Shellie Sulzberger, LPN, CPC, ICDCT-CM Coding & Compliance Initiatives, Inc.

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 Reasonable efforts have been made to provide the most accurate and current information on CPT 2015 code changes. However codes,

guidelines, and policies are subject to change and interpretation. No guarantee is given that this presentation is free of errors, omissions, misuse, or misinterpretation and this

presentation should not be considered a legal or authoritative opinion.

 This presentation does not replace coding manuals or other authoritative resources.


 The audience will have a better

understanding on the importance of

submitting the correct CPT, HCPCS and ICD-9 codes for billing

 The audience will have a better

understanding of how ancillary staff can assist the providers with documentation (i.e. what can the staff perform and


 We will outline some areas of

documentation mishaps in an EMR and discuss the importance of specific


 Proper procedure (CPT/HCPCS) and

diagnosis (ICD) coding is not only critical


 Eliminating healthcare fraud and abuse has

become a top priority for the federal government.

 "Fraud," "abuse," “unbundling,”

“over-coding," “incorrect “over-coding," and


 Investigations are on the rise for

providers in Healthcare.

◦ OIG – Office of Inspector General

◦ DOJ – Department of Justice

◦ CERT – Comprehensive Error Rate Testing

◦ RAC – Recovery Audit Contractors


 Coding is how we communicate and report

data within this federal entitlement system.

 Coding describes/documents the work and


 Determine reason for encounter

◦ Routine exam

 Wellness coverage through employer?

 Medicare patient needing to sign waiver for a complete physical or is this for a covered

wellness visit?

◦ Medical illness


 Determine lab services

 Office should charge

 Resource lab should charge

 Assure encounter form is complete

 All charges captured

 Ancillary services marked

 Diagnosis indicated for services

 Record accident information

 If encounter form does not have this-record it for charge entry


 Complete referral forms (when applicable)  Obtain pre-certification/prior authorization  Obtain Medicare waivers (ABN) for services

that Medicare may not pay for


 Know billing regulations

◦ How to assign a level of service based upon the documentation and service rendered

 Know when you can and cannot charge OV

with procedures

 Know the documentation requirements for


 Proper and needed for diagnosis and treatment

of patient’s medical condition

 Provided for diagnosis, direct care, and

treatment of patient’s medical condition

 Meet standards of good medical practice  Not mainly for convenience of patient or


 Every service billed must indicate specific sign,

symptom, or patient complain necessitating the service


 Ability to evaluate and plan treatment and monitor health over time

 Communication and continuity of care  Accurate and timely claims review and


 Utilization review and quality of care evaluations


1. Medical record should be complete and legible 2. Each encounter should include

 Reason for encounter, relevant history,

physical examination findings, and prior test results

 Assessment, clinical impression, or


 Plan for care


3. Rationale for ordering diagnostic tests

4. Diagnoses accessible to treating/consulting physicians

5. Identify health risk factors

6. Document patient's progress, response to and changes in treatment, and revision of diagnosis


 Must be educated on documentation and coding guidelines

 Must understand what is required for the levels of E/M coding

 Must know the individuals providing the education are on their side

 Must show them what they have done well or need to work on with their own


 Assign ICD-9 diagnosis codes and may link

diagnosis to procedures

 Assure diagnoses and procedures correlate

◦ Wellness exams with “V” codes

◦ E/M services with numeric ICD-9 codes

◦ “E” codes for accidents

◦ Understands modifier usage

◦ Review the instruction notes in the ICD-9 book

 Query physician when medical necessity has


 Must always be at least one (can be more)

ICD-9 diagnosis

 The codes must apply to that particular


 The diagnosis code(s) should be linked


 ICD-9 codes describe the patient’s

condition, not what was performed

 ICD-9 codes generally do not affect


 Computerized physician order entry (CPOE)

◦ Legible

◦ Safeguards

◦ Improved compliance

◦ Timely testing

◦ Better patient care

 Improved tracking of ancillary and

diagnostic tests combined

◦ Reduce duplicative services


 Improved documentation of the service actually provided when the EMR is used correctly

 Time and date stamping  Legible notes

 Improved storage capabilities

◦ Paper charts were limited – sometimes patient’s had 2 and 3 volume charts


 Better communication  Clinical summary

 Improved efficiency

 Allows you to track outcomes for quality care initiatives

◦ Improved outcomes ◦ Financial incentives


 There can be cloning notes from previous


◦ The word 'cloning' refers to documentation that is worded exactly like previous entries.

◦ Medical necessity issues


 Learning curve for the providers =

decreased productivity

 Inadequate training can lead to increased


 Identical documentation


 Inadequate training or lack of interest and

attention can have negative impact on the provider and/or facility

◦ Mistakes

◦ Credibility

◦ Billing


 Loss of human touch and individuality ◦

 Difficult to determine what the provider is


 Documentation is not always patient and

chief complaint specific

 Inconsistencies in the documentation

 Difficult to determine who performed

specific elements


Time and date stamping



 The EMR can drive a provider to include

documentation that is not applicable for the severity of the presenting problem.

◦ A 25 year old patient who comes in for a cough has documentation to support a complete review of

systems (i.e. 10 or 12 point) and a family history because the EMR can automatically imports such text from the previous visit.

 Medicare and other payors will look to see


 Documentation templates default to

multisystem reviews, exams, past problems that are no longer active, but still indicate “Active Problems,” etc. whether you do them or not.

◦ Usually it takes too much time and trouble to edit them out so the providers leave the information in the note for that date of service.


Patient presented with knee pain. A

complete review of systems was


 A specialty provider (cardiologist) saw a


 I was asked to review several notes for a

Work Comp case because the provider had a very high percentage of 99214.

◦ I reviewed 5 patients and looked at 3-4 dates of service for each patient. Only a few items changed with each review and there were

documentation errors due to pulling the


 A gastrointestinal provider had a complete

physical including “genitourinary” when


 I was reviewing documentation in a

surgeons office and noticed several


 During a chart audit for a specialty provider I noted several instances where the

documentation in the Review of Systems

included several positives (i.e. shortness of breath, anxiety, depression, etc.) which may or may not have been related to the

presenting problem.


 Obtain an independent assessment of your EMR documentation

◦ Evaluate the documentation in comparison to the presenting problem

 Review several dates of services, types of services, etc.

 Review 2-3 dates of service in for the same patient by the same provider

◦ Ask the auditor to look at the templates you have


 Ask for a list of everything that

automatically pulls forward and a list of everything that can pull forward

◦ Query the provider on how they are using the EMR.

 Print out the note


 Training done up front

◦ Reduces risk (legal liability)

◦ Saves time

◦ Saves money

◦ Improves compliance

◦ Decreases frustration

◦ Improves efficiency


 Secret Patient

◦ A secret patient is similar to a secret

shopper. Ask the patient to see a few of the providers with different issues and then determine if the documentation

adequately reflects the work performed.

 Example: if a complete Review of Systems is


 Clearly understand who is doing what in the


◦ Audit trails offer a back‐end view of system use.

 Technology is only as good as the user.  The leading cause of failure for Electronic

Medical Record usage is inadequate training.

 Investing time and effort on the front end


 Review multiple E/M services for the same

providers and beneficiaries to identify electronic health records (EHR)

documentation practices associated with potentially improper payments.

 Medicare contractors have noted an


 Is your coding module turned on?


 Do your providers understand CPT coding?  Do you perform internal and/or external

chart reviews? If yes, what is your process?  Do you offer lunch and learn sessions?

 Shadowing?


 Purchasing resources or contracting for

assistance – ask you self the following questions:

◦ Will the resource help mitigate compliance risk? ◦ Will the resource improved our bottom line?

◦ Will the resource improve accuracy?


 Maintain your knowledge ◦ Specialize

 Monitor the coding patterns in the office ◦ Audit

 Educate all staff members  Build payer relations






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