E/M Coding Tips and Risks [Podcast] | Healthicity

Episode 10: E/M Coding Tips and Risks

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Avoid Common E/M Mistakes

For this episode of Compliance Conversations, I sat down with Chad Peterson, a senior consultant at a large hospital, in their professional coding and reimbursement group. He educates physicians, mid-level providers/ advanced practice providers and even ancillary staff about E/M coding.

Peterson explained some of the most common E/M coding mistakes. For example, in 2013 they came out with the status of 3 chronic conditions in addition to the already set guidelines. There’s often confusion around when to use regular HPI elements or when to use the status of 3 chronic conditions. “This is something really useful for your physicians,” Peterson added.

Tune in to this episode of Compliance Conversations, “E/M Coding Tips and Risks,” to learn:

  • How to Navigate the Gray Areas of Medical Necessity
  • When to Use the Chronic Conditions Status
  • Why the Risks of EMR Upcoding and Auto-populating Are So Grave

Interested in being a guest on the show? Email CJ directly here.

Subscribe to Our Podcast.

Episode Transcript

CJ: Welcome everybody to another episode of Compliance Conversations, I’m CJ Wolf, Healthicity’s senior compliance executive. Today we’re talking with Chad Peterson, who is a senior consultant with Intermountain Healthcare in their professional coding and reimbursement group. This is a department I actually use to work for when I first started many years ago in kind of coding and compliance when I left a medical career and got started in this, So I’m really grateful for your time, Chad.

Chad: I’m grateful to be here. Thank you for having me.

CJ: And Chad, maybe we can start with just a brief introduction and kind of how you got into, we’re going to be talking about E/M coding today, and how you got into that, and what special credentials or certifications you have in that area.

Chad: Yeah, I got interested in the E/M, or the evaluation management service stuff because it was needed in our department. There wasn’t really a certified person, or really anybody that had a good understanding, I mean we had some good concepts, and so I kind of took it upon myself and was asked by my director to make it kind of my niche. And so I went and sought out the best certification, and was certified in evaluation management coder offered by the AACP. So, I did that, got my CEMC. I have my CPC and I’ve been here with intermountain about 11 years, all the way from being a billing office manager, had a little stint with Select Health and got the insurance side of that, and then came back, I say come back, but came back to the Intermountain side and have been doing coding for the last 5 plus years.

CJ: Awesome, and part of your duties are to go out and educate physicians and other maybe mid-level providers or advance practice providers, however you term them, and teaching them about E/M right?

Chad: Yeah, yup, and even with an added focus right now of teaching other ancillary staff about it who try to help the physicians with the E/M coding. We learn that everyone needs to learn a little bit more about that.

CJ: So, like medical assistance who might be taking chief complaints even, is that what you’re talking about?

Chad: Yep. Even billing, people that are doing the billing right now we’re helping with them. Charge entry people, just to help with them to help identify it. Everyone who has something to do with it we try to talk to.

CJ: Cool. Well thanks for being here again. We have lots of things to talk about, you know, we can kind of let it go where we want it to go. But I’ll let you start. Kind of keep it in mind that we will have some of our listeners who do have expertise in coding, but we have a lot of folks that are compliance officers. They know that coding can be a compliance risk, so some of them might just need a basic understanding of where these codes came from. We talked about E/M, I already jumped into that abbreviation without saying it’s evaluation in management services, and those are kind of the bread and butter, it’s the non-procedural stuff. You go in and tell your Dr. you have a cough, and they ask you how long and what helped and what’s hurting it, and all of that kind history and physical exam and then decision making, which is non-procedural but which is work, and that gets put down in the medical record and then coded as an evaluation in management code. And there are different guidelines for Medicare. We refer to the 95 or 97 guidelines, referring to 1995 or 1997. Is that a good place for us to start a little bit, about talking about ENM, and could you explain a little bit about those?

Chad: Yes, absolutely, that is a good intro into that. We talk about these evaluation and management services, well where do they happen. When I go out and I educate I really like to give a history of where they came from. You know, we’re being asked to code within these guidelines, but where do they come from, why do we have them, what’s the intent of them. So, I really like to teach about where they came from and why we have them. Before 1992 they didn’t, we didn’t really have any guidelines. Providers, if you saw a provider, they submitted and, based on time or whatever other metrics were used, and so it was a really interesting scenario, and so the office of management budget, OMB, said listen, “We need to have a better way for you to quantify and qualify the amount of work that is going in that, or what a physician is putting into that.” So that’s where we get into, between 92 to 94, AMA, CMS, is coming up with these different guidelines. And then in 1995 they published these first guidelines. That’s where we get those 1995 DG’s, document guidelines. And they were, they are fairly specific to a point, but then it left a lot of room for interpretation, and then it also left a lot of room for some specialty providers were upset.

CJ: Yeah, I’m an ophthalmologist and I don’t listen to the heart, necessarily. I mean you can and should in some circumstances, but in general.

Chad: And so, what we do good, or what the health care community does really well is we complain about things. Right? And so that’s what kind of happened, they started complaining. They thought that it wasn’t a fair process, and they said, “Give us something different.” So then we get these 1997 guidelines. So, two years later they publish these different guidelines. And if you’ve looked at 95 and 97 the 97 are extremely specific. I mean, down to every granular detail of how you can get basically the examination was the big portion of that. So anyway, the reason we talk about that is there are so many people that say I audit based on a 95 guideline or a 97, but they are meshing these, they are these hybrid systems. So, when I go in and I teach about the differences in them it really helps their level of coding because now they understand, “Oh, I was combining, or I was doing this.”

CJ: Yes, so when somebody is choosing a code, you pick one set or the other, and you’re allowed to do that, but you have to live in the space that you pick.

Chad: Right. Medicare was very specific, it said whatever is most advantageous for the provider you can use. If it’s specialty provider, so whatever yields the greatest, you can use that, as long as you work within the confines of each rule.

CJ: For that given encounter. So, at my 8am appointment I could use the 95 guidelines and at my 10am appointment I could use the 97.

Chad: Correct, yep. But we have these combining, the confusing comes with the combining of all the rules. And so, we run into a lot of that confusion. And to add to that confusion, you know, we have the different carriers, all of our MACs. Who all, if you look at their guidelines they are all different. Some say you can combine. Some say you can’t combine. So, it even adds to the conversation.

CJ: So, what do you do, if you’re mac is saying you can combine, do you go with that? Because if I’m a doc and I learn the rules, I’m going to pull that card out and say, “Hey, our own mac says we can combine!”

Chad: Right. Well, what we’ve tried to do as a healthcare is, we’re pretty conservative. But the doc, if you go back and you really look at the documentation guidelines and you understand its origin and its intent, it’s pretty self-explanatory. Not self-explanatory but it walks you in the direction you should probably be coding. Do you know what I mean? Even though we have these other interpretations, because they are not statutes they are guidelines that say you should. And so, we audit based on the guidelines as true to the intent as possible. Yes, we have discussions, yes, we have to make calls at times at what we believe the interpretation, but that’s what’s awesome about our department, too, is we have some really highly educated people and we can balance those. But to answer your question about the MACs, we do take that into consideration of what are they saying, because obviously, they are going to be auditing us.

CJ: Exactly.

Chad: So, we do take that into consideration.

CJ: Kay, well good. Let’s break down the E/M encounters a little bit. Can you talk to us a little bit about the different components that are in there and what a compliance officer or an auditory should look for as common mistakes in those areas?

Chad: The common mistakes that I teach on right now, we’ll take it piece by piece within the history, is, there was this. In 2013 they came out with the status of 3 chronic conditions, so that was in addition to the already set guidelines for that. And so that’s been kind of an interesting thing. Well when do I get just regular HPI elements or can I use the status of 3 chronic conditions. So, we’ve been teaching that quite a bit of, hey this is something to help your physician.

CJ: Right.

Chad: Instead of, especially for these ongoing chronic conditions.

CJ: Yeah, so if I’m an internist and I’m seeing elderly patient after elderly patient, and they all have hypertension, diabetes and high cholesterol and I’m monitoring like their labs for that, I don’t need to retake the history that this started in 1972. It’s obviously clearly established in their medical record. So that’s what you mean by the 3 chronic conditions.

Chad: Exactly, because to get an interval history from the last visit to this visit of new elements is extremely difficult, but to give the status of these chronic conditions from the last time to this time is more advantageous for the provider.

CJ: Gotcha

Chad: I like the addition, but it’s interesting to teach that some have not even heard of the new provision or whatever. So, I teach on that quite a bit, and physicians like that.

CJ: Yeah, exactly. And like an internist, like most Dr.s who are in primary care probably get that, and that’s probably more advantageous for Dr.s in primary care as opposed to a trauma surgeon. You’re not going to be looking at chronic conditions typically.

Chad: Has its place, I mean, acute new illnesses or injuries are really easy to get HPI elements, whereas the chronic conditions it’s better for the status. So I teach that to help coders, physicians understand that. It’s easier, or not easier but there are better rules for the conditions.

CJ: Can you use 3 chronic conditions in both the 95 and 97 guidelines, or is it just one of them?

Chad: Yep, it’s opened up for both of them.

CJ: And you said that was in 2013?

Chad: It was 2013.

CJ: And was that a CMS clarification or something?

Chad: I don’t know if it was a clarification, but just an addendum or an addition, too, hey you can do this or you can get these, probably from the healthcare community showing concern or interest, like we do.

CJ: Because I remember back in the day the 3 chronic conditions was something we utilized in certain cases. I just couldn’t remember, it’s been a while since I was in the weeds on E/M, so that’s kind of why I was asking that. So, let me ask you if we can skip the physical exam for a second and kind of jump down to medical decision making. I was at a conference last week and Dr. Julie Tatesman, who is the chief medical officer for the OIG, are you familiar with her or have you heard her name?

Chad: OIG, no, I mean yes OIG but not her specifically.

CJ: So she’s their chief medical officer. She’s both an attorney and a physician, and she was speaking and we were talking specifically about medical decision making, and somebody in the audience asked, “Okay, you know you get these electronic medical records, and you get these tools, even if it’s not an EMR, where doctors are getting more and more trained, so to speak, to make sure they are hitting all of the items on the list, but that doesn’t necessarily mean it’s medically necessary to do all of that.” So, in other words, somebody could come in for a cough and I could do a full exam. I could do a rectal exam. I could do all sorts of things, but is it medically necessary for a cough? Now there may be some cases where it actually is medical necessary, but how do you teach the difference between medical decision making, which is a component of E/M, and has kind of points and those sorts of things, versus if it’s actually medically necessary. Which they sound similar, but they are completely different.

Chad: They are, and this is, ultimately, giving the history of where we’ve been, where we’re at, and then where we’re going, this is that. What is the difference between medical decision making and medical necessity? And really the intent of these documentation guidelines was to help capture the amount of work that goes into it. Not necessarily focused on medical necessity, and the reason I say that is that it’s just capturing work, not necessarily the specific work that the provider needs to do for a specific problem. This is just measuring how much work can the provider do. And so, what I like to teach when I do that is if you look at medical necessity as what’s clinically required, the action required to diagnose something compared to the amount of work that he can do…

CJ: Right.

Chad: It’s different. And what we’re seeing right now is all audits, not all audits, but the audits that we’re seeing come back from the government are all being driven on medical necessity, instead of what components can the provider gather. And so one thing that I like to teach is a parallel or a story or something, is let’s say you take your car in to get the oil changed, and really all you want is the oil changed, but the mechanic takes it upon himself to change the wipers without asking you, or to change the transmission fluid.

CJ: And the air filter needs to be changed…

Chad: I mean, he can do that, right? And he can make a strong argument of why you need that, but really the intent of what you came in for, or the complaint that you came in for was just the oil change, and that’s that concept that providers may or may not are doing more work than what is necessary for the chief complaint or problem the provider, or the patient is complaining of. And so, it’s hard, and it’s a subjective matter.

CJ: And there is not always a hard and fast rule, because some people say a headache should never be a level 5. Well, I can give you two scenarios of a headache. “Well, Dr. I have a headache.” “Okay, when does it start?” “Well, it always starts Monday morning when I start my drive to work. I never get them on the weekends, and I never get them when I’m on vacation, and they seem to go away after 5 o’clock when I get home.” So this type of headache is typically like a stress a headache or kind of versus. “Dr., I have a headache.” “Okay when did it start?” “It started this morning.” “Can you describe it, is it all over or is it on one, can you point to it?” “Yeah, it’s right here on my right temple.” “Okay, have you had any vision changes?” “Well yeah, actually my vision has started to change a little bit.” “ Okay do you have any other conditions?” So they do a review of systems. “Oh yeah, I have arthritis…” and those sorts of things, and those pieces, if you’re not clinic, all of those things that I just said are text book symptoms of temporal arteritis, which is an inflammation of the temporal artery. They cause unilateral headache and that patient can go blind if you don’t put them on steroids right away. So, when you get into medical decision making, you have criteria such as as an acute illness that could lead to threat of life or limb or bodily injury or those sorts of things, and I share that because the chief complaint of a headache could follow two completely different paths, and one might be completely appropriate to be a level 5, and the other might be a 2 or 3 or that sort of thing. Any thoughts on that or other examples that you’ve heard?

Chad: Yeah, that’s a great way to put that. What I teach the physicians is “Paint the picture,” I mean you have to, if the patient is sick and you’re concerned and you’re doing things that look out of the norm,…

CJ: But there is a valid medical reason…

Chad: Correct, and have that be supported by, tie your history to the examination, have your medical decision making, make sure you have a logical flowing process of why you’re doing what you’re doing. And then at the very end paint that picture of what your impression was, which will be supported, if you did it right, by the other components of your history. All too often we see all of a sudden in the medical decision making or in their assessment of plan they are diagnosing with something that they never addressed in the history they didn’t address in the… or they don’t support that in the examination.

CJ: Exactly.

Chad: So, with the scrutiny of auditing and everything right now, all the requests, or what they request is the documentation, you don’t get to sit face to face with them initially, so what’s in your documentation that’s going to support the medical necessity of that, and it’s the physicians responsibility to paint that picture or show that concern.

CJ: Yeah, so in my scenario, if I were the Dr. and I were dictating in my assessment and plan I would say, “Given the patients arthritis history, given the nuanced set and the unilateral nature of the headache, I have concerns about temporal arteritis. Patient needs a biopsy of the temporal artery. I’m going to send them to a surgeon. I’m starting high dose steroids today, because the patient could lose their sight. I mean you kind of need to paint that picture a little bit. It’s always a balancing act. Though. I get some docs who say, “Well why should I have to explain 4 years of medical school in a one pager for an auditor who is not going to understand it?” And I get that argument a little bit, like I think there is a burden also on auditors to not assume that it wasn’t medically necessary until you’ve asked some questions. So, I think it goes both ways. I think the Dr.’s need to pain the picture, but I also think the auditors and coders need to elevate their game, so to speak, and learn some of those clinical things, or remain silent. Don’t challenge the Dr. that it wasn’t medically necessary unless you’ve done all your homework.

Chad: I completely agree. One thing we’re trying to elevate our “game” here with Intermountain. Our directors been so great about allotting time every day, every week, every month to continued education clinically, not just coding specifics. We have MDs coming in, other APCs, other educators coming into teach us. We’re going to conferences, we’re trying to do all of that, and a lot of us have some clinical backgrounds. Like I worked on the ambulance, did the paramedic thing for several years, which helps add to the validity or credibility with some of the providers. But you hit another interesting point of you need to know some clinical. Or help elevate your game, not to the level of a physician, but if your questioning it, have a relationship with your providers where you can have that two-way communication, and that’s been huge with, “Walk me though this, this is the same explanation you’re going to need to give if you’re audited, to justify why you did what you did, and if you can’t, let’s work on changing that.”

CJ: Well, and that brings up a great point. I gave a presentation last week at HEALTHCON, and it was on kind of going deeper than the headline. It was a specific Dr. in Florida who’s a dermatologist, and he was doing some superficial radiation of skin cancers in the office. And this was a lawsuit that was brought, it was a whistle blower lawsuit, and what the government did is just what you said. They went and they found an expert in radiation oncology to combat the physician’s way of treating. So, when I get a doctor that’s asking me, “What’s Medicare going to consider medically necessary?” And I say, “Well, generally speaking, and none of us know the temperament of a prosecutor, but generally speaking, you’re going to be on trial in front of peers. So they are going to go find two or three board certified radiation oncologists, in this example, and they are going to say, ‘Was what this Dr. did medically necessary?’” And so, though the coder doesn’t always know that, and even when somebody as myself who’s got medically training, I’m still not an expert in radiation oncology, but I’m smart enough to know if I’m going to challenge a doctor. on medical necessity, I’m going to go find that resource that can tell me whether it actually was medically necessary or not. I don’t know if your coders or your auditors get into actually commenting on medical necessity or if you stick mainly the medical decision making components.

Chad: We have different tiers of consultants here. Some of us are, I don’t want to say allowed, but are encouraged to have those higher-level conversations with some of the physicians about medical necessity. But we also do kind of blind peer reviews, too, with our auditing process. If we don’t agree, we take it to internal kind of coding.

CJ: Smart, kind of like a little panel.

Chad: It is a panel. We talk about it as a panel, and if it needs to get escalated to get some clinical expertise, we have Dr.’s that do that, and we learn so much from them. It’s just so beneficial for everybody. So, there is due process, for sure, because we don’t want to call them liars, but we do need to say hey there are some guidelines out there that if you don’t follow you can be in trouble.

CJ: And I think that’s why we need professionals like yourself and I think that’s why this profession exists, it’s to walk that line, not actually walk the line, but bring people together to kind of be the interpreter between here are the regulations and here is what you’re faced with, Dr., and then learning from that Dr. but also teaching that Dr. certain things. I think that only through that collaborative way can you really get good compliant behavior over time, because, like you said, a lot of these lawsuits and settlements that we’re seeing they stem from medical necessity. I mean upcoding is another one, where the documentation just flat out doesn’t support what you bill. Do you bill a level 5 but you didn’t do… I mean that is kind of a little bit easier, right? I mean the formula or guidelines; the checkboxes are not checked.

Chad: Yeah, that’s the easier part.

CJ: Let me ask you in the last few minutes here, kind of what impact electronic medical records, and kind of auto-populating has had, in your view. It reminds me of a story years ago when I took my son to an emergency room, because he had fallen and we thought he had broken his arm. He was young. he was like 2. So I was in the exam room the entire time with my son. The Dr. did his exam, did his review of systems, didn’t ask very many questions. Then I got the bill, and because I was in the coding field, I requested the medical records, and his review of systems was complete. And I was in the room the whole time, so I know for a fact he didn’t ask all those questions, but he had some sort of auto-populator that did that so that he could get a higher level. I challenged it, mainly on principal, and eventually got him to see the light. But what are your thoughts on these auto population tools, and what warnings could you give people?

Chad: It’s a fun, hot topic right now, because with all of the great electronics that we have currently, a lot of the physicians complain that, “I got into healthcare because I want to treat a patient not to be a documentation specialist,” and so when it’s appropriately used to use hot text and macro’s and everything, absolutely let’s speed up their work, let’s use that. However, it’s being audited, and it’s a risk area because sometimes they can hurry and put it in and they really didn’t do it. And so, we teach about that for copy and paste issues. And so it’s just having that conversation with the physician of, did you really do it, and if you’re putting it in your documentation, be careful because you can get in trouble. And we audit on that too. Hey this is the same for every physician. And so, it is a hot topic of use them when they are appropriate, but make sure.

CJ: And you’re the final, talking to the Dr., you’re the final quality check of when that note gets signed that you don’t want to be saying that this patient is pregnant and it’s a male patient. Because I’ve seen that in copy and paste like scenarios, or the patient’s chief complaint is headache, and then in the review of systems it says no headache. And so it’s like “which is it?” And you’re getting that carry forward, or that copy and paste and that sort of thing. If you’re going to use technology, which I agree, I think you should use it to help get the work, that part of it, done, but you have to be a quality checker too, because people are going to rely on that medical record to get that patient care in the future.

Chad: Yeah, it’s added more work sometimes than what it is to save. We look at it, we try to make sure they are using it appropriately. We’re trying to speed up their time by still having it be medically necessary. It’s a hard game to play.

CJ: Yeah, it’s a balancing act, and that’s why I think professions like you are out there, because it’s not black and white answers, and you need somebody that is intelligent that knows the rules that can also talk to the Dr. I think that is the main message. Well Chad, thank you so much for your time. Appreciate your expertise, and thank you to all our listeners for listening to another episode of Compliance Conversations. Until next time.