Welcome to the first edition of The Office. Each column will feature an expert's advice for managing the business and politics of running an office. Appropriately, this first installment features coding expert Emily Hill's recommendations for avoiding costly coding blunders.
Dollars are at stake when evaluation and management service category definitions are not well understood. So, taking the time to read the Evaluation & Management Services Guidelines—and specifically the section that reviews patient definitions—is wise. Different categories of service have different relative value units, even for the same level of service. Each additional relative value unit (RVU) means additional reimbursement. For Medicare, each RVU is worth $37.90; for other payers, it's usually more. The additional reimbursement could add up fast. Following are details about some problematic areas:
▸ New versus established patients. How many times a day do you see a patient who comes into the office for the first time in 4 years? It's a common scenario for most family physicians. The problem is that 4 years is a tricky duration. Many physicians might clearly remember the individual and therefore make the mistake of classifying him or her as an established patient. But in this case, the physician can rightfully code the service as a new patient visit, which is billed at a higher RVU, because more than 3 years have elapsed. Most patients won't be affected financially, because the copayment will be the same regardless of E & M category.
▸ Call it a consult. Family physicians frequently miss the opportunity to code a visit as a consultation. A typical example is the physician who is called upon to clear a patient for a surgical procedure. The default may be to code such a visit as a new or established patient service. But doing so means being paid less. A level 3 new patient and a level 3 consultation require the same extent of history and medical decision making, but the consultation pays about $130 versus $97. The caveat: Consultation coding requires meeting the CPT definition for a consultation and some additional documentation requirements, but it's well worth it.
▸ Code PM. Not choosing a preventive medicine code when it is appropriate to do so might actually have a negative financial impact on the patient. Many physicians don't bill visits as preventive medicine because either they assume that patients won't have coverage for those services or they believe that they will be paid better for a problem visit. But often, the assumption or belief is inaccurate. The patient with coverage from a health savings account might have a very high deductible; however, most plans carve out preventive medicine or screening services from being applied to the deductible. If such services are coded as something other than preventive medicine, the patient bears full responsibility as opposed to having no out-of-pocket costs.
▸ Code for time. Family physicians frequently spend a lot of time speaking with patients, and when an encounter is predominately counseling, one can select services based on time. Often, this coding option pays better. As is frequently the case, however, a physician will do little history and feel that they should code at a lower level, such as 99212, because they haven't done what they think of as a problem visit. Yet in fact, they've been with the patient for 15 minutes and that would be a 99213. If the visit has been 25 minutes or longer, that's a 99214. When counseling or coordination of care dominates more than 50% of the visit, time can be the factor for determining level of E & M service, as long as the discussion is well documented.
P Limit use of the Goldilocks code. Overuse of 99213 can be a red flag for an auditor. Busy physicians will often use this code because they think that more extensive documentation will be needed for anything higher. At the same time, they believe 99213 is safe. It's not too high and not too low, and so the assumption is that the coding will go unnoticed. The problem is that physicians lose reimbursement when they get stuck on 99213. Alternatively, others make 99214 their default, and that's a problem too, because it's a flag for overcoding. One's risk for an audit is always higher when there is not a reasonable distribution of codes within a practice. If a single code is predominant, the assumption is that the physician isn't really coding for individual encounters. Figuring out coding patterns can easily be done by gathering data off the billing system, which will also allow a comparison with the nationalMedicare norms. Gather several years of data at first to see if there are any outliers or problems.