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
◦ 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
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)
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)
◦ 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
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 =
Inadequate training can lead to increased
Inadequate training or lack of interest and
attention can have negative impact on the provider and/or facility
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
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
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
◦ 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?
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