Audits Look At More Than Correct E/M Coding

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Inside Angle blogger Rebecca Caux-Harry discusses E/M coding guidelines with Andee Andriole, 3M senior manager of outpatient consulting services. This post was originally featured on 3M Health Information Systems.

Rebecca:  Hi Andee, it was great seeing you at the AHIMA Convention and hearing about some of the past work you’ve done for 3M on physician litigation support. Here’s a question that I didn’t get a chance to ask you.

I’ve done my fair share of appeals on denied claims in the past. My process was to find definitive coding direction and write up a response as to why I thought the denial was in error.  It’s a little trickier when it comes to E/M denials based on level of service, as there are many different interpretations of the guidelines. Can you tell me a bit about your experience with these kind of denials?

Andee: Good question! When we look at preparing to defend the coding for the services the physician provided, there are two types of errors captured: coding and reimbursement.  As far as reimbursement of the coded services, CMS permits the off-set of reimbursement for both under and overcoding situations in the sample. Here’s a simple example: If ten inpatient admit E/M visit/records are reviewed and eight are accurately coded per the documentation and one visit was undercoded by one level (99221 supported 99222)  and one visit was overcoded by one level (99222 supported 99221), the review would reflect the reimbursement impact of both the overcoded and undercoded documents. So, the result was 80 percent coding accuracy with 100 percent accuracy of reimbursement.

With that said, most carriers focus on the reimbursement error rate percentage. There are times that the coding is inaccurate but the reimbursement error rate is less than 5 percent.  With a less than 5 percent error in reimbursement there typically isn’t a need to expand the sample past the probe sample or extrapolate the error rate to the population. Refunds and education are expected based on the findings.

Rebecca:  This would be the desired outcome. What percentage of your cases ended this way? And what were the steps that led up to this point?

Andee: The desired outcome is both accurate coding and reimbursement, but sometimes a lack of understanding of the billing rules prevents the accurate coding of all services provided. I can’t really give you a percentage, but I can say that we were successful in a majority of the cases we took on. Let me see if I can explain what I’m talking about with an example of a case where we assisted a physician with an audit of his billing of critical care service.

As you know, just because the patient is in the ICU or CCU the provider shouldn’t necessarily bill critical care services.  In essence, critical care codes are used when billing for critical illness or injury acutely impairing one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition. These codes indicate that the patient’s condition required urgent intervention to prevent further deterioration. For the most part, once the patient stabilizes, the subsequent hospital visit codes should be billed.  So, the critical care codes shouldn’t really be associated with a physician’s daily rounding visits.  The patient condition should drive billing. CPT coding guidelines indicate that there are certain services that are included in critical care service codes such as chest x-rays, gastric intubation, ventilator management, vascular access, etc.

In this instance, the carrier determined that the patient didn’t meet the critical care requirements and reduced the CPT from 99291 to 99233, giving the physician a 100 percent coding error rate with a reimbursement error rate at approximately a 54 percent ($100.12 of $216.23) overpayment to the provider.

In all records, the provider documented time in direct patient care. In most of the cases, the provider should have billed the subsequent inpatient E/M code and the first hour inpatient prolonged service code (several additional half hour of prolonged service codes too) with documented time spent at bedside of greater than 70  minutes.  Looking at the coding rules for prolonged service, 74 minutes of direct patient care signal that the provider should bill a subsequent inpatient E/M and the first hour of prolonged inpatient care code (99233 (35 min) and 99356 (30 min) minimal time 65 minute) which would reduce the reimbursement error rate to approximately 13 percent overpayment to the provider.

What was interesting in this case was the lack of coding for the bedside procedures that the provider performed, such as central lines, debridements and other services that are included in critical care but not subsequent daily visits. The provider was able to bill for the personally performed procedures and the E/M (and prolonged services codes), providing the criteria for a separately identifiable modifier was met. This further reduced the reimbursement error percentage.

In several records, we found that the physician’s documentation supported a CVAD insertion.  If the provider had coded just the procedure it would have led to an undercoding situation resulting in an underpayment of 25 percent. If supporting documentation of separately identifiable E/M, the underpayment would be even greater.

In looking back, the provider’s documentation was pivotal in successfully defending the audit.  If the documentation was lacking then there isn’t much you can defend…..LOL!

Rebecca:  Thanks for that explanation, Andee.  It’s very interesting to see how the reimbursement differences dictate the decisions made by the payer regarding extrapolation.  Here’s hoping these are rare events indeed!

Andee Andriole is senior manager of outpatient consulting services with 3M Health Information Systems

Rebecca Caux-Harry, CPC, is the CodeRyte product specialist for cardiology with 3M Health Information Systems.

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