Evaluation & Management
Approximately 70-80% of all CPT codes submitted by physician practices are Evaluation and Management (E/M) codes. With that stated, it makes sense that the primary focus of reviews performed by auditors today is the assessment of clinical documentation in support of reported E/M levels.
Additionally, payors, especially Medicare, perform E/M utilization analyses to identify providers that report E/M levels in patterns that are not consistent with their peers. Known as outliers, these providers are then targeted for review. Physicians typically think that it is better to under code an E/M visit so they will not fall under the scrutiny of a payer audit. However, payers are looking for any deviation from the national averages, under coding or over coding.
When providers under code levels of E/M services they are negatively impacting not only current revenue, but future revenue as well. HSMN has advised physicians to code levels of E/M based on the medical complexity of the patient’s condition that they are treating; making sure documentation supports the level of E/M reported. We point out to providers that by under coding their services, they are sending a message to the payors that the diseases they are treating in their patient population is of low complexity, thereby, hurting future reimbursement.
HSMN can help you assess your E/M utilization patterns to determine if, based on specialty peer comparison, you fall outside of the typical “bell-curve.” Our staff has expertise in reviewing E/M documentation under both the 95’ and 97’ guidelines and can assist you in improving E/M documentation to reflect the severity of the patient’s conditions you are treating.
Procedural coding is complex; more so in some specialties such as services related to end Stage Renal disease, then in others. For specialized providers, procedural coding can definitely be challenging due to a shortage of individuals who have expert knowledge in reporting services for specialized provider types; each reimbursement methodology being unique to the provider type. Therefore, the provider risks losing revenue or risks non-compliance due to inaccurate, incomplete coding.
After a warning from the AMA that the new diagnosis code set; ICD-10, would pose too great a burden for providers, CMS announced that the Obama administration would look into delaying a transition to ICD-10. Providers should consider this potential delay as an opportunity to develop a personalized roadmap to ICD-10 transition. Fortunately, most specialized providers will only be impacted by ICD-9-CM diagnosis code changes but going from a classification system that has 14,000 diagnosis codes to a system that has approximately 68,000 diagnosis codes will still require significant preparation.
ICD-9 Coding Specificity & Medical Necessity
Many providers types place little importance on diagnosis coding; however, carelessness in diagnosis coding can lead to denied claims. Diagnoses are relevant to reimbursement in two respects:
- In the context of ICD-9-CM coding, the “highest degree of specificity” refers to assigning the most precise ICD-9-CM code that most fully explains the narrative description of the symptom or diagnosis.
- Medical Necessity
- Defined as accepted health care services and supplies provided by health care entities, appropriate to the evaluation and treatment of a disease, illness or injury and consistent with standards of care. Payor coverage determinations determine medical necessity criteria for specified diagnostics and services.
Many provider types still struggle producing “clean claims.” The goal of course is to produce 100% clean claims. So what is a clean claim? Correct completion of a claim is crucial to filing a clean claim. A clean claim has no deficiencies that delay payment. From the payer’s perspective, facility and professional claims are considered to be “clean” if they meet the following general requirements:
- All required information and data elements has been received,
- The claim has been properly, accurately and completely coded,
- Only medically necessary services provided are provided,
- Payment liability (i.e. subscriber, patient demographics) can be established, and
- Most importantly, a claim that has not been denied.
Understanding complex billing rules, medical necessity criteria, coding rules and numerous payer regulations is the key to meeting the goal of 100% clean claims. HSMN staff has expert knowledge of payment rules, particularity Medicare and Medicaid. Our approach to performing a claims assessment starts with scheduling – determining why the patient was presenting for care. We follow the patient encounter/stay through to looking at the Remittance Advice to ensure that the payor has appropriately adjudicated the claim. HSMN has been performing specialized provider management assessments and revenue cycle assessments for over 20 years.
As part of our medical documentation, coding and billing assessments, we follow the patient encounter from appointment scheduling all the way though to account reconciliation.
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