmedicare.com/j8macpartb/resources/modifiers/pricingmodifiers.shtml

Q5.  Should a provider code a possible fracture as a final diagnosis?

A5. While the terms “rule out”, “suspected” and “probable” relating to conditions cannot be coded as established diagnoses for physician billing.

However, recording of these differential diagnoses are valuable for the inpatient-coded record, which must capture these for inpatient diagnosis billing purposes within the hospital. The HPI, ROS, PMH, and Clinical Impression documentation are important to support reimbursement for the hospital coding and billing.

If diagnoses have confirmed symptoms and a list of possible causes, the coder is to assign the symptom alone. If it is a critical factor for the patient’s health and coding of the etiology of the symptom which has not been clarified at discharge, it will be necessary to break out the physician query process for a confirmed diagnosis.

Stay tuned for Part 3 of this series to get more answers to your most pertinent E/M audit questions. Have questions? Put them in the comments below!

The questions in this post were taken from attendees of our auditing webinar, "The 5 Problem Areas in E/M Audits". You can watch the webinar on-demand by clicking the button below: