Around here, we get a lot of questions from you, our audience, on the topics of medical billing, coding and auditing. It’s a complicated field, with a lot of ambiguity around best practices and what state and federal regulations require of us. And we love nothing more than to provide answers to those questions, when we have the spare time.
So recently, we asked you to send us the questions that most perplex you while on the job. And we got a ton of great questions (thank you), some of which even had us scratching our heads, too. So, I compiled all of your questions and took a bunch of them to our resident coding and auditing experts, Stephani Scott and Lori Cox, and sat down for a little chat. Best news of all, we recorded the Q and A and are now releasing it as our latest episode of Compliance Conversations, titled “Ask an Auditor Anything.”
Here’s a sneak peak at some of the questions we discussed, and answered:
Is documentation of a previous allergic reaction to a drug able to be used under ROS for allergies or is it only utilized in PMH?
If the physician states "same/unchanged from last visit" to History and ROS items, what credit should be given, will he receive credit for reviewing the last visit information? Or, should the statement not be considered since indication of specific date is not present?
When an MC patient comes in for an acute problem, let's say an earache, and the provider doesn't mention it in the ROS, but has findings in the exam, but besides using OM as a dx he also adds chronic dx's in his assessment, stating they are either stable or uncontrolled, making the visit a higher level than if the only dx was the OM. So, my question is, if the provider states stable, or uncontrolled in the assessment are we to use those dx? wouldn't adding chronic conditions to an acute visit be overarching? We are discussing the medical necessity/medical decision making of the 2 out of 3 components that MDM is 1 of the 2 for Medicare to determine a LOS. I know there is a difference and I know that medical necessity is the overarching criteria, but isn't the 3 areas for the MDM make up the medical decision making? AMA states any 2 out of 3 so actually we could bill higher just based on those two (Example: C,C, and L for MDM) so we could give the provider a 99215 instead of a 99213 but I thought Medicare audits that the MDM is one of the components and would like to find something in writing as to the way they audit.
An organizational decision was made to use medical decision making as 1 of the 3 key components when leveling visits. This is not a requirement of our Medicare contractor, WPS. There are times when, based on the presenting problem, I am completely comfortable leveling the visit based on the History and Examination details.
If the documentation states: "NO PFSH" is this applicable on a new PT or Consult Visit?
If you’re interested in hearing what our experts had to say, or to see if your question was one of the lucky ones, head over here and listen now >>
CJ: HI everybody, welcome to another episode of Compliance Conversations. Today’s episode is a really exciting one. It’s where you get to ask questions you’ve already submitted. We have wonderful guests today. Stephanie Scott is here, and Lori Cox. I’d like them both to take a moment and introduce themselves. Tell us a little bit about what you do and why you love it.
Stephanie: Thanks CJ. This is Stephani Scott. I’m the VP over AAPC Audit Services. I have been with AAPC Healthicity now coming up on 8 years.
CJ: Yeah, wow.
Stephani: This January it will be 8 years. I absolutely love what I do. I love working for these two organizations. I love working with the clients and helping them with their audit programs and assisting them in getting that work done. It’s a lot of fun. We work with so many different types of organizations and people it makes it very well worthwhile.
CJ: Yeah, it’s neat when you can get exposure to lots of different types of organizations and people have different needs and those sorts of things. Thank you, Stephani, for joining. And Lori, welcome.
Lori: Hi, thank you, welcome, thank you for having me. I’m excited to be here, my first podcast ever, so I’m super excited. I’m Lori Cox; I’m one of the regional directors here at AAPC Services. Been here about 2 years now. I do a lot of the training and education for our clients as well as I’m doing physician and coder training education. Also I’m the member relations officer for AAPC’s national advisor board. I get to speak at conferences, I get to go out and travel and meet our AAPC members. I love being part of, just like Steph said, part of both of these organizations, it’s really great.
CJ: Great. Thank you for joining us. I don’t know if I introduced myself, but you’ve probably recognized my voice if you’ve been listening to the podcast. I’m CJ Wolf, I’m Healthicity’s Sr. Compliance Executive. Today’s topic, I think, is a really special one. We often, and Stephanie and Lori, you are often getting questions, and sometimes it’s hard to respond to all those questions. We thought, "Let’s set aside some dedicated time and answer your questions." What we’ve done is we’ve selected some questions that people have submitted about coding and billing and those sorts of topics, and that’s how we’re going to proceed today. We’re going to get expert answers and advice from Stephani and Lori. The first question comes from Kathie. She asks “Is documentation of a previous allergic reaction to a drug allowed to be used under the review of systems for allergies, or is it only utilized in PMA, past medical history?" I think, Lori ,we’ll let you try to take a stab of that first. What do you think about that?
Lori: Yep, so I have a couple thoughts on this. Let’s remember that the review of systems is supposed to be the provider asking the patient questions about their signs and symptoms as related to their chief complaint. It’s really going to fall back to, "What is the patient here for today? Are they here for a possible allergic reaction to a drug?" For example, maybe they were prescribed a new medication and they are having some wheezing or some coughing, so the provider is going to ask them if they have had any reactions to drugs in the past. In that context I would count it as review systems if it directly relates to the patient's chief complaint, but, if the patient is there for something, let’s say along the lines of diabetes or neoplasm or something, and it’s really documented really towards the past history, then that’s how I would count it. The patient has had an allergic reaction to penicillin in the past, then I’m going to count that as history, not so much as review of systems.
CJ: Gotcha, so the context is important there. Stephanie do you have anything to add there?
Stephani: I totally agree with Lori’s response.
CJ: Cool, great. Thank you for that information. Our second question comes from Adriana, she asks “If the physician states, 'Same or unchanged from last visit',” so that kind of phrase we see a lot. "So, physician states for history or review of system items, what credit should be given? Will the physician receive credit for reviewing the last visit information, or should the statement not be considered since there are no indications of specific dates?"
Stephani: This is a great question, because there are two opposite answers.
Stephani: It really depends on the date of service. When that date of service occurred, because if we look back at the CMS documentation guidelines it would require that the physician, if the physician is going to reference in past family social history review of systems, the documentation needed to include when that past history and that review of systems was taken, and if there were any changes or not.
Stephani: Okay, however, since the CMS update for 2019 changed, so if we remember that CMS wanted to lift that documentation burden off the physicians, this was one area that they made that requirement. It’s no longer required for the physician to document at that level of detail of when and what history and review of systems they are referencing. All they need to simply say at this point of time is that they did review that information.
Stephani: I actually pulled the E/M guidelines from CMS and let me read that for just a minute. It says, "If the information is already documented, the billing practitioner can review the information, update or supplement it as necessary, and indicate in the medical record that he or she did so."
Stephani: So, it doesn’t say much. It doesn’t say they have to say they "updated" or that there were any changes. Just simply that they did review that information.
CJ: Yeah. Very interesting, Lori any thing that you want to add on that one?
Lori: No, that was a perfect answer.
CJ: Great. This next one comes from Melissa. It’s a little bit of a scenario, so I’m going to describe a scenario first then get to the specific question. Bear with me for a little bit. Try to imagine the scenario. "A patient comes in for an acute problem, let’s say it’s an earache. The provider doesn’t mention it in the review of systems but has findings in the exam. Besides using otitus media as a diagnosis, the physician also adds chronic diagnoses in the assessment, stating that they are either stable or uncontrolled, making the visit a higher level than if only the diagnosis of otitus media was there." That’s the scenario, the specific question is, "If the provider states 'stable' or 'uncontrolled' in the assessment, should the coder or biller use those diagnoses? Wouldn’t adding chronic conditions to an acute visit be overarching or overreaching?" What are your thoughts on that? Lori, let’s start with you.
Lori: This is a good question; we get this asked of us quite a bit. First of all, we as coders, auditors, billers, we want our providers to document the very best of the very best, and sometimes we forget that is not really why they are there. They are there to treat the patient. We cannot make a determination, we are not a clinician, we’re not in the office with them, so we can not say that a provider did or did not address the chronic condition. If they are listed in the assessment and plan, we need to take that as consideration that yes, the provider did address those chronic conditions. He likely had a reason to do so. What if he’s prescribing the patient medication for their otitus media but it might react to something else they are taking, or it might change their diabetes? For example, perhaps this is a steroid, it’s going to change their blood sugar or something along those lines.
Lori: We need to remember that it is not up to us to determine medical necessity. Now, certainly we do not want our providers to beef up their documentation just to get a higher level of service, right? CJ that’s more of a compliance issue.
Lori: We have to say," Was this addressed in the assessment plan?" Then our understanding needs to be that the provider addressed it for whatever reason and we’re going to allow it.
CJ: Yeah, I think that’s a really good point. A lot of providers, their thinking of multiple things. So when a patient comes in for otitus media, that’s not looked at in a vacuum. You have to consider does this patient have other conditions, your treatment, your review of systems, all that. Well that might me related to a different chronic condition; I think that’s good advice. Stephani what do you think?
Stephani: Here’s another thought. What if this provider is participating in a risk adjustment program, documenting for MIPS and MACRA, and what if this patient had not come in in their regular visit cycle for these chronic problems and wanted to do a thorough job since the patient did present?
CJ: Yeah, exactly.
Stephani: You’re going to see those extra, by the way elements. That physician is wanting to make sure that he or she is providing the quality care and addressing those chronic problems.
CJ: That’s a great point. Think of yourself as the patient for a moment. When you go in, you go, I’m here for an earache, but by the way Dr., what about my refill for this or that?" You take advantage of your time there, so that needs to be considered. Good comments.
Stephanie: For sure.
CJ: This next kind of question and discussion comes from Carol, and it seems like their practice or their department they are discussing medical necessity, medical decision making, and this concept of two-out-of-three components, and that medical decision making is one of those two for Medicare to determine the level of service. This is probably in the context of an established patient visit, where you only need two of three key components, and they're thinking and discussing, "Do we require-should we require--medical decision making be one of those two? If for example, it’s a Medicare patient." Carol says she knows there is a difference, and she knows that medical necessity is the overarching criteria, but aren’t the three areas for medical decision making, make up the medical decision making? In other words, AMA or CPT states two out of three, so actually you could bill higher strictly if you’re going from CPT, based on those two, if you had a comprehensive history and comprehensive exam. But maybe the medical decision making is low. They are thinking about this, and could you bill that 99215 instead of a 99213, and she’s asking, but she thought that Medicare audits, that the Medicare decision making is one of those components. They would like to know if there is anything in writing that that’s the way they should audit. So, Steph, we’re going to start with you.
Stephani: Yes, there actually is. There are two different places that you can look. You can pull up the official 1995 / 1997 E/M guidelines, that 56 page document. And if you look at the first couple of pages, it actually has a statement here that the volume of the documentation should not be used to determine the specific level.
Stephani: It goes on and talks about the medical necessity of it. You can also look at the Medicare manual, if you look at the internet/online version. They actually have a couple of really good statements there, which they reiterate that the volume of the documentation shouldn’t be the primary influence upon the specific level of the E/M service.
Stephani: They go onto say that medical necessity cannot be qualified by using a coding point system. That there are lots of different factors that can come into play when a physician is trying to look at that medical necessity. Like the clinical judgement.
Stephani: So that clinical thought process that the doctor has to go through, like we talked about in the previous question. Standards of care. Depending on how, what, the patient presented for one of those medical standards of care, and that may include capturing a full history and a full examination. Why does the patient need to be seen, the stability and acuity of the patient, the patient’s co-morbidities, those other chronic conditions that the patient has, and then what the management is? All of those things are going to factor into why, perhaps, the providers documenting a comprehensive service.
CJ: Yeah, it makes me think because I’ve had people ask me before, "The chief complaint was just a headache, headaches can never be a level five." And I don’t agree. There may be scenarios where headaches, it may be true that most headaches don’t turn out to be that, but there are scenarios, and the scenario I often give people is, let’s say it’s an elderly women with a unilateral headache, but she also has a past medical history of polymyalgia rheumatica, which is a condition of the joints, but headache when it’s associated with someone that has that underlying condition, can also be temporal arteritis, and people can go blind from that. That automatically brings your risk levels, and your medical decision making, as far as a medical necessity, this could be a very urgent situation. The person could have just come in and said I have headache, there are examples where you just can’t say, always the chief complaint is going to . . .
Stephani: Absolutely. I was a coder in a hospital emergency room for years. Oftentimes patients would come in complaining for a headache, and some of the key words we would be, “The worst headache they have ever had”, because then all of a sudden, you, correct me if I’m wrong, CJ, the physician is thinking stroke or something like that.
CJ: Yeah, some sort of hemorrhage, aneurism even, and they have to rule those things out, because if you don’t . . . Sometimes I’ve coders say but 99% of the time that is not the case, but they are not working on that. They ware working on that one case where it is the case.
Stephani: The nature of the presenting problem.
CJ: Yeah, exactly. Lori do you have any thoughts on that question, or this discussion.
Lori: Just to add onto that, remember that in 2021 the guidelines are changing, and really the doctors are going to take their level of service based on the medical decision making. The history and exams are not going to apply as much as they do now. If your company is saying that the MDM has to be the 2 of the 3, that’s likely because they are going along the lines of eventually we’re not going to have the 2 of the 3 or the 3 of the 3, it’s going to be medical decision making based. This is a good time to start educating your providers, that hey, MDM is very important.
CJ: That’s a great point, thinking into the future and those regs, and how those are changing. Thanks for adding that. The next question is kind of a continuation of this discussion. It comes from Kathy. She states that they made an organizational decision to use medical decision making as one of those key components when leveling visits. In their scenario this is not a requirement of our Medicare contract for WPS, there are times when, based on the presenting problem, I’m completely comfortable leveling the visit based on the history and exam details. Your input is appreciated on this topic. I think we’ve probably covered some of that already, but any other thoughts on that particular scenario Lori?
Lori: We do see this; in fact, I was working with a client today that an issue like this came up. The context of pregnancy, in their context their Medicaid requires the to bill all their pregnancy separately instead of a global maternity care. So they are billing their maternity visits based on their level of service, so think about pregnancy for example, they might have a expanded problem focused history and exam, but if it’s a normal pregnancy, really, then you end up with one established, stable, condition. It comes to straight forward, if they are requiring the MDM to do 2 of the 3, then they end up with a 99212 and I don’t feel like any of us think that pregnancy is a straightforward, shouldn’t have even come to see the doctor type of thing, right? It’s usually a 3 or so, you need to take into consideration the whole picture, not just the 2 of the 3, but looking at the whole note as a whole, and then what we do, and what they might be able to institute is something along the lines of a comment. If they are auditing and they are saying that yes, the MDM is straight forward but the nature of the presenting problem supports a level 3, then perhaps they could make some kind of a comment like that on their audit report, then I would imagine what would happen is that their providers would come back to the organization and say why are you down coding all of my levels, this is not a level 2.
Lori: We’ve seen that before, and that’s one of the downsides of using MDM as your level. That’s, again, this is good education going forward, as we go into the future with the MDM becoming the main quality.
CJ: Yeah, good. Excellent. So, we have another question here, this one comes from Christine, it’s a little bit on the history. “If the documentation states ‘No PFSH,’” so no past family social history, “is that statement, is that applicable on a new patient, or consult visit?” Lori, let’s start with you.
Lori: It kind of goes back to what we were talking about earlier. It’s not up to us to determine if it’s medically necessary. I’m not sure by what she means by the term applicable, is she meaning that it’s medically necessary for the doctor to document, or is she meaning in order to count it like a key component?
CJ: Yeah. Let’s take it that way, can you count it if they state that.
Lori: Some Medicare carriers say no, because they need to get it. They need to tell us why they at least tried to get it. For instance, in family history, a lot of carriers will say if you document family history noncontributory, that doesn’t count, because what is it, why is it noncontributory?
Lori: But if they are just saying they are not getting it, we need to know why, and if I don’t at least have an indication as to why, if the H-kind doesn’t say something along the lines of “the patient has severe dementia” or “the patient is adopted,” for example, I would allow that. But I would not allow, I would not count it, if I didn’t have a very good reason as to why they didn’t get it.
CJ: Gotcha. Stephanie, what are your thoughts on that?
Stephani: I worked for a major EMR vendor for a very long time. Looking at a lot of these notes that are coming from different EMR systems, when I see that, to me it looks like it’s a default in the system.
Stephani: That no, that past family social history just was not obtained, and it’s a template, their output statements, their medical record note, it’s a computer output document, is just saying that wasn’t done. So, when I look at those statements, that’s what I see, and piggy backing off of what Lori said, you’ve got to look at why was that work not done.
CJ: Gotcha. Really good insights. We’re getting towards the end of our time here, I want to give each of you just a moment, if you have any last minute’s thoughts or comments. As you’re thinking of, if you have anything to say, this is an ASA, this kind of episode, I think is something we’re going to continue in the future, make it a regular type of episode, have it recur, because these questions will continue to come in, and we know that because you get them all the time, right?
CJ: It’s good to kind of set aside some time and actually kind of formally think, "Here’s the question, here’s how we’d answer that." For those of you who are listening, keep your eyes open for other invitations, emails, that will come to solicit your questions, and please submit them and we can choose questions and have them on the episode. Stephanie, any last-minute thoughts or questions?
Stephanie: Nope, just wanted to thank you for inviting Lori and myself to come, this was a lot of fun, looking forward to those other questions that are going to come in.
CJ: Lori any last-minute thoughts or comments?
Lori: Nope, not at all, just like what Stephanie said. We really do want to help our members out there get the best of the best, so that’s what we’re here for.
CJ: Well great! Thank you all for listening to another episode of Compliance Conversations, until next time.