Coding

HM15 presenters: Joshua D. Lenchus, DO, FACP, SFHM, and Nilam Soni, MD, FHM

Summary: Drs. Lenchus and Soni focused on the forces that are driving the value and success of established procedure teams in hospital medicine groups (HMGs). These stem from a need to rapidly address the growing shortage of skilled internists who can perform diagnostic and therapeutic procedures, thus leading to a subset of hospitalists who are willing to provide these services, particularly with the assistance of bedside ultrasonography.

They stressed the importance of providing a platform that is preemptive, proprietary, and scalable. With a defined set of value-creating metrics such as faster turn-around times, a reduction in complication rates, and ultimately a reduction in cost, LOS, and utilization, data must be collected to adequately measure the impact of these services on the institution.

They also discussed the key components necessary to create a procedure service, starting with the logistics of adequate training and demonstration of competence, proper staffing, supplies and equipment, ultrasound image archiving, and the use of documentation templates. The process is followed by the development of pre-procedure and post-procedure guidelines, as well as standardized procedural techniques.

The session also reviewed billing practices and professional fees. An analysis was made comparing Medicare reimbursement and work RVUs for each procedure service with and without a full procedure consultation. A complete consultation significantly increases the allowable fee and associated wRVU. The caveat is that billing for consults is limited to services rendered for patients that are not cared for by the same hospitalist group.

Furthermore, sub-specialists historically perform these procedures. The argument can be made that hospitalists will reduce an unnecessary burden on interventional radiologists, thereby enabling them to focus on more acomplex invasive and highly technical procedures.

The key to success is the ability to find a strategic partner in the C-suite who will directly or indirectly provide the financial and political support. Other sources of funding include private foundations, medical schools, the Department of Veteran Affairs, and such patient safety organizations as AHRQ, IOM, and IHI. HMG leaders also should consider scalability across other hospitalist groups.

“If you build it, they will come."

HM takeaways

• Create a business plan;
• Find institutional financial and political support;
• Start small and selective;
• Plan for standardization and training of colleagues;
• Create a credentialing/privileging process;
• Bill for services and consider billing for full consults; and
• Gather baseline and follow-up data.

HM15 presenters: Joshua D. Lenchus, DO, FACP, SFHM, and Nilam Soni, MD, FHM

Summary: Drs. Lenchus and Soni focused on the forces that are driving the value and success of established procedure teams in hospital medicine groups (HMGs). These stem from a need to rapidly address the growing shortage of skilled internists who can perform diagnostic and therapeutic procedures, thus leading to a subset of hospitalists who are willing to provide these services, particularly with the assistance of bedside ultrasonography.

They stressed the importance of providing a platform that is preemptive, proprietary, and scalable. With a defined set of value-creating metrics such as faster turn-around times, a reduction in complication rates, and ultimately a reduction in cost, LOS, and utilization, data must be collected to adequately measure the impact of these services on the institution.

They also discussed the key components necessary to create a procedure service, starting with the logistics of adequate training and demonstration of competence, proper staffing, supplies and equipment, ultrasound image archiving, and the use of documentation templates. The process is followed by the development of pre-procedure and post-procedure guidelines, as well as standardized procedural techniques.

The session also reviewed billing practices and professional fees. An analysis was made comparing Medicare reimbursement and work RVUs for each procedure service with and without a full procedure consultation. A complete consultation significantly increases the allowable fee and associated wRVU. The caveat is that billing for consults is limited to services rendered for patients that are not cared for by the same hospitalist group.

Furthermore, sub-specialists historically perform these procedures. The argument can be made that hospitalists will reduce an unnecessary burden on interventional radiologists, thereby enabling them to focus on more acomplex invasive and highly technical procedures.

The key to success is the ability to find a strategic partner in the C-suite who will directly or indirectly provide the financial and political support. Other sources of funding include private foundations, medical schools, the Department of Veteran Affairs, and such patient safety organizations as AHRQ, IOM, and IHI. HMG leaders also should consider scalability across other hospitalist groups.

“If you build it, they will come."

HM takeaways

• Create a business plan;
• Find institutional financial and political support;
• Start small and selective;
• Plan for standardization and training of colleagues;
• Create a credentialing/privileging process;
• Bill for services and consider billing for full consults; and
• Gather baseline and follow-up data.

HM15 presenters: Joshua D. Lenchus, DO, FACP, SFHM, and Nilam Soni, MD, FHM

Summary: Drs. Lenchus and Soni focused on the forces that are driving the value and success of established procedure teams in hospital medicine groups (HMGs). These stem from a need to rapidly address the growing shortage of skilled internists who can perform diagnostic and therapeutic procedures, thus leading to a subset of hospitalists who are willing to provide these services, particularly with the assistance of bedside ultrasonography.

They stressed the importance of providing a platform that is preemptive, proprietary, and scalable. With a defined set of value-creating metrics such as faster turn-around times, a reduction in complication rates, and ultimately a reduction in cost, LOS, and utilization, data must be collected to adequately measure the impact of these services on the institution.

They also discussed the key components necessary to create a procedure service, starting with the logistics of adequate training and demonstration of competence, proper staffing, supplies and equipment, ultrasound image archiving, and the use of documentation templates. The process is followed by the development of pre-procedure and post-procedure guidelines, as well as standardized procedural techniques.

The session also reviewed billing practices and professional fees. An analysis was made comparing Medicare reimbursement and work RVUs for each procedure service with and without a full procedure consultation. A complete consultation significantly increases the allowable fee and associated wRVU. The caveat is that billing for consults is limited to services rendered for patients that are not cared for by the same hospitalist group.

Furthermore, sub-specialists historically perform these procedures. The argument can be made that hospitalists will reduce an unnecessary burden on interventional radiologists, thereby enabling them to focus on more acomplex invasive and highly technical procedures.

The key to success is the ability to find a strategic partner in the C-suite who will directly or indirectly provide the financial and political support. Other sources of funding include private foundations, medical schools, the Department of Veteran Affairs, and such patient safety organizations as AHRQ, IOM, and IHI. HMG leaders also should consider scalability across other hospitalist groups.

“If you build it, they will come."

HM takeaways

• Create a business plan;
• Find institutional financial and political support;
• Start small and selective;
• Plan for standardization and training of colleagues;
• Create a credentialing/privileging process;
• Bill for services and consider billing for full consults; and
• Gather baseline and follow-up data.

In this session, Drs. Michelle Mourad and Christopher Moriates took a systematic approach to answer quality questions that we commonly encounter in our hospitalist practice. They reviewed current evidence including meta-analyses and systematic reviews to arrive at an answer for various quality-related questions. These are summarized below:

1. What are the common features of interventions that have successfully reduced re-admissions? Effective interventions that enhance patient capacity to reliably access and engage in post-discharge care has been associated with success in decreasing re-admissions.

2. 

   Does patient engagement correlate with decreased resource use or readmissions? Patient activation is defined as knowledge, skills, confidence and inclination to assume responsibility for managing one’s own health. A higher patient activation score reduced the risk of 30-day hospital re-utilization.
3. Does patients’ report of their healthcare experience reflect quality of care? Patient satisfaction scores may be a reflection of their desires (for example, to get pain medications) regardless of clinical benefit. In these situations, quality should be based on achieving a mutual understanding of patient situation and treatment plan between the provider and patient.
4. Is there any relationship between quality of care and health outcomes? Positive associations were found between patient experience and safety/effectiveness. Including patient experience in quality improvement, therefore, may lead to improvements in safety and effectiveness. Reducing the trauma of hospitalization could improve patient satisfaction and outcomes. Efforts such as personalization, providing rest and nourishment, reducing stress disruption and surprises as well as providing a post discharge safety net are strategies to reduce the trauma of hospitalization, improve satisfaction and patient outcomes.
5. Is there anything we can do to make hand-offs safer? The I-PASS hand-off bundle for a systematic hand-off process was reviewed (Illness severity, Patient summary, Action list, Situation awareness, Synthesis by receiver) as a means of reducing medical errors. When used in conjunction with training, faculty development and a culture-change campaign, this was associated with improving patient safety without negatively affecting workflow.
6. How can hospitalists deflate medical bills? Patient expectations of the benefits and harms of clinical interventions influences physician decision making and contributes to overuse and increased healthcare costs. Harm of excessive testing was underestimated in such situations. Conversations with patients, colleagues and the public are crucial to decreasing low value care. Physicians should discuss potential benefits and risks to address patient expectations. In addition, they should seek opportunities to better understand healthcare costs.
7. How big of a problem is antibiotic overuse in hospitals and can we do better? In a national database review, more than half of all patients (55.7%) discharged from a hospital received antibiotics during their stay. There is a wide variation in antibiotic use across hospital wards. Reducing this exposure to broad spectrum antibiotics would lead to a 26% reduction in C. diff infections and reduce antibiotic resistance. To improve this over-utilization, stewardship programs should actively engage and educate clinicians, encourage clear antibiotic documentation in daily progress notes and use 72-hour antibiotic time-out during multidisciplinary rounds. TH

In this session, Drs. Michelle Mourad and Christopher Moriates took a systematic approach to answer quality questions that we commonly encounter in our hospitalist practice. They reviewed current evidence including meta-analyses and systematic reviews to arrive at an answer for various quality-related questions. These are summarized below:

1. What are the common features of interventions that have successfully reduced re-admissions? Effective interventions that enhance patient capacity to reliably access and engage in post-discharge care has been associated with success in decreasing re-admissions.

2. 

   Does patient engagement correlate with decreased resource use or readmissions? Patient activation is defined as knowledge, skills, confidence and inclination to assume responsibility for managing one’s own health. A higher patient activation score reduced the risk of 30-day hospital re-utilization.
3. Does patients’ report of their healthcare experience reflect quality of care? Patient satisfaction scores may be a reflection of their desires (for example, to get pain medications) regardless of clinical benefit. In these situations, quality should be based on achieving a mutual understanding of patient situation and treatment plan between the provider and patient.
4. Is there any relationship between quality of care and health outcomes? Positive associations were found between patient experience and safety/effectiveness. Including patient experience in quality improvement, therefore, may lead to improvements in safety and effectiveness. Reducing the trauma of hospitalization could improve patient satisfaction and outcomes. Efforts such as personalization, providing rest and nourishment, reducing stress disruption and surprises as well as providing a post discharge safety net are strategies to reduce the trauma of hospitalization, improve satisfaction and patient outcomes.
5. Is there anything we can do to make hand-offs safer? The I-PASS hand-off bundle for a systematic hand-off process was reviewed (Illness severity, Patient summary, Action list, Situation awareness, Synthesis by receiver) as a means of reducing medical errors. When used in conjunction with training, faculty development and a culture-change campaign, this was associated with improving patient safety without negatively affecting workflow.
6. How can hospitalists deflate medical bills? Patient expectations of the benefits and harms of clinical interventions influences physician decision making and contributes to overuse and increased healthcare costs. Harm of excessive testing was underestimated in such situations. Conversations with patients, colleagues and the public are crucial to decreasing low value care. Physicians should discuss potential benefits and risks to address patient expectations. In addition, they should seek opportunities to better understand healthcare costs.
7. How big of a problem is antibiotic overuse in hospitals and can we do better? In a national database review, more than half of all patients (55.7%) discharged from a hospital received antibiotics during their stay. There is a wide variation in antibiotic use across hospital wards. Reducing this exposure to broad spectrum antibiotics would lead to a 26% reduction in C. diff infections and reduce antibiotic resistance. To improve this over-utilization, stewardship programs should actively engage and educate clinicians, encourage clear antibiotic documentation in daily progress notes and use 72-hour antibiotic time-out during multidisciplinary rounds. TH

In this session, Drs. Michelle Mourad and Christopher Moriates took a systematic approach to answer quality questions that we commonly encounter in our hospitalist practice. They reviewed current evidence including meta-analyses and systematic reviews to arrive at an answer for various quality-related questions. These are summarized below:

1. What are the common features of interventions that have successfully reduced re-admissions? Effective interventions that enhance patient capacity to reliably access and engage in post-discharge care has been associated with success in decreasing re-admissions.

2. 

   Does patient engagement correlate with decreased resource use or readmissions? Patient activation is defined as knowledge, skills, confidence and inclination to assume responsibility for managing one’s own health. A higher patient activation score reduced the risk of 30-day hospital re-utilization.
3. Does patients’ report of their healthcare experience reflect quality of care? Patient satisfaction scores may be a reflection of their desires (for example, to get pain medications) regardless of clinical benefit. In these situations, quality should be based on achieving a mutual understanding of patient situation and treatment plan between the provider and patient.
4. Is there any relationship between quality of care and health outcomes? Positive associations were found between patient experience and safety/effectiveness. Including patient experience in quality improvement, therefore, may lead to improvements in safety and effectiveness. Reducing the trauma of hospitalization could improve patient satisfaction and outcomes. Efforts such as personalization, providing rest and nourishment, reducing stress disruption and surprises as well as providing a post discharge safety net are strategies to reduce the trauma of hospitalization, improve satisfaction and patient outcomes.
5. Is there anything we can do to make hand-offs safer? The I-PASS hand-off bundle for a systematic hand-off process was reviewed (Illness severity, Patient summary, Action list, Situation awareness, Synthesis by receiver) as a means of reducing medical errors. When used in conjunction with training, faculty development and a culture-change campaign, this was associated with improving patient safety without negatively affecting workflow.
6. How can hospitalists deflate medical bills? Patient expectations of the benefits and harms of clinical interventions influences physician decision making and contributes to overuse and increased healthcare costs. Harm of excessive testing was underestimated in such situations. Conversations with patients, colleagues and the public are crucial to decreasing low value care. Physicians should discuss potential benefits and risks to address patient expectations. In addition, they should seek opportunities to better understand healthcare costs.
7. How big of a problem is antibiotic overuse in hospitals and can we do better? In a national database review, more than half of all patients (55.7%) discharged from a hospital received antibiotics during their stay. There is a wide variation in antibiotic use across hospital wards. Reducing this exposure to broad spectrum antibiotics would lead to a 26% reduction in C. diff infections and reduce antibiotic resistance. To improve this over-utilization, stewardship programs should actively engage and educate clinicians, encourage clear antibiotic documentation in daily progress notes and use 72-hour antibiotic time-out during multidisciplinary rounds. TH

Should the admitting physician or the discharge physician bill the CPT code (99234-99236) for a patient who is admitted and discharged in the same 24-hour period?

—Charlette

Dr. Hospitalist responds:

Assuming both physicians are part of the same group and specialty, they are considered one physician. Since it appears that both face-to-face encounters are separated by eight hours, you’re correct, only one physician can bill the bundled care code 99234-99236. The group must decide which physician gets the RVU credit for the bundled code. Our group gives the credit to the admitting physician.

Should the admitting physician or the discharge physician bill the CPT code (99234-99236) for a patient who is admitted and discharged in the same 24-hour period?

—Charlette

Dr. Hospitalist responds:

Assuming both physicians are part of the same group and specialty, they are considered one physician. Since it appears that both face-to-face encounters are separated by eight hours, you’re correct, only one physician can bill the bundled care code 99234-99236. The group must decide which physician gets the RVU credit for the bundled code. Our group gives the credit to the admitting physician.

Should the admitting physician or the discharge physician bill the CPT code (99234-99236) for a patient who is admitted and discharged in the same 24-hour period?

—Charlette

Dr. Hospitalist responds:

Assuming both physicians are part of the same group and specialty, they are considered one physician. Since it appears that both face-to-face encounters are separated by eight hours, you’re correct, only one physician can bill the bundled care code 99234-99236. The group must decide which physician gets the RVU credit for the bundled code. Our group gives the credit to the admitting physician.

It’s spring. Have you started your Meaningful Use reporting yet? More important, have you begun reporting at all?

“Say the words Meaningful Use to most orthopedists, and they usually roll their eyes or shake their heads,” says Cheyenne Brinson, MBA, CPA, a KarenZupko & Associates consultant who has been advising surgical practices on Meaningful Use since the program’s inception. Although many orthopedists are successfully using certified electronic health records (EHRs) to e-prescribe and enter radiology and laboratory orders, Brinson says many other requirements are misunderstood and perceived as overly complex. In many cases, practices are doing more work than they need to in order to attest.

“It’s actually not that complicated to meet Meaningful Use requirements,” she says. “The trick is to zero in on what’s relevant only for surgeons. This isn’t crystal clear in the CMS [Centers for Medicare & Medicaid Services] documents, and it’s not the forte of most EHR vendors or trainers either.” In fact, in Brinson’s experience, most EHR trainers present Meaningful Use to every practice as if it were primary care. Yet, the requirements for surgeons are different for primary care and are, frankly, less involved.

That’s good news. Because if you didn’t attest for Meaningful Use in 2014, the first year that reporting was required, you’re automatically getting dinged 2% on your Medicare payments in 2015. So, it’s time to get organized and get moving to avoid further penalties.

Avoid These Four Common Faux Pas

Brinson says the Clinical Quality Measures (CQMs) are hands down the most misunderstood component of Meaningful Use. “When I explain Meaningful Use to surgeons, I can’t jump up and down and wave my hands in the air enough to call attention to this,” she quips.

At issue: There are 64 CQMs, but very few are applicable to surgeons. Yet, many surgeons think they have to perform them for Meaningful Use. Not so, says Brinson. “Surgeons have to report a CQM only if it’s clinically relevant. If none of the CQMs are clinically relevant in your practice, it’s okay to report a zero value if you have not actually performed it.”

Here’s how this plays out. In Stage 2, physicians must report 9 CQMs across 3 domains; Population/Public Health, Patient Safety, and Efficient Use of Healthcare Resources are examples of domains that are most applicable to orthopedists. “If you choose Low Back Pain: Use of Imaging Studies as one of these, it’s possible an orthopedist would have a numeric value to report,” Brinson says. “But if you also choose Use of High-Risk Medications in the Elderly, an orthopedist will probably report a zero value. And that’s totally acceptable. You will not be penalized for reporting zero.”

Another common misconception is around the Vital Signs and Smoking Status measures. “We have worked with surgical practices that think Meaningful Use is requiring them to collect vital signs and smoking status at every visit, even though they may not be clinically relevant,” says Brinson. Again, not true.

“Height and/or weight and blood pressure, as well as smoking status measures, need to be reported only once per patient during the reporting period,” Brinson clarifies. “So from a practical standpoint, most orthopedic practices can collect this data from new patients and then again as clinically necessary,” adding there are even exclusions for physicians who attest that either height and weight and/or blood pressure has no relevance to their scope of practice at all.

Brinson also sees practices do more work than they need to when it comes to Patient Care Reminders. She recently worked with a surgery practice that sent reminders for colonoscopies. “Not exactly clinically relevant,” she says, “and an unnecessary step for staff.” That’s because physicians aren’t required to send reminders that aren’t relevant to their specialty.

The Federal Register states, “An eligible provider (EP) should use clinically relevant information stored within the [EHR] to identify patients who should receive reminders…. The EP is best positioned to decide which information is clinically relevant for this purpose.”

“In orthopedics, clinically relevant reminders could be for an outside referral, a follow-up on an MRI or other test, or a reminder to schedule a postoperative appointment,” Brinson explains. “Work with your EHR vendor to create the reminders that are most appropriate for your patient base.”

The final faux pas that Brinson finds: “Meaningful Use requires you to report data for all patients, not just Medicare patients. That seems to be a point of confusion for many.”

Three Cheers for the Patient Portal Requirement

Stage 2 saw the addition of the Patient Portal Requirement, and Brinson suggests that the benefits of this tool go far beyond Meaningful Use. “Patient portals are essential to a modern practice,” she says. “Patients use them to complete a health history prior to their appointment, pay their bill, schedule follow-up appointments, and more.” Further, the patient portal facilitates another Meaningful Use Stage 2 requirement: secure electronic messaging with patients. For both Meaningful Use and risk management, moving away from e-mail and texting and toward secure/encrypted messaging is a must. The patient portal has this feature already built in, and all messages are stored securely and archived—which meets the HIPAA (Health Insurance Portability and Accountability Act) Omnibus requirements, too.

So if you’ve implemented a patient portal, that’s good for your practice and your patients on many levels. But there is a caveat about meeting the Meaningful Use requirement. “For this requirement, 5% of the unique patients seen during the reporting period must ‘view, download, or transmit to a third party their health information,’” Brinson explains. “So the onus is on your practice to ‘sell’ the benefits of the patient portal and get patients to use it so you can achieve the 5% threshold.”

Clinical Decision Support and Summaries

The requirements of Clinical Decision Support Interventions and Clinical Summaries may seem daunting, but, if you think beyond Meaningful Use for a moment, both facilitate better care.

Take Clinical Decision Support Interventions. What would be helpful for you to know about a patient before surgery? What information would enable you to deliver better care?

“One surgeon told me that a family history of malignant hyperthermia would mean the difference between performing the case in the operating room versus the ambulatory surgery center,” Brinson says. “This is a good example of an intervention that a surgeon would work with their EHR vendor to set up.”

The objective states that each intervention is to be an evidence-based decision-support intervention based on each one and at least one combination of the following data: problem list, medication list, medication allergy list, demographics, laboratory tests and values/results, and vital signs. “Stage 1 requires physicians to implement 1 Clinical Decision Support Intervention, and Stage 2 requires 5,” reminds Brinson.

And here’s all you need to know about Clinical Summaries. Although there are 20 specific required elements of a clinical summary, physicians themselves need to provide details only for clinical instructions and the care plan, including goals and instructions. Ancillary staff can populate the other elements.

Brinson points out that surgeons are not expected to provide a copy of the patient’s note, or to complete the note, before the patient checks out. The requirement under Stage 2 is that the clinical summary is provided to the patient within 1 business day. “From a practical standpoint, practices can print the clinical summary for patients at checkout. A well-done clinical summary is a practice efficiency tool as much as a clinical document. It can reduce phone calls from patients asking, ‘Now what did the doctor tell me to do?’”

Often Overlooked

There are requirements that, Brinson says, surgeons often gloss over: Protect Electronic Health Information and Text-Searchable Progress Notes.

“Stage 2 requires physicians to conduct a privacy risk analysis to protect electronic health information,” she explains. “Most EHR vendors don’t offer this as part of their product, so it’s frequently overlooked.” Such an analysis typically requires an outside vendor, but there are free, do-it-yourself tools available, such as the Privacy and Security Toolkit for Small Provider Organizations,^* from the Healthcare Information and Management Systems Society (HIMSS).

The analysis should follow HIPAA guidelines, and the most intensive part of this requirement is to conduct or review a privacy risk analysis of the clinical technology. “You’ve also got to address data encryption and security in the EHR, and ensure HIPAA policies and procedures are in place,” Brinson states.

Text-Searchable Progress Notes are also a new requirement in Stage 2. All progress notes must be text searchable—practices can no longer include progress notes as scanned attachments. “That means no more PDFs,” Brinson says. “Surgeons can still dictate, but the dictation must be entered into the EHR in such a way that it’s searchable. In Stage 2, 30% of unique patients must have a minimum of 1 text-searchable electronic progress note created, edited, and signed in the EHR.”

Conclusion

Meaningful Use does not have to be cumbersome. Focus on what surgical practices need to know, and attestation won’t be as complicated as you think.

It’s spring. Have you started your Meaningful Use reporting yet? More important, have you begun reporting at all?

“Say the words Meaningful Use to most orthopedists, and they usually roll their eyes or shake their heads,” says Cheyenne Brinson, MBA, CPA, a KarenZupko & Associates consultant who has been advising surgical practices on Meaningful Use since the program’s inception. Although many orthopedists are successfully using certified electronic health records (EHRs) to e-prescribe and enter radiology and laboratory orders, Brinson says many other requirements are misunderstood and perceived as overly complex. In many cases, practices are doing more work than they need to in order to attest.

“It’s actually not that complicated to meet Meaningful Use requirements,” she says. “The trick is to zero in on what’s relevant only for surgeons. This isn’t crystal clear in the CMS [Centers for Medicare & Medicaid Services] documents, and it’s not the forte of most EHR vendors or trainers either.” In fact, in Brinson’s experience, most EHR trainers present Meaningful Use to every practice as if it were primary care. Yet, the requirements for surgeons are different for primary care and are, frankly, less involved.

That’s good news. Because if you didn’t attest for Meaningful Use in 2014, the first year that reporting was required, you’re automatically getting dinged 2% on your Medicare payments in 2015. So, it’s time to get organized and get moving to avoid further penalties.

Avoid These Four Common Faux Pas

Brinson says the Clinical Quality Measures (CQMs) are hands down the most misunderstood component of Meaningful Use. “When I explain Meaningful Use to surgeons, I can’t jump up and down and wave my hands in the air enough to call attention to this,” she quips.

At issue: There are 64 CQMs, but very few are applicable to surgeons. Yet, many surgeons think they have to perform them for Meaningful Use. Not so, says Brinson. “Surgeons have to report a CQM only if it’s clinically relevant. If none of the CQMs are clinically relevant in your practice, it’s okay to report a zero value if you have not actually performed it.”

Here’s how this plays out. In Stage 2, physicians must report 9 CQMs across 3 domains; Population/Public Health, Patient Safety, and Efficient Use of Healthcare Resources are examples of domains that are most applicable to orthopedists. “If you choose Low Back Pain: Use of Imaging Studies as one of these, it’s possible an orthopedist would have a numeric value to report,” Brinson says. “But if you also choose Use of High-Risk Medications in the Elderly, an orthopedist will probably report a zero value. And that’s totally acceptable. You will not be penalized for reporting zero.”

Another common misconception is around the Vital Signs and Smoking Status measures. “We have worked with surgical practices that think Meaningful Use is requiring them to collect vital signs and smoking status at every visit, even though they may not be clinically relevant,” says Brinson. Again, not true.

“Height and/or weight and blood pressure, as well as smoking status measures, need to be reported only once per patient during the reporting period,” Brinson clarifies. “So from a practical standpoint, most orthopedic practices can collect this data from new patients and then again as clinically necessary,” adding there are even exclusions for physicians who attest that either height and weight and/or blood pressure has no relevance to their scope of practice at all.

Brinson also sees practices do more work than they need to when it comes to Patient Care Reminders. She recently worked with a surgery practice that sent reminders for colonoscopies. “Not exactly clinically relevant,” she says, “and an unnecessary step for staff.” That’s because physicians aren’t required to send reminders that aren’t relevant to their specialty.

The Federal Register states, “An eligible provider (EP) should use clinically relevant information stored within the [EHR] to identify patients who should receive reminders…. The EP is best positioned to decide which information is clinically relevant for this purpose.”

“In orthopedics, clinically relevant reminders could be for an outside referral, a follow-up on an MRI or other test, or a reminder to schedule a postoperative appointment,” Brinson explains. “Work with your EHR vendor to create the reminders that are most appropriate for your patient base.”

The final faux pas that Brinson finds: “Meaningful Use requires you to report data for all patients, not just Medicare patients. That seems to be a point of confusion for many.”

Three Cheers for the Patient Portal Requirement

Stage 2 saw the addition of the Patient Portal Requirement, and Brinson suggests that the benefits of this tool go far beyond Meaningful Use. “Patient portals are essential to a modern practice,” she says. “Patients use them to complete a health history prior to their appointment, pay their bill, schedule follow-up appointments, and more.” Further, the patient portal facilitates another Meaningful Use Stage 2 requirement: secure electronic messaging with patients. For both Meaningful Use and risk management, moving away from e-mail and texting and toward secure/encrypted messaging is a must. The patient portal has this feature already built in, and all messages are stored securely and archived—which meets the HIPAA (Health Insurance Portability and Accountability Act) Omnibus requirements, too.

So if you’ve implemented a patient portal, that’s good for your practice and your patients on many levels. But there is a caveat about meeting the Meaningful Use requirement. “For this requirement, 5% of the unique patients seen during the reporting period must ‘view, download, or transmit to a third party their health information,’” Brinson explains. “So the onus is on your practice to ‘sell’ the benefits of the patient portal and get patients to use it so you can achieve the 5% threshold.”

Clinical Decision Support and Summaries

The requirements of Clinical Decision Support Interventions and Clinical Summaries may seem daunting, but, if you think beyond Meaningful Use for a moment, both facilitate better care.

Take Clinical Decision Support Interventions. What would be helpful for you to know about a patient before surgery? What information would enable you to deliver better care?

“One surgeon told me that a family history of malignant hyperthermia would mean the difference between performing the case in the operating room versus the ambulatory surgery center,” Brinson says. “This is a good example of an intervention that a surgeon would work with their EHR vendor to set up.”

The objective states that each intervention is to be an evidence-based decision-support intervention based on each one and at least one combination of the following data: problem list, medication list, medication allergy list, demographics, laboratory tests and values/results, and vital signs. “Stage 1 requires physicians to implement 1 Clinical Decision Support Intervention, and Stage 2 requires 5,” reminds Brinson.

And here’s all you need to know about Clinical Summaries. Although there are 20 specific required elements of a clinical summary, physicians themselves need to provide details only for clinical instructions and the care plan, including goals and instructions. Ancillary staff can populate the other elements.

Brinson points out that surgeons are not expected to provide a copy of the patient’s note, or to complete the note, before the patient checks out. The requirement under Stage 2 is that the clinical summary is provided to the patient within 1 business day. “From a practical standpoint, practices can print the clinical summary for patients at checkout. A well-done clinical summary is a practice efficiency tool as much as a clinical document. It can reduce phone calls from patients asking, ‘Now what did the doctor tell me to do?’”

Often Overlooked

There are requirements that, Brinson says, surgeons often gloss over: Protect Electronic Health Information and Text-Searchable Progress Notes.

“Stage 2 requires physicians to conduct a privacy risk analysis to protect electronic health information,” she explains. “Most EHR vendors don’t offer this as part of their product, so it’s frequently overlooked.” Such an analysis typically requires an outside vendor, but there are free, do-it-yourself tools available, such as the Privacy and Security Toolkit for Small Provider Organizations,^* from the Healthcare Information and Management Systems Society (HIMSS).

The analysis should follow HIPAA guidelines, and the most intensive part of this requirement is to conduct or review a privacy risk analysis of the clinical technology. “You’ve also got to address data encryption and security in the EHR, and ensure HIPAA policies and procedures are in place,” Brinson states.

Text-Searchable Progress Notes are also a new requirement in Stage 2. All progress notes must be text searchable—practices can no longer include progress notes as scanned attachments. “That means no more PDFs,” Brinson says. “Surgeons can still dictate, but the dictation must be entered into the EHR in such a way that it’s searchable. In Stage 2, 30% of unique patients must have a minimum of 1 text-searchable electronic progress note created, edited, and signed in the EHR.”

Conclusion

Meaningful Use does not have to be cumbersome. Focus on what surgical practices need to know, and attestation won’t be as complicated as you think.

It’s spring. Have you started your Meaningful Use reporting yet? More important, have you begun reporting at all?

“Say the words Meaningful Use to most orthopedists, and they usually roll their eyes or shake their heads,” says Cheyenne Brinson, MBA, CPA, a KarenZupko & Associates consultant who has been advising surgical practices on Meaningful Use since the program’s inception. Although many orthopedists are successfully using certified electronic health records (EHRs) to e-prescribe and enter radiology and laboratory orders, Brinson says many other requirements are misunderstood and perceived as overly complex. In many cases, practices are doing more work than they need to in order to attest.

“It’s actually not that complicated to meet Meaningful Use requirements,” she says. “The trick is to zero in on what’s relevant only for surgeons. This isn’t crystal clear in the CMS [Centers for Medicare & Medicaid Services] documents, and it’s not the forte of most EHR vendors or trainers either.” In fact, in Brinson’s experience, most EHR trainers present Meaningful Use to every practice as if it were primary care. Yet, the requirements for surgeons are different for primary care and are, frankly, less involved.

That’s good news. Because if you didn’t attest for Meaningful Use in 2014, the first year that reporting was required, you’re automatically getting dinged 2% on your Medicare payments in 2015. So, it’s time to get organized and get moving to avoid further penalties.

Avoid These Four Common Faux Pas

Brinson says the Clinical Quality Measures (CQMs) are hands down the most misunderstood component of Meaningful Use. “When I explain Meaningful Use to surgeons, I can’t jump up and down and wave my hands in the air enough to call attention to this,” she quips.

At issue: There are 64 CQMs, but very few are applicable to surgeons. Yet, many surgeons think they have to perform them for Meaningful Use. Not so, says Brinson. “Surgeons have to report a CQM only if it’s clinically relevant. If none of the CQMs are clinically relevant in your practice, it’s okay to report a zero value if you have not actually performed it.”

Here’s how this plays out. In Stage 2, physicians must report 9 CQMs across 3 domains; Population/Public Health, Patient Safety, and Efficient Use of Healthcare Resources are examples of domains that are most applicable to orthopedists. “If you choose Low Back Pain: Use of Imaging Studies as one of these, it’s possible an orthopedist would have a numeric value to report,” Brinson says. “But if you also choose Use of High-Risk Medications in the Elderly, an orthopedist will probably report a zero value. And that’s totally acceptable. You will not be penalized for reporting zero.”

Another common misconception is around the Vital Signs and Smoking Status measures. “We have worked with surgical practices that think Meaningful Use is requiring them to collect vital signs and smoking status at every visit, even though they may not be clinically relevant,” says Brinson. Again, not true.

“Height and/or weight and blood pressure, as well as smoking status measures, need to be reported only once per patient during the reporting period,” Brinson clarifies. “So from a practical standpoint, most orthopedic practices can collect this data from new patients and then again as clinically necessary,” adding there are even exclusions for physicians who attest that either height and weight and/or blood pressure has no relevance to their scope of practice at all.

Brinson also sees practices do more work than they need to when it comes to Patient Care Reminders. She recently worked with a surgery practice that sent reminders for colonoscopies. “Not exactly clinically relevant,” she says, “and an unnecessary step for staff.” That’s because physicians aren’t required to send reminders that aren’t relevant to their specialty.

The Federal Register states, “An eligible provider (EP) should use clinically relevant information stored within the [EHR] to identify patients who should receive reminders…. The EP is best positioned to decide which information is clinically relevant for this purpose.”

“In orthopedics, clinically relevant reminders could be for an outside referral, a follow-up on an MRI or other test, or a reminder to schedule a postoperative appointment,” Brinson explains. “Work with your EHR vendor to create the reminders that are most appropriate for your patient base.”

The final faux pas that Brinson finds: “Meaningful Use requires you to report data for all patients, not just Medicare patients. That seems to be a point of confusion for many.”

Three Cheers for the Patient Portal Requirement

Stage 2 saw the addition of the Patient Portal Requirement, and Brinson suggests that the benefits of this tool go far beyond Meaningful Use. “Patient portals are essential to a modern practice,” she says. “Patients use them to complete a health history prior to their appointment, pay their bill, schedule follow-up appointments, and more.” Further, the patient portal facilitates another Meaningful Use Stage 2 requirement: secure electronic messaging with patients. For both Meaningful Use and risk management, moving away from e-mail and texting and toward secure/encrypted messaging is a must. The patient portal has this feature already built in, and all messages are stored securely and archived—which meets the HIPAA (Health Insurance Portability and Accountability Act) Omnibus requirements, too.

So if you’ve implemented a patient portal, that’s good for your practice and your patients on many levels. But there is a caveat about meeting the Meaningful Use requirement. “For this requirement, 5% of the unique patients seen during the reporting period must ‘view, download, or transmit to a third party their health information,’” Brinson explains. “So the onus is on your practice to ‘sell’ the benefits of the patient portal and get patients to use it so you can achieve the 5% threshold.”

Clinical Decision Support and Summaries

The requirements of Clinical Decision Support Interventions and Clinical Summaries may seem daunting, but, if you think beyond Meaningful Use for a moment, both facilitate better care.

Take Clinical Decision Support Interventions. What would be helpful for you to know about a patient before surgery? What information would enable you to deliver better care?

“One surgeon told me that a family history of malignant hyperthermia would mean the difference between performing the case in the operating room versus the ambulatory surgery center,” Brinson says. “This is a good example of an intervention that a surgeon would work with their EHR vendor to set up.”

The objective states that each intervention is to be an evidence-based decision-support intervention based on each one and at least one combination of the following data: problem list, medication list, medication allergy list, demographics, laboratory tests and values/results, and vital signs. “Stage 1 requires physicians to implement 1 Clinical Decision Support Intervention, and Stage 2 requires 5,” reminds Brinson.

And here’s all you need to know about Clinical Summaries. Although there are 20 specific required elements of a clinical summary, physicians themselves need to provide details only for clinical instructions and the care plan, including goals and instructions. Ancillary staff can populate the other elements.

Brinson points out that surgeons are not expected to provide a copy of the patient’s note, or to complete the note, before the patient checks out. The requirement under Stage 2 is that the clinical summary is provided to the patient within 1 business day. “From a practical standpoint, practices can print the clinical summary for patients at checkout. A well-done clinical summary is a practice efficiency tool as much as a clinical document. It can reduce phone calls from patients asking, ‘Now what did the doctor tell me to do?’”

Often Overlooked

There are requirements that, Brinson says, surgeons often gloss over: Protect Electronic Health Information and Text-Searchable Progress Notes.

“Stage 2 requires physicians to conduct a privacy risk analysis to protect electronic health information,” she explains. “Most EHR vendors don’t offer this as part of their product, so it’s frequently overlooked.” Such an analysis typically requires an outside vendor, but there are free, do-it-yourself tools available, such as the Privacy and Security Toolkit for Small Provider Organizations,^* from the Healthcare Information and Management Systems Society (HIMSS).

The analysis should follow HIPAA guidelines, and the most intensive part of this requirement is to conduct or review a privacy risk analysis of the clinical technology. “You’ve also got to address data encryption and security in the EHR, and ensure HIPAA policies and procedures are in place,” Brinson states.

Text-Searchable Progress Notes are also a new requirement in Stage 2. All progress notes must be text searchable—practices can no longer include progress notes as scanned attachments. “That means no more PDFs,” Brinson says. “Surgeons can still dictate, but the dictation must be entered into the EHR in such a way that it’s searchable. In Stage 2, 30% of unique patients must have a minimum of 1 text-searchable electronic progress note created, edited, and signed in the EHR.”

Conclusion

Meaningful Use does not have to be cumbersome. Focus on what surgical practices need to know, and attestation won’t be as complicated as you think.

According to Current Procedural Terminology (CPT), modifier -25 is to be used to identify “significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.”¹ Modifier -25 frequently is integral to the description of patient visits in dermatology. Dermatologists use modifier -25 more than physicians of any other specialty, and in recent years, more than 50% of dermatology evaluation and management (E/M) visits have been appended with this modifier.

When patients present for assessment and management of various skin findings, a dermatologist may deem it appropriate to proceed with a diagnostic or therapeutic procedure at the same visit after obtaining the patient’s medical history, completing a review of systems, and conducting a clinical examination. Most commonly, a skin biopsy or destruction of a benign or malignant lesion may be performed, but other simple procedures also may be appropriate. The ability to assess and intervene during the same visit is optimal for patients who subsequently may require fewer follow-up visits and experience more immediate relief from their symptoms.

When E/M Cannot Be Billed Separately

Regulatory guidance from the National Correct Coding Initiative (NCCI) dated January 2013 indicates that procedures with a global period of 90 days are major surgical procedures, and if an E/M service is performed on the same day as such a procedure to decide whether or not to perform that procedure, then the E/M service should be reported with modifier -57.² On the other hand, CPT defines procedures with a 0- or 10-day global period as minor surgical procedures, and E/M services provided on the same day of service as these procedures are included in the procedure code and cannot be billed separately. For review, common dermatologic procedures with 0-day global periods include biopsies (CPT code 11000), shave removals (11300–11313), debridements (11000, 11011–11042), and Mohs micrographic surgery (17311–17315); procedures with 10-day global periods include destructions (17000–17286), excisions (11400–11646), and repairs (12001–13153). If an E/M service is performed on the same day as one of these procedures to decide whether to proceed with the minor surgical procedure, this E/M service cannot be reported separately. Additionally, the fact that the patient is new to the physician is not sufficient to allow reporting of an E/M with such a minor procedure.

When E/M Can Be Billed Separately

However, a “significant and separately identifiable E/M service unrelated to the decision to perform the minor procedure” is separately reportable with modifier -25. According to the NCCI, the minor procedure and the E/M do not require different diagnoses, but the E/M service must be above and beyond what is usually required for the minor surgical procedure.² Because a certain amount of so-called preservice time is built into minor procedure codes, the implication is that substantially more E/M was needed than envisioned in this preservice time, necessitating inclusion of an E/M in addition to a minor procedure when there is a single diagnosis.

When there is a single diagnosis, the physician has to decide when such a significant and separately identifiable service exists. If the physician determines that it is appropriate to code for E/M in addition to the minor procedure, clear documentation of the additional E/M service provided will reduce the likelihood of this choice being questioned. Specifically, it may be helpful to describe the additional history, examination results, medical knowledge, professional skill, and work time above and beyond what is usually required for the minor surgical procedure.

When there are many diagnosis codes for a single visit and only a subset of them are associated with the minor procedure, as is common in dermatology, then the decision to include an E/M service is simpler. In this case, if E/M services were provided that pertained to a diagnosis or diagnoses other than the one(s) associated with the minor procedure(s), then these additional E/M services will clearly not be included in the preservice time for the procedure and an E/M can virtually always be coded separately. For instance, if a patient presents with a growing scaly bump (clinically apparent squamous cell carcinoma) on the leg that the dermatologist deems is appropriate for biopsy but concurrently notices nummular dermatitis of the legs, which the patient describes as itchy and uncomfortable, then the diagnosis and management of the dermatitis would clearly be a separate E/M service and would not be included in the workup for the biopsy. The E/M code that is applied should, of course, reflect the services provided exclusive of those integral to the minor procedure. To make it easier for regulators and auditors, it may be helpful to clearly itemize the additional diagnoses unrelated to the minor procedure and describe the specific E/M services provided for these diagnoses. Although it is certainly not necessary or required, it also may be helpful to physically separate the documentation for the minor procedure from the E/M services for the additional diagnoses within the medical chart.

Final Thoughts

It is clear that frequent use of modifier -25 is appropriate in routine, high-quality dermatologic practice. Simultaneous provision of E/M services and minor procedures often is in the patient’s best interest, as it minimizes unnecessary office visits and expedites treatment. When modifier -25 is appropriately appended, careful documentation by the dermatologist can help to clarify the precise basis for its use. Recent NCCI edits provide guidelines for use of this modifier that can be adapted by individual dermatologists for particular patient circumstances.²

According to Current Procedural Terminology (CPT), modifier -25 is to be used to identify “significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.”¹ Modifier -25 frequently is integral to the description of patient visits in dermatology. Dermatologists use modifier -25 more than physicians of any other specialty, and in recent years, more than 50% of dermatology evaluation and management (E/M) visits have been appended with this modifier.

When patients present for assessment and management of various skin findings, a dermatologist may deem it appropriate to proceed with a diagnostic or therapeutic procedure at the same visit after obtaining the patient’s medical history, completing a review of systems, and conducting a clinical examination. Most commonly, a skin biopsy or destruction of a benign or malignant lesion may be performed, but other simple procedures also may be appropriate. The ability to assess and intervene during the same visit is optimal for patients who subsequently may require fewer follow-up visits and experience more immediate relief from their symptoms.

When E/M Cannot Be Billed Separately

Regulatory guidance from the National Correct Coding Initiative (NCCI) dated January 2013 indicates that procedures with a global period of 90 days are major surgical procedures, and if an E/M service is performed on the same day as such a procedure to decide whether or not to perform that procedure, then the E/M service should be reported with modifier -57.² On the other hand, CPT defines procedures with a 0- or 10-day global period as minor surgical procedures, and E/M services provided on the same day of service as these procedures are included in the procedure code and cannot be billed separately. For review, common dermatologic procedures with 0-day global periods include biopsies (CPT code 11000), shave removals (11300–11313), debridements (11000, 11011–11042), and Mohs micrographic surgery (17311–17315); procedures with 10-day global periods include destructions (17000–17286), excisions (11400–11646), and repairs (12001–13153). If an E/M service is performed on the same day as one of these procedures to decide whether to proceed with the minor surgical procedure, this E/M service cannot be reported separately. Additionally, the fact that the patient is new to the physician is not sufficient to allow reporting of an E/M with such a minor procedure.

When E/M Can Be Billed Separately

However, a “significant and separately identifiable E/M service unrelated to the decision to perform the minor procedure” is separately reportable with modifier -25. According to the NCCI, the minor procedure and the E/M do not require different diagnoses, but the E/M service must be above and beyond what is usually required for the minor surgical procedure.² Because a certain amount of so-called preservice time is built into minor procedure codes, the implication is that substantially more E/M was needed than envisioned in this preservice time, necessitating inclusion of an E/M in addition to a minor procedure when there is a single diagnosis.

When there is a single diagnosis, the physician has to decide when such a significant and separately identifiable service exists. If the physician determines that it is appropriate to code for E/M in addition to the minor procedure, clear documentation of the additional E/M service provided will reduce the likelihood of this choice being questioned. Specifically, it may be helpful to describe the additional history, examination results, medical knowledge, professional skill, and work time above and beyond what is usually required for the minor surgical procedure.

When there are many diagnosis codes for a single visit and only a subset of them are associated with the minor procedure, as is common in dermatology, then the decision to include an E/M service is simpler. In this case, if E/M services were provided that pertained to a diagnosis or diagnoses other than the one(s) associated with the minor procedure(s), then these additional E/M services will clearly not be included in the preservice time for the procedure and an E/M can virtually always be coded separately. For instance, if a patient presents with a growing scaly bump (clinically apparent squamous cell carcinoma) on the leg that the dermatologist deems is appropriate for biopsy but concurrently notices nummular dermatitis of the legs, which the patient describes as itchy and uncomfortable, then the diagnosis and management of the dermatitis would clearly be a separate E/M service and would not be included in the workup for the biopsy. The E/M code that is applied should, of course, reflect the services provided exclusive of those integral to the minor procedure. To make it easier for regulators and auditors, it may be helpful to clearly itemize the additional diagnoses unrelated to the minor procedure and describe the specific E/M services provided for these diagnoses. Although it is certainly not necessary or required, it also may be helpful to physically separate the documentation for the minor procedure from the E/M services for the additional diagnoses within the medical chart.

Final Thoughts

It is clear that frequent use of modifier -25 is appropriate in routine, high-quality dermatologic practice. Simultaneous provision of E/M services and minor procedures often is in the patient’s best interest, as it minimizes unnecessary office visits and expedites treatment. When modifier -25 is appropriately appended, careful documentation by the dermatologist can help to clarify the precise basis for its use. Recent NCCI edits provide guidelines for use of this modifier that can be adapted by individual dermatologists for particular patient circumstances.²

According to Current Procedural Terminology (CPT), modifier -25 is to be used to identify “significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.”¹ Modifier -25 frequently is integral to the description of patient visits in dermatology. Dermatologists use modifier -25 more than physicians of any other specialty, and in recent years, more than 50% of dermatology evaluation and management (E/M) visits have been appended with this modifier.

When patients present for assessment and management of various skin findings, a dermatologist may deem it appropriate to proceed with a diagnostic or therapeutic procedure at the same visit after obtaining the patient’s medical history, completing a review of systems, and conducting a clinical examination. Most commonly, a skin biopsy or destruction of a benign or malignant lesion may be performed, but other simple procedures also may be appropriate. The ability to assess and intervene during the same visit is optimal for patients who subsequently may require fewer follow-up visits and experience more immediate relief from their symptoms.

When E/M Cannot Be Billed Separately

Regulatory guidance from the National Correct Coding Initiative (NCCI) dated January 2013 indicates that procedures with a global period of 90 days are major surgical procedures, and if an E/M service is performed on the same day as such a procedure to decide whether or not to perform that procedure, then the E/M service should be reported with modifier -57.² On the other hand, CPT defines procedures with a 0- or 10-day global period as minor surgical procedures, and E/M services provided on the same day of service as these procedures are included in the procedure code and cannot be billed separately. For review, common dermatologic procedures with 0-day global periods include biopsies (CPT code 11000), shave removals (11300–11313), debridements (11000, 11011–11042), and Mohs micrographic surgery (17311–17315); procedures with 10-day global periods include destructions (17000–17286), excisions (11400–11646), and repairs (12001–13153). If an E/M service is performed on the same day as one of these procedures to decide whether to proceed with the minor surgical procedure, this E/M service cannot be reported separately. Additionally, the fact that the patient is new to the physician is not sufficient to allow reporting of an E/M with such a minor procedure.

When E/M Can Be Billed Separately

However, a “significant and separately identifiable E/M service unrelated to the decision to perform the minor procedure” is separately reportable with modifier -25. According to the NCCI, the minor procedure and the E/M do not require different diagnoses, but the E/M service must be above and beyond what is usually required for the minor surgical procedure.² Because a certain amount of so-called preservice time is built into minor procedure codes, the implication is that substantially more E/M was needed than envisioned in this preservice time, necessitating inclusion of an E/M in addition to a minor procedure when there is a single diagnosis.

When there is a single diagnosis, the physician has to decide when such a significant and separately identifiable service exists. If the physician determines that it is appropriate to code for E/M in addition to the minor procedure, clear documentation of the additional E/M service provided will reduce the likelihood of this choice being questioned. Specifically, it may be helpful to describe the additional history, examination results, medical knowledge, professional skill, and work time above and beyond what is usually required for the minor surgical procedure.

When there are many diagnosis codes for a single visit and only a subset of them are associated with the minor procedure, as is common in dermatology, then the decision to include an E/M service is simpler. In this case, if E/M services were provided that pertained to a diagnosis or diagnoses other than the one(s) associated with the minor procedure(s), then these additional E/M services will clearly not be included in the preservice time for the procedure and an E/M can virtually always be coded separately. For instance, if a patient presents with a growing scaly bump (clinically apparent squamous cell carcinoma) on the leg that the dermatologist deems is appropriate for biopsy but concurrently notices nummular dermatitis of the legs, which the patient describes as itchy and uncomfortable, then the diagnosis and management of the dermatitis would clearly be a separate E/M service and would not be included in the workup for the biopsy. The E/M code that is applied should, of course, reflect the services provided exclusive of those integral to the minor procedure. To make it easier for regulators and auditors, it may be helpful to clearly itemize the additional diagnoses unrelated to the minor procedure and describe the specific E/M services provided for these diagnoses. Although it is certainly not necessary or required, it also may be helpful to physically separate the documentation for the minor procedure from the E/M services for the additional diagnoses within the medical chart.

Final Thoughts

It is clear that frequent use of modifier -25 is appropriate in routine, high-quality dermatologic practice. Simultaneous provision of E/M services and minor procedures often is in the patient’s best interest, as it minimizes unnecessary office visits and expedites treatment. When modifier -25 is appropriately appended, careful documentation by the dermatologist can help to clarify the precise basis for its use. Recent NCCI edits provide guidelines for use of this modifier that can be adapted by individual dermatologists for particular patient circumstances.²

Providers typically rely on the “key components” (history, exam, medical decision-making) when documenting in the medical record, and they often misunderstand the use of time when selecting visit levels. Sometimes providers may report a lower service level than warranted because they didn’t feel that they spent the required amount of time with the patient; however, the duration of the visit is an ancillary factor and does not control the level of service to be billed unless more than 50% of the face-to-face time (for non-inpatient services) or more than 50% of the floor time (for inpatient services) is spent providing counseling or coordination of care (C/CC).¹ In these instances, providers may choose to document only a brief history and exam, or none at all. They should update the medical decision-making based on the discussion.

Consider the hospitalization of an elderly patient who is newly diagnosed with diabetes. In addition to stabilizing the patient’s glucose levels and devising the appropriate care plan, the patient and/or caregivers also require extensive counseling regarding disease management, lifestyle modification, and medication regime. Coordination of care for outpatient programs and resources is also crucial. To make sure that this qualifies as a time-based service, ensure that the documentation contains the duration, the issues addressed, and the signature of the service provider.

Duration of Counseling and/or Coordination of Care

Time is not used for visit level selection if C/CC is minimal (<50%) or absent from the patient encounter. For inpatient services, total visit time is identified as provider face-to-face time (i.e., at the bedside) combined with time spent on the patient’s unit/floor performing services that are directly related to that patient, such as reviewing data, obtaining relevant patient information, and discussing the case with other involved healthcare providers.

Time associated with activities performed in locations other than the patient’s unit/floor (e.g. reviewing current results or images from the physician’s office) is not allowable in calculating the total visit time. Time associated with teaching students/interns is also excluded, because this doesn’t reflect patient care activities. Once the provider documents all services rendered on a given calendar date, the provider selects the visit level that corresponds with the cumulative visit time documented in the chart (see Tables 1 and 2).

Issues Addressed

When counseling and/or coordination of care dominate more than 50% of the time a physician spends with a patient during an evaluation and management (E/M) service, then time may be considered as the controlling factor to qualify the E/M service for a particular level of care.² The following must be documented in the patient’s medical record in order to report an E/M service based on time:

• The total length of time of the E/M visit;
• Evidence that more than half of the total length of time of the E/M visit was spent in counseling and coordinating of care; and
• The content of the counseling and coordination of care provided during the E/M visit.

History and exam, if performed or updated, should also be documented, along with the patient response or comprehension of information. An acceptable C/CC time entry may be noted as, “Total visit time = 35 minutes; > 50% spent counseling/coordinating care” or “20 of 35 minutes spent counseling/coordinating care.”

A payer may prefer one documentation style over another. It is always best to query payer policy and review local documentation standards to ensure compliance. Please remember that while this example constitutes the required elements for the notation of time, documentation must also include the details of counseling, care plan revisions, and any information that is pertinent to patient care and communication with other healthcare professionals.

Family Discussions

Family discussions are a typical event involved in taking care of patients and are appropriate to count as C/CC time. Special circumstances are considered when discussions must take place without the patient present. This type of counseling time is recognized but only counts towards C/CC time if the following criteria are met and documented:

• The patient is unable or clinically incompetent to participate in discussions;
• The time is spent on the unit/floor with the family members or surrogate decision makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or limitation(s) of treatment; and
• The conversation bears directly on the management of the patient.³

Time cannot be counted if the discussion takes place in an area outside of the patient’s unit/floor (e.g. in the physician’s office) or if the time is spent counseling the family members through their grieving process.

It is fairly common for the family discussion to take place later in the day, after the physician has completed morning rounds. If the earlier encounter involved C/CC, the physician would report the cumulative time spent for that service date. If the earlier encounter was a typical patient assessment incorporating the components of an evaluation (i.e., history update and physical) and management (i.e., care plan review/revision) service, the meeting time may qualify for prolonged care services.

Service Provider

Be sure to count only the physician’s time spent in C/CC. Counseling time by the nursing staff, the social worker, or the resident cannot contribute toward the physician’s total visit time. When more than one physician is involved in services throughout the day, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level under one physician’s name.⁴

Consider the following example: The hospitalist takes a brief history about overnight events and reviews some of the pertinent information with the patient. He/she then leaves the room to coordinate the patient’s ongoing care in anticipation that the patient will be discharged over the next few days (25 minutes). The resident is asked to continue the assessment and counsel the patient on the patient’s current disease process (20 minutes).

In the above scenario, the hospitalist is only able to report 99232, because the time spent by the resident is “nonbillable time.”

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12: Physicians/Nonphysician Practitioners, Section 30.6.1B. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed December 11, 2014.
2. Novitas Solutions, Inc. Frequently Asked Questions: Evaluation and Management Services (Part B). Available at: http://www.novitas-solutions.com/webcenter/faces/oracle/webcenter/page/scopedMD/sad78b265_6797_4ed0_a02f_81627913bc78/Page57.jspx?wc.contextURL=%2Fspaces%2FMedicareJH&wc.originURL=%2Fspaces%2FMedicareJH%2Fpage%2Fpagebyid&contentId=00005056&_afrLoop=1728453012371000#%40%3F_afrLoop%3D1728453012371000%26wc.originURL%3D%252Fspaces%252FMedicareJH%252Fpage%252Fpagebyid%26contentId%3D00005056%26wc.contextURL%3D%252Fspaces%252FMedicareJH%26_adf.ctrl-state%3D610bhasa4_134. Accessed on December 11, 2014.
3. Centers for Medicare and Medicaid Services. Medicare National Coverage Determinations Manual: Chapter 1, Part 1: Coverage Determinations, Section 70.1. Available at: www.cms.gov/manuals/downloads/ncd103c1_Part1.pdf. Accessed December 11, 2014.
4. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12: Physicians/Nonphysician Practitioners, Section 30.6.5. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed December 11, 2014.
5. Abraham M, Ahlman JT, Boudreau AJ, Connelly J, Levreau-Davis L. Current Procedural Terminology 2014 Professional Edition. Chicago: American Medical Association Press; 2013:1-32.
6. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12: Physicians/Nonphysician Practitioners, Section 30.6.1C. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed December 11, 2014.
7. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12: Physicians/Nonphysician Practitioners, Section 30.6.15.1G. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf.

Providers typically rely on the “key components” (history, exam, medical decision-making) when documenting in the medical record, and they often misunderstand the use of time when selecting visit levels. Sometimes providers may report a lower service level than warranted because they didn’t feel that they spent the required amount of time with the patient; however, the duration of the visit is an ancillary factor and does not control the level of service to be billed unless more than 50% of the face-to-face time (for non-inpatient services) or more than 50% of the floor time (for inpatient services) is spent providing counseling or coordination of care (C/CC).¹ In these instances, providers may choose to document only a brief history and exam, or none at all. They should update the medical decision-making based on the discussion.

Consider the hospitalization of an elderly patient who is newly diagnosed with diabetes. In addition to stabilizing the patient’s glucose levels and devising the appropriate care plan, the patient and/or caregivers also require extensive counseling regarding disease management, lifestyle modification, and medication regime. Coordination of care for outpatient programs and resources is also crucial. To make sure that this qualifies as a time-based service, ensure that the documentation contains the duration, the issues addressed, and the signature of the service provider.

Duration of Counseling and/or Coordination of Care

Time is not used for visit level selection if C/CC is minimal (<50%) or absent from the patient encounter. For inpatient services, total visit time is identified as provider face-to-face time (i.e., at the bedside) combined with time spent on the patient’s unit/floor performing services that are directly related to that patient, such as reviewing data, obtaining relevant patient information, and discussing the case with other involved healthcare providers.

Time associated with activities performed in locations other than the patient’s unit/floor (e.g. reviewing current results or images from the physician’s office) is not allowable in calculating the total visit time. Time associated with teaching students/interns is also excluded, because this doesn’t reflect patient care activities. Once the provider documents all services rendered on a given calendar date, the provider selects the visit level that corresponds with the cumulative visit time documented in the chart (see Tables 1 and 2).

Issues Addressed

When counseling and/or coordination of care dominate more than 50% of the time a physician spends with a patient during an evaluation and management (E/M) service, then time may be considered as the controlling factor to qualify the E/M service for a particular level of care.² The following must be documented in the patient’s medical record in order to report an E/M service based on time:

• The total length of time of the E/M visit;
• Evidence that more than half of the total length of time of the E/M visit was spent in counseling and coordinating of care; and
• The content of the counseling and coordination of care provided during the E/M visit.

History and exam, if performed or updated, should also be documented, along with the patient response or comprehension of information. An acceptable C/CC time entry may be noted as, “Total visit time = 35 minutes; > 50% spent counseling/coordinating care” or “20 of 35 minutes spent counseling/coordinating care.”

A payer may prefer one documentation style over another. It is always best to query payer policy and review local documentation standards to ensure compliance. Please remember that while this example constitutes the required elements for the notation of time, documentation must also include the details of counseling, care plan revisions, and any information that is pertinent to patient care and communication with other healthcare professionals.

Family Discussions

Family discussions are a typical event involved in taking care of patients and are appropriate to count as C/CC time. Special circumstances are considered when discussions must take place without the patient present. This type of counseling time is recognized but only counts towards C/CC time if the following criteria are met and documented:

• The patient is unable or clinically incompetent to participate in discussions;
• The time is spent on the unit/floor with the family members or surrogate decision makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or limitation(s) of treatment; and
• The conversation bears directly on the management of the patient.³

Time cannot be counted if the discussion takes place in an area outside of the patient’s unit/floor (e.g. in the physician’s office) or if the time is spent counseling the family members through their grieving process.

It is fairly common for the family discussion to take place later in the day, after the physician has completed morning rounds. If the earlier encounter involved C/CC, the physician would report the cumulative time spent for that service date. If the earlier encounter was a typical patient assessment incorporating the components of an evaluation (i.e., history update and physical) and management (i.e., care plan review/revision) service, the meeting time may qualify for prolonged care services.

Service Provider

Be sure to count only the physician’s time spent in C/CC. Counseling time by the nursing staff, the social worker, or the resident cannot contribute toward the physician’s total visit time. When more than one physician is involved in services throughout the day, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level under one physician’s name.⁴

Consider the following example: The hospitalist takes a brief history about overnight events and reviews some of the pertinent information with the patient. He/she then leaves the room to coordinate the patient’s ongoing care in anticipation that the patient will be discharged over the next few days (25 minutes). The resident is asked to continue the assessment and counsel the patient on the patient’s current disease process (20 minutes).

In the above scenario, the hospitalist is only able to report 99232, because the time spent by the resident is “nonbillable time.”

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12: Physicians/Nonphysician Practitioners, Section 30.6.1B. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed December 11, 2014.
2. Novitas Solutions, Inc. Frequently Asked Questions: Evaluation and Management Services (Part B). Available at: http://www.novitas-solutions.com/webcenter/faces/oracle/webcenter/page/scopedMD/sad78b265_6797_4ed0_a02f_81627913bc78/Page57.jspx?wc.contextURL=%2Fspaces%2FMedicareJH&wc.originURL=%2Fspaces%2FMedicareJH%2Fpage%2Fpagebyid&contentId=00005056&_afrLoop=1728453012371000#%40%3F_afrLoop%3D1728453012371000%26wc.originURL%3D%252Fspaces%252FMedicareJH%252Fpage%252Fpagebyid%26contentId%3D00005056%26wc.contextURL%3D%252Fspaces%252FMedicareJH%26_adf.ctrl-state%3D610bhasa4_134. Accessed on December 11, 2014.
3. Centers for Medicare and Medicaid Services. Medicare National Coverage Determinations Manual: Chapter 1, Part 1: Coverage Determinations, Section 70.1. Available at: www.cms.gov/manuals/downloads/ncd103c1_Part1.pdf. Accessed December 11, 2014.
4. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12: Physicians/Nonphysician Practitioners, Section 30.6.5. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed December 11, 2014.
5. Abraham M, Ahlman JT, Boudreau AJ, Connelly J, Levreau-Davis L. Current Procedural Terminology 2014 Professional Edition. Chicago: American Medical Association Press; 2013:1-32.
6. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12: Physicians/Nonphysician Practitioners, Section 30.6.1C. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed December 11, 2014.
7. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12: Physicians/Nonphysician Practitioners, Section 30.6.15.1G. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf.

Providers typically rely on the “key components” (history, exam, medical decision-making) when documenting in the medical record, and they often misunderstand the use of time when selecting visit levels. Sometimes providers may report a lower service level than warranted because they didn’t feel that they spent the required amount of time with the patient; however, the duration of the visit is an ancillary factor and does not control the level of service to be billed unless more than 50% of the face-to-face time (for non-inpatient services) or more than 50% of the floor time (for inpatient services) is spent providing counseling or coordination of care (C/CC).¹ In these instances, providers may choose to document only a brief history and exam, or none at all. They should update the medical decision-making based on the discussion.

Consider the hospitalization of an elderly patient who is newly diagnosed with diabetes. In addition to stabilizing the patient’s glucose levels and devising the appropriate care plan, the patient and/or caregivers also require extensive counseling regarding disease management, lifestyle modification, and medication regime. Coordination of care for outpatient programs and resources is also crucial. To make sure that this qualifies as a time-based service, ensure that the documentation contains the duration, the issues addressed, and the signature of the service provider.

Duration of Counseling and/or Coordination of Care

Time is not used for visit level selection if C/CC is minimal (<50%) or absent from the patient encounter. For inpatient services, total visit time is identified as provider face-to-face time (i.e., at the bedside) combined with time spent on the patient’s unit/floor performing services that are directly related to that patient, such as reviewing data, obtaining relevant patient information, and discussing the case with other involved healthcare providers.

Time associated with activities performed in locations other than the patient’s unit/floor (e.g. reviewing current results or images from the physician’s office) is not allowable in calculating the total visit time. Time associated with teaching students/interns is also excluded, because this doesn’t reflect patient care activities. Once the provider documents all services rendered on a given calendar date, the provider selects the visit level that corresponds with the cumulative visit time documented in the chart (see Tables 1 and 2).

Issues Addressed

When counseling and/or coordination of care dominate more than 50% of the time a physician spends with a patient during an evaluation and management (E/M) service, then time may be considered as the controlling factor to qualify the E/M service for a particular level of care.² The following must be documented in the patient’s medical record in order to report an E/M service based on time:

• The total length of time of the E/M visit;
• Evidence that more than half of the total length of time of the E/M visit was spent in counseling and coordinating of care; and
• The content of the counseling and coordination of care provided during the E/M visit.

History and exam, if performed or updated, should also be documented, along with the patient response or comprehension of information. An acceptable C/CC time entry may be noted as, “Total visit time = 35 minutes; > 50% spent counseling/coordinating care” or “20 of 35 minutes spent counseling/coordinating care.”

A payer may prefer one documentation style over another. It is always best to query payer policy and review local documentation standards to ensure compliance. Please remember that while this example constitutes the required elements for the notation of time, documentation must also include the details of counseling, care plan revisions, and any information that is pertinent to patient care and communication with other healthcare professionals.

Family Discussions

Family discussions are a typical event involved in taking care of patients and are appropriate to count as C/CC time. Special circumstances are considered when discussions must take place without the patient present. This type of counseling time is recognized but only counts towards C/CC time if the following criteria are met and documented:

• The patient is unable or clinically incompetent to participate in discussions;
• The time is spent on the unit/floor with the family members or surrogate decision makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or limitation(s) of treatment; and
• The conversation bears directly on the management of the patient.³

Time cannot be counted if the discussion takes place in an area outside of the patient’s unit/floor (e.g. in the physician’s office) or if the time is spent counseling the family members through their grieving process.

It is fairly common for the family discussion to take place later in the day, after the physician has completed morning rounds. If the earlier encounter involved C/CC, the physician would report the cumulative time spent for that service date. If the earlier encounter was a typical patient assessment incorporating the components of an evaluation (i.e., history update and physical) and management (i.e., care plan review/revision) service, the meeting time may qualify for prolonged care services.

Service Provider

Be sure to count only the physician’s time spent in C/CC. Counseling time by the nursing staff, the social worker, or the resident cannot contribute toward the physician’s total visit time. When more than one physician is involved in services throughout the day, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level under one physician’s name.⁴

Consider the following example: The hospitalist takes a brief history about overnight events and reviews some of the pertinent information with the patient. He/she then leaves the room to coordinate the patient’s ongoing care in anticipation that the patient will be discharged over the next few days (25 minutes). The resident is asked to continue the assessment and counsel the patient on the patient’s current disease process (20 minutes).

In the above scenario, the hospitalist is only able to report 99232, because the time spent by the resident is “nonbillable time.”

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12: Physicians/Nonphysician Practitioners, Section 30.6.1B. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed December 11, 2014.
2. Novitas Solutions, Inc. Frequently Asked Questions: Evaluation and Management Services (Part B). Available at: http://www.novitas-solutions.com/webcenter/faces/oracle/webcenter/page/scopedMD/sad78b265_6797_4ed0_a02f_81627913bc78/Page57.jspx?wc.contextURL=%2Fspaces%2FMedicareJH&wc.originURL=%2Fspaces%2FMedicareJH%2Fpage%2Fpagebyid&contentId=00005056&_afrLoop=1728453012371000#%40%3F_afrLoop%3D1728453012371000%26wc.originURL%3D%252Fspaces%252FMedicareJH%252Fpage%252Fpagebyid%26contentId%3D00005056%26wc.contextURL%3D%252Fspaces%252FMedicareJH%26_adf.ctrl-state%3D610bhasa4_134. Accessed on December 11, 2014.
3. Centers for Medicare and Medicaid Services. Medicare National Coverage Determinations Manual: Chapter 1, Part 1: Coverage Determinations, Section 70.1. Available at: www.cms.gov/manuals/downloads/ncd103c1_Part1.pdf. Accessed December 11, 2014.
4. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12: Physicians/Nonphysician Practitioners, Section 30.6.5. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed December 11, 2014.
5. Abraham M, Ahlman JT, Boudreau AJ, Connelly J, Levreau-Davis L. Current Procedural Terminology 2014 Professional Edition. Chicago: American Medical Association Press; 2013:1-32.
6. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12: Physicians/Nonphysician Practitioners, Section 30.6.1C. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed December 11, 2014.
7. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12: Physicians/Nonphysician Practitioners, Section 30.6.15.1G. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf.

In a previous column I discussed the challenges inherent to incorporating the Patient Protection and Affordable Care Act’s health insurance exchanges into private practices.¹ While it is important to pay close attention to newer third-party vehicles, do not ignore established payers or assume their compensation schedules are up-to-date.

Because traditional insurers and managed care organizations typically do not take it upon themselves to update their payment schedules for private practices on a regular basis, you should take a close look at your third-party plans; you may be surprised to find that you have unknowingly remained associated with an outdated plan with an inappropriate fee schedule or with few patients generating negligible remuneration for your practice when you could have replaced it with a young, aggressive, well-paying organization long ago.

As is usually the case, you will never know unless you look. The process is the sort of disagreeable task that smaller practices often postpone or ignore completely, but the effort is well worth it. First, ask your employees to assemble some data. Start with lists of the last 50 patients affiliated with each third-party contract; your electronic records should allow you to assemble these data easily. For each patient, note the diagnoses; the procedure codes billed; the amounts billed and paid for each code; and any problems encountered, especially payment delays and records requests. Also ask for any correspondence you have on file with claims departments and medical directors over the last year.

Next, send out a questionnaire to the provider relations department for each third-party payer. Tell them you are updating your managed care data. Include a list of your 25 most commonly used Current Procedural Terminology (CPT) codes and ask for their maximum allowable reimbursement on each code. Then ask some basic questions. There are 5 questions we routinely ask in my practice:

Have a staffer follow-up with a telephone call 10 days later on each letter to make sure it was received and will be answered promptly.

Once these questions have been answered, schedule a meeting with your office manager and your insurance specialist. Put the telephones on service, ask someone else to cover emergencies, and otherwise make sure you will not be disturbed during this time. Armed with the answers received from each payer and the data you have collected, analyze each plan in detail during this meeting. How many of the payer’s patients are currently active in your practice? Is that number increasing or decreasing? How well does each one compensate you compared to other payers, Medicare, and your regular fees, and how promptly are you paid? What problems have you had with referral and claim forms? Are you permitted to bill patients for uncovered charges?

More specific issues also should be addressed. For instance, what services, precisely, are not covered? Which procedures are paid particularly well and which are paid poorly (or not at all) despite being ostensibly “covered”? Are there any unusual or unorthodox rules for certain surgical or diagnostic procedures? Do you get an inordinate number of requests for further information from the payer? Are you asked for the same information repeatedly? Are there problems with CPT modifiers 25 and 78, or other modifiers?

Then take a hard look at the numbers. What fraction of your accounts receivable is attributed to each plan at any particular moment? Is that number increasing? If so, is it because the number of patients in that plan is increasing, or is it because the plan is losing momentum in paying its bills? The latter is a red flag; either growth is outstripping efficiency or financial problems are looming.

It also is important to look at mechanics of each plan. How easy is it for patients to get a referral to your office? Do primary care practitioners dole out referrals as if they were diamonds? Be sure to review the referral requirements in each of your contracts. On those all-too-common occasions when patients show up for an appointment without a valid referral, how easy does the plan make it to get them one quickly?

Finally, talk to your insurance representatives, the staffers who deal with these plans on a daily basis. Their subjective impressions are just as important as any hard data. They will immediately separate the good plans from the bad, but it also is important to ask them some specific questions. Is your staff constantly cutting through red tape to get patients seen? Are claim forms confusing or hard to file? How hard is it to get a hold of provider relations representatives, and once contacted, are they helpful and courteous? Are provider relations representatives constantly calling your office with unnecessary or inappropriate questions?

After you collect all of this information, you will have your own up-to-the-minute managed care database, which you can consult immediately to determine which plans you will keep and which you should disengage. Repeat this exercise regularly—we now do it yearly in my practice—because the private insurance environment is evolving ever more rapidly due to the advent of the Patient Protection and Affordable Care Act and other factors.

Another important use for your managed care database is to renegotiate your fee schedule. Any payer with fees that are below your average remuneration should receive a letter informing them that the payments are below the level that is recognized as usual and customary in your area. Inform them that your office will be pleased to give them the opportunity to remain associated with your practice if their reimbursements are immediately increased. Although insurers are not always receptive to requests for increased compensation, they are usually willing to open a dialogue; if not, you will need to reconsider your practice’s continued association with that plan.

This exercise requires a lot of work, but your time and effort will be well spent. In addition to ensuring that your services are properly compensated, you will be putting your third-party payers on notice that you are paying attention and that your office will not tolerate unfair remuneration or inordinate delays in payment.  

In a previous column I discussed the challenges inherent to incorporating the Patient Protection and Affordable Care Act’s health insurance exchanges into private practices.¹ While it is important to pay close attention to newer third-party vehicles, do not ignore established payers or assume their compensation schedules are up-to-date.

Because traditional insurers and managed care organizations typically do not take it upon themselves to update their payment schedules for private practices on a regular basis, you should take a close look at your third-party plans; you may be surprised to find that you have unknowingly remained associated with an outdated plan with an inappropriate fee schedule or with few patients generating negligible remuneration for your practice when you could have replaced it with a young, aggressive, well-paying organization long ago.

As is usually the case, you will never know unless you look. The process is the sort of disagreeable task that smaller practices often postpone or ignore completely, but the effort is well worth it. First, ask your employees to assemble some data. Start with lists of the last 50 patients affiliated with each third-party contract; your electronic records should allow you to assemble these data easily. For each patient, note the diagnoses; the procedure codes billed; the amounts billed and paid for each code; and any problems encountered, especially payment delays and records requests. Also ask for any correspondence you have on file with claims departments and medical directors over the last year.

Next, send out a questionnaire to the provider relations department for each third-party payer. Tell them you are updating your managed care data. Include a list of your 25 most commonly used Current Procedural Terminology (CPT) codes and ask for their maximum allowable reimbursement on each code. Then ask some basic questions. There are 5 questions we routinely ask in my practice:

Have a staffer follow-up with a telephone call 10 days later on each letter to make sure it was received and will be answered promptly.

Once these questions have been answered, schedule a meeting with your office manager and your insurance specialist. Put the telephones on service, ask someone else to cover emergencies, and otherwise make sure you will not be disturbed during this time. Armed with the answers received from each payer and the data you have collected, analyze each plan in detail during this meeting. How many of the payer’s patients are currently active in your practice? Is that number increasing or decreasing? How well does each one compensate you compared to other payers, Medicare, and your regular fees, and how promptly are you paid? What problems have you had with referral and claim forms? Are you permitted to bill patients for uncovered charges?

More specific issues also should be addressed. For instance, what services, precisely, are not covered? Which procedures are paid particularly well and which are paid poorly (or not at all) despite being ostensibly “covered”? Are there any unusual or unorthodox rules for certain surgical or diagnostic procedures? Do you get an inordinate number of requests for further information from the payer? Are you asked for the same information repeatedly? Are there problems with CPT modifiers 25 and 78, or other modifiers?

Then take a hard look at the numbers. What fraction of your accounts receivable is attributed to each plan at any particular moment? Is that number increasing? If so, is it because the number of patients in that plan is increasing, or is it because the plan is losing momentum in paying its bills? The latter is a red flag; either growth is outstripping efficiency or financial problems are looming.

It also is important to look at mechanics of each plan. How easy is it for patients to get a referral to your office? Do primary care practitioners dole out referrals as if they were diamonds? Be sure to review the referral requirements in each of your contracts. On those all-too-common occasions when patients show up for an appointment without a valid referral, how easy does the plan make it to get them one quickly?

Finally, talk to your insurance representatives, the staffers who deal with these plans on a daily basis. Their subjective impressions are just as important as any hard data. They will immediately separate the good plans from the bad, but it also is important to ask them some specific questions. Is your staff constantly cutting through red tape to get patients seen? Are claim forms confusing or hard to file? How hard is it to get a hold of provider relations representatives, and once contacted, are they helpful and courteous? Are provider relations representatives constantly calling your office with unnecessary or inappropriate questions?

After you collect all of this information, you will have your own up-to-the-minute managed care database, which you can consult immediately to determine which plans you will keep and which you should disengage. Repeat this exercise regularly—we now do it yearly in my practice—because the private insurance environment is evolving ever more rapidly due to the advent of the Patient Protection and Affordable Care Act and other factors.

Another important use for your managed care database is to renegotiate your fee schedule. Any payer with fees that are below your average remuneration should receive a letter informing them that the payments are below the level that is recognized as usual and customary in your area. Inform them that your office will be pleased to give them the opportunity to remain associated with your practice if their reimbursements are immediately increased. Although insurers are not always receptive to requests for increased compensation, they are usually willing to open a dialogue; if not, you will need to reconsider your practice’s continued association with that plan.

This exercise requires a lot of work, but your time and effort will be well spent. In addition to ensuring that your services are properly compensated, you will be putting your third-party payers on notice that you are paying attention and that your office will not tolerate unfair remuneration or inordinate delays in payment.  

In a previous column I discussed the challenges inherent to incorporating the Patient Protection and Affordable Care Act’s health insurance exchanges into private practices.¹ While it is important to pay close attention to newer third-party vehicles, do not ignore established payers or assume their compensation schedules are up-to-date.

Because traditional insurers and managed care organizations typically do not take it upon themselves to update their payment schedules for private practices on a regular basis, you should take a close look at your third-party plans; you may be surprised to find that you have unknowingly remained associated with an outdated plan with an inappropriate fee schedule or with few patients generating negligible remuneration for your practice when you could have replaced it with a young, aggressive, well-paying organization long ago.

As is usually the case, you will never know unless you look. The process is the sort of disagreeable task that smaller practices often postpone or ignore completely, but the effort is well worth it. First, ask your employees to assemble some data. Start with lists of the last 50 patients affiliated with each third-party contract; your electronic records should allow you to assemble these data easily. For each patient, note the diagnoses; the procedure codes billed; the amounts billed and paid for each code; and any problems encountered, especially payment delays and records requests. Also ask for any correspondence you have on file with claims departments and medical directors over the last year.

Next, send out a questionnaire to the provider relations department for each third-party payer. Tell them you are updating your managed care data. Include a list of your 25 most commonly used Current Procedural Terminology (CPT) codes and ask for their maximum allowable reimbursement on each code. Then ask some basic questions. There are 5 questions we routinely ask in my practice:

Have a staffer follow-up with a telephone call 10 days later on each letter to make sure it was received and will be answered promptly.

Once these questions have been answered, schedule a meeting with your office manager and your insurance specialist. Put the telephones on service, ask someone else to cover emergencies, and otherwise make sure you will not be disturbed during this time. Armed with the answers received from each payer and the data you have collected, analyze each plan in detail during this meeting. How many of the payer’s patients are currently active in your practice? Is that number increasing or decreasing? How well does each one compensate you compared to other payers, Medicare, and your regular fees, and how promptly are you paid? What problems have you had with referral and claim forms? Are you permitted to bill patients for uncovered charges?

More specific issues also should be addressed. For instance, what services, precisely, are not covered? Which procedures are paid particularly well and which are paid poorly (or not at all) despite being ostensibly “covered”? Are there any unusual or unorthodox rules for certain surgical or diagnostic procedures? Do you get an inordinate number of requests for further information from the payer? Are you asked for the same information repeatedly? Are there problems with CPT modifiers 25 and 78, or other modifiers?

Then take a hard look at the numbers. What fraction of your accounts receivable is attributed to each plan at any particular moment? Is that number increasing? If so, is it because the number of patients in that plan is increasing, or is it because the plan is losing momentum in paying its bills? The latter is a red flag; either growth is outstripping efficiency or financial problems are looming.

It also is important to look at mechanics of each plan. How easy is it for patients to get a referral to your office? Do primary care practitioners dole out referrals as if they were diamonds? Be sure to review the referral requirements in each of your contracts. On those all-too-common occasions when patients show up for an appointment without a valid referral, how easy does the plan make it to get them one quickly?

Finally, talk to your insurance representatives, the staffers who deal with these plans on a daily basis. Their subjective impressions are just as important as any hard data. They will immediately separate the good plans from the bad, but it also is important to ask them some specific questions. Is your staff constantly cutting through red tape to get patients seen? Are claim forms confusing or hard to file? How hard is it to get a hold of provider relations representatives, and once contacted, are they helpful and courteous? Are provider relations representatives constantly calling your office with unnecessary or inappropriate questions?

After you collect all of this information, you will have your own up-to-the-minute managed care database, which you can consult immediately to determine which plans you will keep and which you should disengage. Repeat this exercise regularly—we now do it yearly in my practice—because the private insurance environment is evolving ever more rapidly due to the advent of the Patient Protection and Affordable Care Act and other factors.

Another important use for your managed care database is to renegotiate your fee schedule. Any payer with fees that are below your average remuneration should receive a letter informing them that the payments are below the level that is recognized as usual and customary in your area. Inform them that your office will be pleased to give them the opportunity to remain associated with your practice if their reimbursements are immediately increased. Although insurers are not always receptive to requests for increased compensation, they are usually willing to open a dialogue; if not, you will need to reconsider your practice’s continued association with that plan.

This exercise requires a lot of work, but your time and effort will be well spent. In addition to ensuring that your services are properly compensated, you will be putting your third-party payers on notice that you are paying attention and that your office will not tolerate unfair remuneration or inordinate delays in payment.  

Preventable medical errors rank as the third most common cause of death in the United States after heart disease and cancer.¹ They are responsible for 400,000 deaths each year (over 1095 per day) and another 10,000 serious complications resulting from medical errors each day.¹ That is the equivalent of two 747 airliner midair crashes per day. The economic cost to our nation is $1 trillion per year.¹

On July 17, 2014, the US Senate Subcommittee on Primary Health and Aging met to address this crisis. Participants included senators and John James, PhD, Founder, Patient Safety America, Houston, Texas; Ashish Jha, MD, MPH, Professor of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts; Tejal Gandhi, MD, MPH, President, National Patient Safety Foundation, and Associate Professor of Medicine, Harvard Medical School, Boston, Massachusetts; Peter Pronovost, MD, PhD, Senior Vice President for Patient Safety and Quality, and Director of the Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland; Joanne Disch, PhD, RN, Professor ad Honorem, University of Minnesota School of Nursing, Minneapolis, Minnesota; and Lisa McGiffert, Director, Safe Patient Project, Consumers Union, Austin, Texas. While each speaker suggested various strategies for improving patient safety, they all agreed that information technology is not living up to our expectations for meeting this need. They also agreed that health care has become increasingly “high tech and low touch,” and, as a result, the medical community is leveraging neither technology nor the knowledge accrued from individual patient/physician interactions to improve patient safety and outcomes.¹

Last year my mother had a spinal fusion. The surgery was a success by all measures. Two days after she was discharged home, she became weak and was unable to walk. She went to the emergency room, where it was noted that she was severely hyponatremic, weak, and experiencing severe back pain. For the next 36 hours she was not seen by a physician or physician assistant (PA), as the PA who admitted her to the hospital had not notified the “team” that she was admitted. My father, who is a vascular surgeon, notified her spine surgeon, who came to see her. Her hyponatremia was markedly worse, and she was transferred to the intensive care unit (ICU). She continued to decline and was started on hypertonic intravenous (IV) saline. Over the next several days her hyponatremia improved, and she was transferred out of the ICU but continued to have pain. The spine surgeon examined her several times, and imaging showed no evidence of epidural bleeding, infection, or misplaced hardware.

Over the next several days, I was informed by family members that the nurses were “keeping the pain in check” with IV narcotics and that my mom was heavily sedated most of the time. My dad later informed me that she had a foot drop on the left, and the next day another family member told me the foot drop was on the right. My dad and stepbrother each assured me that they were right. When my mom could talk, she told me how weak she was and that sometimes it was her right leg and other times her left. She was seen by a neurologist on 6 out of the next 10 days and underwent 3 computed tomography scans and magnetic resonance imaging, and the neurologist assured us that she had not had a stroke. On a Friday evening, I called my mom, who was progressively short of breath, and she told me that she felt weaker and weaker each day. The “foot drop,” which was now bilateral according to the neurologist, was from “not using it while she was in the ICU.”

My mom, who is an artist, commented that she was having trouble using her hands now and unable to hold a cup. I called the physician on call, who assured me that she was taking care of my mom’s blood pressure (which was labile for the first time ever; she had no history of hypertension) and her pain score was a 5. I explained that I knew that she was not “looking to play mystery diagnosis with an orthopedic surgeon 500 miles away, but I think my mom has Guillain-Barré syndrome.” Fortunately, the doctor said, “Oh my god, I think you’re right.” Monday morning, her diagnosis was confirmed and she has made a remarkable recovery. So how is it that she could be seen by a neurologist and a team of nurses, doctors, therapists, and resident staff and no one made a diagnosis? Certainly contributing factors include a system of multiple medical teams with frequent turnovers and a desire to consult others but no real “quarterback” who was looking at the overall care in a responsible and critical way. A thorough history and physical examination, rather than a multitude of expensive and unnecessary imaging studies, could certainly have led to a quicker diagnosis and avoidance of a protracted hospital stay and rehabilitation.

To be sure, there are many factors that lead to delays in diagnosis. The reliance on advanced imaging, the lack of a simple physical examination, and the lack of critical thinking played prominently in the failure to make a diagnosis in my mom’s case. Some would argue that we need information technology (IT) systems that will allow us to better diagnose and treat patients. They believe that with electronic medical records (EMRs) data points will be entered and a diagnosis will be made. Major corporations like IBM and GE are working to make this a reality. Although Watson (the artificially intelligent computer system created by IBM) may be able to win on Jeopardy and may move the needle forward to improving patient care, 2 things are certain: (1) Appropriate data will need to be input by people, and (2) without critical thinking, the appropriate data can’t be entered or interpreted correctly. 

The fact remains that EMR has fallen short of expectations. We have more data at our fingertips but this has not translated into a significant improvement in patient safety. The human factor remains critical. Even though industry and health care workers strive to innovate and merge technological advances with improved patient outcomes, technology will continue to fall short of expectations without the input of critical thinking. There are things that computers and technological advances can do that people can’t, and there are things that people can do that computers can’t.

We cannot become a profession reliant on technology to substitute for critical thinking, and we cannot become a profession that doesn’t recognize what technology can bring to us and our patients. Like a railroad track that needs 2 parallel tracks to move trains, we must continue to build on 2 tracks: innovation and critical thinking. ◾

Preventable medical errors rank as the third most common cause of death in the United States after heart disease and cancer.¹ They are responsible for 400,000 deaths each year (over 1095 per day) and another 10,000 serious complications resulting from medical errors each day.¹ That is the equivalent of two 747 airliner midair crashes per day. The economic cost to our nation is $1 trillion per year.¹

On July 17, 2014, the US Senate Subcommittee on Primary Health and Aging met to address this crisis. Participants included senators and John James, PhD, Founder, Patient Safety America, Houston, Texas; Ashish Jha, MD, MPH, Professor of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts; Tejal Gandhi, MD, MPH, President, National Patient Safety Foundation, and Associate Professor of Medicine, Harvard Medical School, Boston, Massachusetts; Peter Pronovost, MD, PhD, Senior Vice President for Patient Safety and Quality, and Director of the Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland; Joanne Disch, PhD, RN, Professor ad Honorem, University of Minnesota School of Nursing, Minneapolis, Minnesota; and Lisa McGiffert, Director, Safe Patient Project, Consumers Union, Austin, Texas. While each speaker suggested various strategies for improving patient safety, they all agreed that information technology is not living up to our expectations for meeting this need. They also agreed that health care has become increasingly “high tech and low touch,” and, as a result, the medical community is leveraging neither technology nor the knowledge accrued from individual patient/physician interactions to improve patient safety and outcomes.¹

Last year my mother had a spinal fusion. The surgery was a success by all measures. Two days after she was discharged home, she became weak and was unable to walk. She went to the emergency room, where it was noted that she was severely hyponatremic, weak, and experiencing severe back pain. For the next 36 hours she was not seen by a physician or physician assistant (PA), as the PA who admitted her to the hospital had not notified the “team” that she was admitted. My father, who is a vascular surgeon, notified her spine surgeon, who came to see her. Her hyponatremia was markedly worse, and she was transferred to the intensive care unit (ICU). She continued to decline and was started on hypertonic intravenous (IV) saline. Over the next several days her hyponatremia improved, and she was transferred out of the ICU but continued to have pain. The spine surgeon examined her several times, and imaging showed no evidence of epidural bleeding, infection, or misplaced hardware.

Over the next several days, I was informed by family members that the nurses were “keeping the pain in check” with IV narcotics and that my mom was heavily sedated most of the time. My dad later informed me that she had a foot drop on the left, and the next day another family member told me the foot drop was on the right. My dad and stepbrother each assured me that they were right. When my mom could talk, she told me how weak she was and that sometimes it was her right leg and other times her left. She was seen by a neurologist on 6 out of the next 10 days and underwent 3 computed tomography scans and magnetic resonance imaging, and the neurologist assured us that she had not had a stroke. On a Friday evening, I called my mom, who was progressively short of breath, and she told me that she felt weaker and weaker each day. The “foot drop,” which was now bilateral according to the neurologist, was from “not using it while she was in the ICU.”

My mom, who is an artist, commented that she was having trouble using her hands now and unable to hold a cup. I called the physician on call, who assured me that she was taking care of my mom’s blood pressure (which was labile for the first time ever; she had no history of hypertension) and her pain score was a 5. I explained that I knew that she was not “looking to play mystery diagnosis with an orthopedic surgeon 500 miles away, but I think my mom has Guillain-Barré syndrome.” Fortunately, the doctor said, “Oh my god, I think you’re right.” Monday morning, her diagnosis was confirmed and she has made a remarkable recovery. So how is it that she could be seen by a neurologist and a team of nurses, doctors, therapists, and resident staff and no one made a diagnosis? Certainly contributing factors include a system of multiple medical teams with frequent turnovers and a desire to consult others but no real “quarterback” who was looking at the overall care in a responsible and critical way. A thorough history and physical examination, rather than a multitude of expensive and unnecessary imaging studies, could certainly have led to a quicker diagnosis and avoidance of a protracted hospital stay and rehabilitation.

To be sure, there are many factors that lead to delays in diagnosis. The reliance on advanced imaging, the lack of a simple physical examination, and the lack of critical thinking played prominently in the failure to make a diagnosis in my mom’s case. Some would argue that we need information technology (IT) systems that will allow us to better diagnose and treat patients. They believe that with electronic medical records (EMRs) data points will be entered and a diagnosis will be made. Major corporations like IBM and GE are working to make this a reality. Although Watson (the artificially intelligent computer system created by IBM) may be able to win on Jeopardy and may move the needle forward to improving patient care, 2 things are certain: (1) Appropriate data will need to be input by people, and (2) without critical thinking, the appropriate data can’t be entered or interpreted correctly. 

The fact remains that EMR has fallen short of expectations. We have more data at our fingertips but this has not translated into a significant improvement in patient safety. The human factor remains critical. Even though industry and health care workers strive to innovate and merge technological advances with improved patient outcomes, technology will continue to fall short of expectations without the input of critical thinking. There are things that computers and technological advances can do that people can’t, and there are things that people can do that computers can’t.

We cannot become a profession reliant on technology to substitute for critical thinking, and we cannot become a profession that doesn’t recognize what technology can bring to us and our patients. Like a railroad track that needs 2 parallel tracks to move trains, we must continue to build on 2 tracks: innovation and critical thinking. ◾

Preventable medical errors rank as the third most common cause of death in the United States after heart disease and cancer.¹ They are responsible for 400,000 deaths each year (over 1095 per day) and another 10,000 serious complications resulting from medical errors each day.¹ That is the equivalent of two 747 airliner midair crashes per day. The economic cost to our nation is $1 trillion per year.¹

On July 17, 2014, the US Senate Subcommittee on Primary Health and Aging met to address this crisis. Participants included senators and John James, PhD, Founder, Patient Safety America, Houston, Texas; Ashish Jha, MD, MPH, Professor of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts; Tejal Gandhi, MD, MPH, President, National Patient Safety Foundation, and Associate Professor of Medicine, Harvard Medical School, Boston, Massachusetts; Peter Pronovost, MD, PhD, Senior Vice President for Patient Safety and Quality, and Director of the Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland; Joanne Disch, PhD, RN, Professor ad Honorem, University of Minnesota School of Nursing, Minneapolis, Minnesota; and Lisa McGiffert, Director, Safe Patient Project, Consumers Union, Austin, Texas. While each speaker suggested various strategies for improving patient safety, they all agreed that information technology is not living up to our expectations for meeting this need. They also agreed that health care has become increasingly “high tech and low touch,” and, as a result, the medical community is leveraging neither technology nor the knowledge accrued from individual patient/physician interactions to improve patient safety and outcomes.¹

Last year my mother had a spinal fusion. The surgery was a success by all measures. Two days after she was discharged home, she became weak and was unable to walk. She went to the emergency room, where it was noted that she was severely hyponatremic, weak, and experiencing severe back pain. For the next 36 hours she was not seen by a physician or physician assistant (PA), as the PA who admitted her to the hospital had not notified the “team” that she was admitted. My father, who is a vascular surgeon, notified her spine surgeon, who came to see her. Her hyponatremia was markedly worse, and she was transferred to the intensive care unit (ICU). She continued to decline and was started on hypertonic intravenous (IV) saline. Over the next several days her hyponatremia improved, and she was transferred out of the ICU but continued to have pain. The spine surgeon examined her several times, and imaging showed no evidence of epidural bleeding, infection, or misplaced hardware.

Over the next several days, I was informed by family members that the nurses were “keeping the pain in check” with IV narcotics and that my mom was heavily sedated most of the time. My dad later informed me that she had a foot drop on the left, and the next day another family member told me the foot drop was on the right. My dad and stepbrother each assured me that they were right. When my mom could talk, she told me how weak she was and that sometimes it was her right leg and other times her left. She was seen by a neurologist on 6 out of the next 10 days and underwent 3 computed tomography scans and magnetic resonance imaging, and the neurologist assured us that she had not had a stroke. On a Friday evening, I called my mom, who was progressively short of breath, and she told me that she felt weaker and weaker each day. The “foot drop,” which was now bilateral according to the neurologist, was from “not using it while she was in the ICU.”

My mom, who is an artist, commented that she was having trouble using her hands now and unable to hold a cup. I called the physician on call, who assured me that she was taking care of my mom’s blood pressure (which was labile for the first time ever; she had no history of hypertension) and her pain score was a 5. I explained that I knew that she was not “looking to play mystery diagnosis with an orthopedic surgeon 500 miles away, but I think my mom has Guillain-Barré syndrome.” Fortunately, the doctor said, “Oh my god, I think you’re right.” Monday morning, her diagnosis was confirmed and she has made a remarkable recovery. So how is it that she could be seen by a neurologist and a team of nurses, doctors, therapists, and resident staff and no one made a diagnosis? Certainly contributing factors include a system of multiple medical teams with frequent turnovers and a desire to consult others but no real “quarterback” who was looking at the overall care in a responsible and critical way. A thorough history and physical examination, rather than a multitude of expensive and unnecessary imaging studies, could certainly have led to a quicker diagnosis and avoidance of a protracted hospital stay and rehabilitation.

To be sure, there are many factors that lead to delays in diagnosis. The reliance on advanced imaging, the lack of a simple physical examination, and the lack of critical thinking played prominently in the failure to make a diagnosis in my mom’s case. Some would argue that we need information technology (IT) systems that will allow us to better diagnose and treat patients. They believe that with electronic medical records (EMRs) data points will be entered and a diagnosis will be made. Major corporations like IBM and GE are working to make this a reality. Although Watson (the artificially intelligent computer system created by IBM) may be able to win on Jeopardy and may move the needle forward to improving patient care, 2 things are certain: (1) Appropriate data will need to be input by people, and (2) without critical thinking, the appropriate data can’t be entered or interpreted correctly. 

The fact remains that EMR has fallen short of expectations. We have more data at our fingertips but this has not translated into a significant improvement in patient safety. The human factor remains critical. Even though industry and health care workers strive to innovate and merge technological advances with improved patient outcomes, technology will continue to fall short of expectations without the input of critical thinking. There are things that computers and technological advances can do that people can’t, and there are things that people can do that computers can’t.

We cannot become a profession reliant on technology to substitute for critical thinking, and we cannot become a profession that doesn’t recognize what technology can bring to us and our patients. Like a railroad track that needs 2 parallel tracks to move trains, we must continue to build on 2 tracks: innovation and critical thinking. ◾

Health care reform has triggered considerable discussion both in print and online about the administrative problems it has created for private practitioners, including decreased cash flow, increased paperwork and business expenses, and an increasing number of high-deductible insurance exchanges with the infamous 90-day “grace periods.” Extending discounts to patients who pay at the time of service or out of pocket may mitigate damage caused by all 3 of these issues; however, caution is necessary, as discounts often can run afoul of federal and state laws, including anti-kickback statutes,¹ the anti-inducement provision of the Health Insurance Portability and Accountability Act,² the Medicare exclusion provision,³ and state insurance antidiscrimination provisions.⁴

Avoid Kickback Penalties From Patient Discounts

From a legal standpoint, any discount is technically a kickback of sorts because you are returning part of your fee to the patient, and many laws designed to thwart true kickbacks can apply to patient discounts. Take the relatively straightforward case of time-of-service discounts for cosmetic procedures and other services not normally covered by insurance. You would think that these transactions are strictly between you and your patients, but if these discounts appear to be marketing incentives to attract patients, you may face a penalty.⁵

Patient discounts also may impact third-party payers. Many provider agreements contain “most favored nation” clauses, which require you to automatically give that payer the lowest price you offer to anyone else, regardless of what would be paid otherwise. In other words, the payer could demand the same discount you offer any individual patient. A time-of-service discount is, of course, exactly that: it is offered only when payment is made immediately. Third parties never pay at the time of service and would not be entitled to it, but they may try to invoke their agreement.

If you want to extend discounts for covered services, you must be sure that the discounted fee you charge the patient also is reflected on the claim submitted to the insurer. Billing the insurer more than you charged the patient invites a charge of fraud.⁶ It is important to avoid discounting so regularly that the discounted fee becomes your usual and customary rate in the eyes of the insurer.

Waiving Costs and Kickbacks

Waiving coinsurance and deductibles can be trouble too, particularly with Medicare and Medicaid. You might intend it as a good deed, but the Centers for Medicare & Medicaid Services (CMS) will see it as an inducement or kickback, especially if you do it routinely, and similar to private carriers, they will consider the discounted fee your new customary fee. The CMS has no problem with an occasional waiver, especially “after determining in good faith that the individual is in financial need,” according to the Office of Inspector General,⁷ but thorough documentation is necessary in such cases.

Waiving co-pays for privately insured patients can be equally problematic. Nearly all insurers impose a contractual duty on providers to make a reasonable effort to collect applicable co-pays and/or deductibles. They view the routine waiver of patient payments as a breach of contract, and litigation may occur against providers who flout this requirement.⁸ As with the CMS, accommodating patients with individually documented financial limitations is acceptable, but if there is a pattern of routine waivers and a paucity of documentation, you will have difficulty defending it.

Antidiscrimination Laws

In addition to kickback laws, some states also have antidiscrimination laws that forbid lower charges to any subset of insurance payers or to direct payers.⁴ Some states make specific exceptions for legitimate discounts, such as individual cases of financial hardship, or if you pass along your lower billing and collection expenditures to patients who pay immediately, but other states do not.

Determining Discount Amounts

The discount amount depends on the physician’s situation and deserves careful consideration. If the amount or percentage that you choose to offer as a discount is completely out of proportion with the administrative costs of submitting paperwork as well as the hassles associated with waiting for third-party payments, you could be accused of running a discount policy that is in effect a de facto increase to insurance carriers, which also could result in charges of fraud.²

In cases of legitimate financial hardship, the most effective and least problematic strategy may be to offer a sliding scale. Many large clinics and community agencies as well as all hospitals have written policies for this system, often based on federal poverty guidelines. To avoid any potential issues, contact your local social service agencies and welfare clinics, learn the community standard in your area, and formulate a written policy with guidelines for determining a patient’s indigence.

Final Thoughts

Consistency of administration, objectivity in policies, and documentation of individual eligibility will ensure that the discounts you offer patients are in line with legal and payer regulations. Before you establish a discount policy, be sure to check your state’s applicable laws, and as always, run everything by your attorney.

Health care reform has triggered considerable discussion both in print and online about the administrative problems it has created for private practitioners, including decreased cash flow, increased paperwork and business expenses, and an increasing number of high-deductible insurance exchanges with the infamous 90-day “grace periods.” Extending discounts to patients who pay at the time of service or out of pocket may mitigate damage caused by all 3 of these issues; however, caution is necessary, as discounts often can run afoul of federal and state laws, including anti-kickback statutes,¹ the anti-inducement provision of the Health Insurance Portability and Accountability Act,² the Medicare exclusion provision,³ and state insurance antidiscrimination provisions.⁴

Avoid Kickback Penalties From Patient Discounts

From a legal standpoint, any discount is technically a kickback of sorts because you are returning part of your fee to the patient, and many laws designed to thwart true kickbacks can apply to patient discounts. Take the relatively straightforward case of time-of-service discounts for cosmetic procedures and other services not normally covered by insurance. You would think that these transactions are strictly between you and your patients, but if these discounts appear to be marketing incentives to attract patients, you may face a penalty.⁵

Patient discounts also may impact third-party payers. Many provider agreements contain “most favored nation” clauses, which require you to automatically give that payer the lowest price you offer to anyone else, regardless of what would be paid otherwise. In other words, the payer could demand the same discount you offer any individual patient. A time-of-service discount is, of course, exactly that: it is offered only when payment is made immediately. Third parties never pay at the time of service and would not be entitled to it, but they may try to invoke their agreement.

If you want to extend discounts for covered services, you must be sure that the discounted fee you charge the patient also is reflected on the claim submitted to the insurer. Billing the insurer more than you charged the patient invites a charge of fraud.⁶ It is important to avoid discounting so regularly that the discounted fee becomes your usual and customary rate in the eyes of the insurer.

Waiving Costs and Kickbacks

Waiving coinsurance and deductibles can be trouble too, particularly with Medicare and Medicaid. You might intend it as a good deed, but the Centers for Medicare & Medicaid Services (CMS) will see it as an inducement or kickback, especially if you do it routinely, and similar to private carriers, they will consider the discounted fee your new customary fee. The CMS has no problem with an occasional waiver, especially “after determining in good faith that the individual is in financial need,” according to the Office of Inspector General,⁷ but thorough documentation is necessary in such cases.

Waiving co-pays for privately insured patients can be equally problematic. Nearly all insurers impose a contractual duty on providers to make a reasonable effort to collect applicable co-pays and/or deductibles. They view the routine waiver of patient payments as a breach of contract, and litigation may occur against providers who flout this requirement.⁸ As with the CMS, accommodating patients with individually documented financial limitations is acceptable, but if there is a pattern of routine waivers and a paucity of documentation, you will have difficulty defending it.

Antidiscrimination Laws

In addition to kickback laws, some states also have antidiscrimination laws that forbid lower charges to any subset of insurance payers or to direct payers.⁴ Some states make specific exceptions for legitimate discounts, such as individual cases of financial hardship, or if you pass along your lower billing and collection expenditures to patients who pay immediately, but other states do not.

Determining Discount Amounts

The discount amount depends on the physician’s situation and deserves careful consideration. If the amount or percentage that you choose to offer as a discount is completely out of proportion with the administrative costs of submitting paperwork as well as the hassles associated with waiting for third-party payments, you could be accused of running a discount policy that is in effect a de facto increase to insurance carriers, which also could result in charges of fraud.²

In cases of legitimate financial hardship, the most effective and least problematic strategy may be to offer a sliding scale. Many large clinics and community agencies as well as all hospitals have written policies for this system, often based on federal poverty guidelines. To avoid any potential issues, contact your local social service agencies and welfare clinics, learn the community standard in your area, and formulate a written policy with guidelines for determining a patient’s indigence.

Final Thoughts

Consistency of administration, objectivity in policies, and documentation of individual eligibility will ensure that the discounts you offer patients are in line with legal and payer regulations. Before you establish a discount policy, be sure to check your state’s applicable laws, and as always, run everything by your attorney.

Health care reform has triggered considerable discussion both in print and online about the administrative problems it has created for private practitioners, including decreased cash flow, increased paperwork and business expenses, and an increasing number of high-deductible insurance exchanges with the infamous 90-day “grace periods.” Extending discounts to patients who pay at the time of service or out of pocket may mitigate damage caused by all 3 of these issues; however, caution is necessary, as discounts often can run afoul of federal and state laws, including anti-kickback statutes,¹ the anti-inducement provision of the Health Insurance Portability and Accountability Act,² the Medicare exclusion provision,³ and state insurance antidiscrimination provisions.⁴

Avoid Kickback Penalties From Patient Discounts

From a legal standpoint, any discount is technically a kickback of sorts because you are returning part of your fee to the patient, and many laws designed to thwart true kickbacks can apply to patient discounts. Take the relatively straightforward case of time-of-service discounts for cosmetic procedures and other services not normally covered by insurance. You would think that these transactions are strictly between you and your patients, but if these discounts appear to be marketing incentives to attract patients, you may face a penalty.⁵

Patient discounts also may impact third-party payers. Many provider agreements contain “most favored nation” clauses, which require you to automatically give that payer the lowest price you offer to anyone else, regardless of what would be paid otherwise. In other words, the payer could demand the same discount you offer any individual patient. A time-of-service discount is, of course, exactly that: it is offered only when payment is made immediately. Third parties never pay at the time of service and would not be entitled to it, but they may try to invoke their agreement.

If you want to extend discounts for covered services, you must be sure that the discounted fee you charge the patient also is reflected on the claim submitted to the insurer. Billing the insurer more than you charged the patient invites a charge of fraud.⁶ It is important to avoid discounting so regularly that the discounted fee becomes your usual and customary rate in the eyes of the insurer.

Waiving Costs and Kickbacks

Waiving coinsurance and deductibles can be trouble too, particularly with Medicare and Medicaid. You might intend it as a good deed, but the Centers for Medicare & Medicaid Services (CMS) will see it as an inducement or kickback, especially if you do it routinely, and similar to private carriers, they will consider the discounted fee your new customary fee. The CMS has no problem with an occasional waiver, especially “after determining in good faith that the individual is in financial need,” according to the Office of Inspector General,⁷ but thorough documentation is necessary in such cases.

Waiving co-pays for privately insured patients can be equally problematic. Nearly all insurers impose a contractual duty on providers to make a reasonable effort to collect applicable co-pays and/or deductibles. They view the routine waiver of patient payments as a breach of contract, and litigation may occur against providers who flout this requirement.⁸ As with the CMS, accommodating patients with individually documented financial limitations is acceptable, but if there is a pattern of routine waivers and a paucity of documentation, you will have difficulty defending it.

Antidiscrimination Laws

In addition to kickback laws, some states also have antidiscrimination laws that forbid lower charges to any subset of insurance payers or to direct payers.⁴ Some states make specific exceptions for legitimate discounts, such as individual cases of financial hardship, or if you pass along your lower billing and collection expenditures to patients who pay immediately, but other states do not.

Determining Discount Amounts

The discount amount depends on the physician’s situation and deserves careful consideration. If the amount or percentage that you choose to offer as a discount is completely out of proportion with the administrative costs of submitting paperwork as well as the hassles associated with waiting for third-party payments, you could be accused of running a discount policy that is in effect a de facto increase to insurance carriers, which also could result in charges of fraud.²

In cases of legitimate financial hardship, the most effective and least problematic strategy may be to offer a sliding scale. Many large clinics and community agencies as well as all hospitals have written policies for this system, often based on federal poverty guidelines. To avoid any potential issues, contact your local social service agencies and welfare clinics, learn the community standard in your area, and formulate a written policy with guidelines for determining a patient’s indigence.

Final Thoughts

Consistency of administration, objectivity in policies, and documentation of individual eligibility will ensure that the discounts you offer patients are in line with legal and payer regulations. Before you establish a discount policy, be sure to check your state’s applicable laws, and as always, run everything by your attorney.

• Continue to educate physicians on proper billing for E/M services;
• Encourage its contractors to review physicians’ billing for E/M services; and
• Review physicians who bill higher level E/M codes for appropriate action.¹

When documenting patient history, physicians must be aware of the common discrepancies that occur. Although the physician becomes familiar with the patient as he/she provides care throughout the hospitalization, the auditor must acquaint himself or herself with the patient using only the limited information provided in the progress note.

When documentation is requested by the payer for a specific service date, only the documentation from that service date is considered. Be sure that the information is adequate to support both clinical care and the reported service level.

Patient History Requirements

Chief complaint. The chief complaint (CC) is the reason for the visit as stated in the patient’s own words. Every encounter, regardless of visit type, must include a CC. The physician must personally document and/or validate the CC with reference to a specific condition or symptom (e.g. patient complains of abdominal pain).

• Incomplete CC example: “Follow-up”;
• Better CC example: “Follow-up for severe abdominal cramping.”

History of present illness. The history of present illness (HPI) describes the development or progression of the patient’s current problem(s). The traditional HPI elements recognized in the 1995 documentation guidelines are location, quality, severity, duration, timing, context, modifying factors, and associated signs/symptoms.^2,3

The physician must obtain and personally document the HPI. He/she also has the option to link to the HPI documented by residents (i.e., residents, fellows, interns) in compliance with the teaching physician rules or nonphysician practitioners (i.e., nurse practitioners and physician assistants) as defined by the split-shared billing rules. An auditor will not accept HPI information if the physician attempts to link to any other individual, even if that person may be qualified to obtain this (e.g. registered nurse, medical assistant) or is a student (e.g. medical students, nurse practitioner students).

Because auditors recognize both 1995 and 1997 documentation guidelines, they must also recognize the HPI differences. The 1997 HPI format promotes the status of the patient’s chronic or inactive conditions.⁴ The physician receives one credit for each chronic condition that is noted, along with documentation of what has occurred since the last physician encounter as it relates to the chronic condition (e.g. “patient has a history of chronic obstructive bronchitis without acute exacerbation in past six months”).

Physicians may utilize either style of HPI documentation, and auditors must review provider records against each set of guidelines. The final audited result reflects the highest visit level supported by either set of guidelines. For example, if physician documentation yields an “extended” HPI when 1995 guidelines are used but only a “brief” HPI (see Table 2) when 1997 guidelines are reviewed, the auditor awards the physician credit for the “extended” HPI.

• 1995 example: “The patient has intermittent (duration), sharp (quality) pain in the right upper quadrant (location) without associated nausea, vomiting, or diarrhea (associated signs/symptoms).”
• 1997 example: “Diabetes controlled by oral medication; hyperlipidemia stable on simvastatin with increased dietary efforts; hypertension stable with pressures ranging from 130-140/80-90 overnight” (status of three chronic conditions).

Review of systems. A review of systems (ROS) is a series of questions inquiring about additional signs, symptoms, or problems currently or previously experienced by the patient as related to the CC or presenting problem. The recognized systems are constitutional; eyes; ears, nose, mouth, throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary (including skin and/or breast); neurological; psychiatric; endocrine; hematologic/lymphatic; and allergic/immunologic.^2,3

The physician may choose to document the ROS by making a notation for individual systems: “no fever/chills (constitutional) or blurred vision (eyes); no chest pain (cardiovascular) or shortness of breath (respiratory); intermittent nausea (gastrointestinal) and occasional runny nose (ears, nose, mouth, throat).” Alternatively, the physician may inquire about all of the systems but only document the positive and pertinent negative findings related to the CC, along with an additional comment that “all other systems are negative.” Most Medicare audit contractors currently accept this method as long as all systems were reviewed.^5,6,7,8,9

Be advised that ROS information can be documented by anyone, including the patient. The physician must remember to reference ROS information that is completed by individuals other than residents or nonphysician practitioners (the physician is already required to reference the documentation of the latter individuals under the Teaching Physician Rules or Split-Shared Billing Rules).

Past, family, and social histories. Documentation of past, family, and social histories (PFSH) involves data obtained about the patient’s previous illness or medical conditions/therapies, family occurrences with illness, and relevant patient activities. An auditor credits the physician for a single comment correlated to each history for the PFSH. Using the term “noncontributory” (N/C) with any of the histories can result in downcoding. Many contractors do not allow this statement due to previous misunderstandings over its use.

• Incomplete PFSH example: “Patient is status-post cholecystectomy in August 2013; family history N/C; patient is former smoker” (Note: “family history N/C” is not accepted by most contractors).
• Better PFSH example: “Patient currently on Prilosec 20 mg daily; family history of Barrett’s Esophagus; no tobacco or alcohol use.”

PFSH data can also be documented by anyone, including the patient, and the physician must reference the PFSH information in his own progress note. Re-documenting the PFSH is not necessary unless a revision is required. PFSH documentation is only required for initial care services (i.e., initial hospital care, initial observation care, consultations). It is not required for subsequent care services, unless additional pertinent information that impacts care is obtained during the hospital stay.

Common Problems to Avoid

Information cannot be obtained. Some contractors will not penalize the physician for the inability to ascertain complete historical information as long as there is evidenced documentation of an attempt to obtain the information. When the physician cannot extract historical information from the patient directly and no other source is available, the physician documents that he is “unable to obtain” the history. Additionally, the physician must provide a comment to explain why the information is unobtainable (e.g. patient confused, no caregiver present) along with the available information from the limited resources (e.g. emergency medical technicians, records from previous hospitalizations at the same facility).

Previous information referenced. When referencing items from a previous encounter, be sure to include the referenced information when documentation is requested by the payer. Per CMS guidelines, the ROS and/or PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. The review and update may be documented by either describing any new ROS and/or PFSH information or noting that there has been no change in the information and noting the date and location of the earlier ROS and/or PFSH.²

Pre-op clearance and HPI deficiencies. HPI is typically not as deficient as the ROS or family history elements; however, HPI underdocumentation is mostly associated with encounters for pre-op clearance. The physician may state that “patient requires pre-op clearance for left knee repair.” In the absence of any comorbidities or acute illness, HPI documentation may be missing. The physician should remember to identify the details of the presenting problem: “Patient runs five miles daily. Knee felt unstable after running two weeks ago. Swelling and intermittent sharp pain 7/10. Patient has been taking ibuprofen daily without relief.”

Not medically necessary. Remember not to document any elements for the purpose of “getting paid.” Only document information that is clinically relevant, lends to the quality of care provided, or demonstrates the delivery of healthcare services. This prevents accusations of fraud and abuse, promotes billing compliance, and supports medical necessity for the services provided.

Varying levels of history. E/M services are selected based on the content of the three “key” components: history, exam, and decision-making (or visit time). If counseling and/or coordination of care does not encompass >50% of the physician’s total visit time or the service is not exclusively designated as a time-based service (e.g. critical care and discharge day management), the physician’s service time is not considered.

Documentation for each of the three key components must support the reported visit level when reporting initial hospital care and consultations (for those payers who still recognize consultation codes). Subsequent hospital care (e.g. 99233) only requires supportive documentation from two key components. Medical decision-making should be one of the two supporting components in order to demonstrate the medical necessity and nature of the presenting problem; the other supporting component can be history or exam.

Each visit category (e.g. initial hospital care or subsequent hospital care) and service level (e.g. 99221-99233) identifies corresponding documentation requirements. Failure to document any essential element in a given visit level (e.g. family history required for a comprehensive history when billing for 99222 and 99223) may result in service denial or downcoding (e.g. 99221). Be aware of what an auditor expects when reviewing patient history (see Table 1).

There are four levels of history: problem-focused, expanded problem-focused, detailed, and comprehensive. An auditor determines the number of history elements documented in the progress note (see Table 2). The history level corresponds to the lowest documented element. For example, if physician documentation includes four HPI elements, eight ROS, and a comment in each of the PFSHs, the history level is equivalent to “detailed.” The history would support initial hospital care 99221 or subsequent hospital care 99233.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Levinson DR. Department of Health and Human Services, Office of Inspector General: Coding Trends of Medicare Evaluation and Management Services. May 2012. Available at: oig.hhs.gov/oei/reports/oei-04-10-00180.pdf. Accessed October 4, 2014.
2. Centers for Medicare and Medicaid Services. 1995 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf. Accessed October 4, 2014.
3. Abraham M, Ahlman J, Boudreau A, Connelly J, Levreau-Davis L. CPT 2013 Professional Edition (Current Procedural Terminology). Chicago: American Medical Association Press; 2012:4-10.
4. Centers for Medicare and Medicaid Services. 1997 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf. Accessed October 4, 2014.
5. Noridian Healthcare Solutions. Medicare Part B: Evaluation and Management Workshop Questions and Answers. Available at: www.noridianmedicare.com/cgi-bin/coranto/viewnews.cgi?id=EkZpEVAyylqZyOfqel&tmpl=part_b_viewnews&style=part_ab_viewnews Accessed on October 4, 2014.
6. WPS Medicare Health Insurance. J5 MAC Part B: Documentation (Q&As). Available at: www.wpsmedicare.com/j5macpartb/resources/provider_types/evalmngmntqa.shtml. Accessed October 4, 2014.
7. NHIC, Corp. Building Your Medicare Knowledge: Advanced Building Blocks. Available at: www.medicarenhic.com/providers/pubs/AdvdBuildBlocks061212.pdf.
8. Palmetto GBA. Jurisdiction 11 Part B: History Component. Available at: www.palmettogba.com/Palmetto/Providers.nsf/docsCat/Jurisdiction%2011%20Part%20B~EM%20Help%20Center~General%20Articles~History%20Component?open&Expand=1. Accessed October 4, 2014.
9. Novitas Solutions. Frequently Asked Questions: Evaluation and Management Services (Part B). Available at: https://www.novitas-solutions.com/faq/partb/pet/lpet-evaluation_management_services.html. Accessed October 4, 2014.

• Continue to educate physicians on proper billing for E/M services;
• Encourage its contractors to review physicians’ billing for E/M services; and
• Review physicians who bill higher level E/M codes for appropriate action.¹

When documenting patient history, physicians must be aware of the common discrepancies that occur. Although the physician becomes familiar with the patient as he/she provides care throughout the hospitalization, the auditor must acquaint himself or herself with the patient using only the limited information provided in the progress note.

When documentation is requested by the payer for a specific service date, only the documentation from that service date is considered. Be sure that the information is adequate to support both clinical care and the reported service level.

Patient History Requirements

Chief complaint. The chief complaint (CC) is the reason for the visit as stated in the patient’s own words. Every encounter, regardless of visit type, must include a CC. The physician must personally document and/or validate the CC with reference to a specific condition or symptom (e.g. patient complains of abdominal pain).

• Incomplete CC example: “Follow-up”;
• Better CC example: “Follow-up for severe abdominal cramping.”

History of present illness. The history of present illness (HPI) describes the development or progression of the patient’s current problem(s). The traditional HPI elements recognized in the 1995 documentation guidelines are location, quality, severity, duration, timing, context, modifying factors, and associated signs/symptoms.^2,3

The physician must obtain and personally document the HPI. He/she also has the option to link to the HPI documented by residents (i.e., residents, fellows, interns) in compliance with the teaching physician rules or nonphysician practitioners (i.e., nurse practitioners and physician assistants) as defined by the split-shared billing rules. An auditor will not accept HPI information if the physician attempts to link to any other individual, even if that person may be qualified to obtain this (e.g. registered nurse, medical assistant) or is a student (e.g. medical students, nurse practitioner students).

Because auditors recognize both 1995 and 1997 documentation guidelines, they must also recognize the HPI differences. The 1997 HPI format promotes the status of the patient’s chronic or inactive conditions.⁴ The physician receives one credit for each chronic condition that is noted, along with documentation of what has occurred since the last physician encounter as it relates to the chronic condition (e.g. “patient has a history of chronic obstructive bronchitis without acute exacerbation in past six months”).

Physicians may utilize either style of HPI documentation, and auditors must review provider records against each set of guidelines. The final audited result reflects the highest visit level supported by either set of guidelines. For example, if physician documentation yields an “extended” HPI when 1995 guidelines are used but only a “brief” HPI (see Table 2) when 1997 guidelines are reviewed, the auditor awards the physician credit for the “extended” HPI.

• 1995 example: “The patient has intermittent (duration), sharp (quality) pain in the right upper quadrant (location) without associated nausea, vomiting, or diarrhea (associated signs/symptoms).”
• 1997 example: “Diabetes controlled by oral medication; hyperlipidemia stable on simvastatin with increased dietary efforts; hypertension stable with pressures ranging from 130-140/80-90 overnight” (status of three chronic conditions).

Review of systems. A review of systems (ROS) is a series of questions inquiring about additional signs, symptoms, or problems currently or previously experienced by the patient as related to the CC or presenting problem. The recognized systems are constitutional; eyes; ears, nose, mouth, throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary (including skin and/or breast); neurological; psychiatric; endocrine; hematologic/lymphatic; and allergic/immunologic.^2,3

The physician may choose to document the ROS by making a notation for individual systems: “no fever/chills (constitutional) or blurred vision (eyes); no chest pain (cardiovascular) or shortness of breath (respiratory); intermittent nausea (gastrointestinal) and occasional runny nose (ears, nose, mouth, throat).” Alternatively, the physician may inquire about all of the systems but only document the positive and pertinent negative findings related to the CC, along with an additional comment that “all other systems are negative.” Most Medicare audit contractors currently accept this method as long as all systems were reviewed.^5,6,7,8,9

Be advised that ROS information can be documented by anyone, including the patient. The physician must remember to reference ROS information that is completed by individuals other than residents or nonphysician practitioners (the physician is already required to reference the documentation of the latter individuals under the Teaching Physician Rules or Split-Shared Billing Rules).

Past, family, and social histories. Documentation of past, family, and social histories (PFSH) involves data obtained about the patient’s previous illness or medical conditions/therapies, family occurrences with illness, and relevant patient activities. An auditor credits the physician for a single comment correlated to each history for the PFSH. Using the term “noncontributory” (N/C) with any of the histories can result in downcoding. Many contractors do not allow this statement due to previous misunderstandings over its use.

• Incomplete PFSH example: “Patient is status-post cholecystectomy in August 2013; family history N/C; patient is former smoker” (Note: “family history N/C” is not accepted by most contractors).
• Better PFSH example: “Patient currently on Prilosec 20 mg daily; family history of Barrett’s Esophagus; no tobacco or alcohol use.”

PFSH data can also be documented by anyone, including the patient, and the physician must reference the PFSH information in his own progress note. Re-documenting the PFSH is not necessary unless a revision is required. PFSH documentation is only required for initial care services (i.e., initial hospital care, initial observation care, consultations). It is not required for subsequent care services, unless additional pertinent information that impacts care is obtained during the hospital stay.

Common Problems to Avoid

Information cannot be obtained. Some contractors will not penalize the physician for the inability to ascertain complete historical information as long as there is evidenced documentation of an attempt to obtain the information. When the physician cannot extract historical information from the patient directly and no other source is available, the physician documents that he is “unable to obtain” the history. Additionally, the physician must provide a comment to explain why the information is unobtainable (e.g. patient confused, no caregiver present) along with the available information from the limited resources (e.g. emergency medical technicians, records from previous hospitalizations at the same facility).

Previous information referenced. When referencing items from a previous encounter, be sure to include the referenced information when documentation is requested by the payer. Per CMS guidelines, the ROS and/or PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. The review and update may be documented by either describing any new ROS and/or PFSH information or noting that there has been no change in the information and noting the date and location of the earlier ROS and/or PFSH.²

Pre-op clearance and HPI deficiencies. HPI is typically not as deficient as the ROS or family history elements; however, HPI underdocumentation is mostly associated with encounters for pre-op clearance. The physician may state that “patient requires pre-op clearance for left knee repair.” In the absence of any comorbidities or acute illness, HPI documentation may be missing. The physician should remember to identify the details of the presenting problem: “Patient runs five miles daily. Knee felt unstable after running two weeks ago. Swelling and intermittent sharp pain 7/10. Patient has been taking ibuprofen daily without relief.”

Not medically necessary. Remember not to document any elements for the purpose of “getting paid.” Only document information that is clinically relevant, lends to the quality of care provided, or demonstrates the delivery of healthcare services. This prevents accusations of fraud and abuse, promotes billing compliance, and supports medical necessity for the services provided.

Varying levels of history. E/M services are selected based on the content of the three “key” components: history, exam, and decision-making (or visit time). If counseling and/or coordination of care does not encompass >50% of the physician’s total visit time or the service is not exclusively designated as a time-based service (e.g. critical care and discharge day management), the physician’s service time is not considered.

Documentation for each of the three key components must support the reported visit level when reporting initial hospital care and consultations (for those payers who still recognize consultation codes). Subsequent hospital care (e.g. 99233) only requires supportive documentation from two key components. Medical decision-making should be one of the two supporting components in order to demonstrate the medical necessity and nature of the presenting problem; the other supporting component can be history or exam.

Each visit category (e.g. initial hospital care or subsequent hospital care) and service level (e.g. 99221-99233) identifies corresponding documentation requirements. Failure to document any essential element in a given visit level (e.g. family history required for a comprehensive history when billing for 99222 and 99223) may result in service denial or downcoding (e.g. 99221). Be aware of what an auditor expects when reviewing patient history (see Table 1).

There are four levels of history: problem-focused, expanded problem-focused, detailed, and comprehensive. An auditor determines the number of history elements documented in the progress note (see Table 2). The history level corresponds to the lowest documented element. For example, if physician documentation includes four HPI elements, eight ROS, and a comment in each of the PFSHs, the history level is equivalent to “detailed.” The history would support initial hospital care 99221 or subsequent hospital care 99233.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Levinson DR. Department of Health and Human Services, Office of Inspector General: Coding Trends of Medicare Evaluation and Management Services. May 2012. Available at: oig.hhs.gov/oei/reports/oei-04-10-00180.pdf. Accessed October 4, 2014.
2. Centers for Medicare and Medicaid Services. 1995 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf. Accessed October 4, 2014.
3. Abraham M, Ahlman J, Boudreau A, Connelly J, Levreau-Davis L. CPT 2013 Professional Edition (Current Procedural Terminology). Chicago: American Medical Association Press; 2012:4-10.
4. Centers for Medicare and Medicaid Services. 1997 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf. Accessed October 4, 2014.
5. Noridian Healthcare Solutions. Medicare Part B: Evaluation and Management Workshop Questions and Answers. Available at: www.noridianmedicare.com/cgi-bin/coranto/viewnews.cgi?id=EkZpEVAyylqZyOfqel&tmpl=part_b_viewnews&style=part_ab_viewnews Accessed on October 4, 2014.
6. WPS Medicare Health Insurance. J5 MAC Part B: Documentation (Q&As). Available at: www.wpsmedicare.com/j5macpartb/resources/provider_types/evalmngmntqa.shtml. Accessed October 4, 2014.
7. NHIC, Corp. Building Your Medicare Knowledge: Advanced Building Blocks. Available at: www.medicarenhic.com/providers/pubs/AdvdBuildBlocks061212.pdf.
8. Palmetto GBA. Jurisdiction 11 Part B: History Component. Available at: www.palmettogba.com/Palmetto/Providers.nsf/docsCat/Jurisdiction%2011%20Part%20B~EM%20Help%20Center~General%20Articles~History%20Component?open&Expand=1. Accessed October 4, 2014.
9. Novitas Solutions. Frequently Asked Questions: Evaluation and Management Services (Part B). Available at: https://www.novitas-solutions.com/faq/partb/pet/lpet-evaluation_management_services.html. Accessed October 4, 2014.

• Continue to educate physicians on proper billing for E/M services;
• Encourage its contractors to review physicians’ billing for E/M services; and
• Review physicians who bill higher level E/M codes for appropriate action.¹

When documenting patient history, physicians must be aware of the common discrepancies that occur. Although the physician becomes familiar with the patient as he/she provides care throughout the hospitalization, the auditor must acquaint himself or herself with the patient using only the limited information provided in the progress note.

When documentation is requested by the payer for a specific service date, only the documentation from that service date is considered. Be sure that the information is adequate to support both clinical care and the reported service level.

Patient History Requirements

Chief complaint. The chief complaint (CC) is the reason for the visit as stated in the patient’s own words. Every encounter, regardless of visit type, must include a CC. The physician must personally document and/or validate the CC with reference to a specific condition or symptom (e.g. patient complains of abdominal pain).

• Incomplete CC example: “Follow-up”;
• Better CC example: “Follow-up for severe abdominal cramping.”

History of present illness. The history of present illness (HPI) describes the development or progression of the patient’s current problem(s). The traditional HPI elements recognized in the 1995 documentation guidelines are location, quality, severity, duration, timing, context, modifying factors, and associated signs/symptoms.^2,3

The physician must obtain and personally document the HPI. He/she also has the option to link to the HPI documented by residents (i.e., residents, fellows, interns) in compliance with the teaching physician rules or nonphysician practitioners (i.e., nurse practitioners and physician assistants) as defined by the split-shared billing rules. An auditor will not accept HPI information if the physician attempts to link to any other individual, even if that person may be qualified to obtain this (e.g. registered nurse, medical assistant) or is a student (e.g. medical students, nurse practitioner students).

Because auditors recognize both 1995 and 1997 documentation guidelines, they must also recognize the HPI differences. The 1997 HPI format promotes the status of the patient’s chronic or inactive conditions.⁴ The physician receives one credit for each chronic condition that is noted, along with documentation of what has occurred since the last physician encounter as it relates to the chronic condition (e.g. “patient has a history of chronic obstructive bronchitis without acute exacerbation in past six months”).

Physicians may utilize either style of HPI documentation, and auditors must review provider records against each set of guidelines. The final audited result reflects the highest visit level supported by either set of guidelines. For example, if physician documentation yields an “extended” HPI when 1995 guidelines are used but only a “brief” HPI (see Table 2) when 1997 guidelines are reviewed, the auditor awards the physician credit for the “extended” HPI.

• 1995 example: “The patient has intermittent (duration), sharp (quality) pain in the right upper quadrant (location) without associated nausea, vomiting, or diarrhea (associated signs/symptoms).”
• 1997 example: “Diabetes controlled by oral medication; hyperlipidemia stable on simvastatin with increased dietary efforts; hypertension stable with pressures ranging from 130-140/80-90 overnight” (status of three chronic conditions).

Review of systems. A review of systems (ROS) is a series of questions inquiring about additional signs, symptoms, or problems currently or previously experienced by the patient as related to the CC or presenting problem. The recognized systems are constitutional; eyes; ears, nose, mouth, throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary (including skin and/or breast); neurological; psychiatric; endocrine; hematologic/lymphatic; and allergic/immunologic.^2,3

The physician may choose to document the ROS by making a notation for individual systems: “no fever/chills (constitutional) or blurred vision (eyes); no chest pain (cardiovascular) or shortness of breath (respiratory); intermittent nausea (gastrointestinal) and occasional runny nose (ears, nose, mouth, throat).” Alternatively, the physician may inquire about all of the systems but only document the positive and pertinent negative findings related to the CC, along with an additional comment that “all other systems are negative.” Most Medicare audit contractors currently accept this method as long as all systems were reviewed.^5,6,7,8,9

Be advised that ROS information can be documented by anyone, including the patient. The physician must remember to reference ROS information that is completed by individuals other than residents or nonphysician practitioners (the physician is already required to reference the documentation of the latter individuals under the Teaching Physician Rules or Split-Shared Billing Rules).

Past, family, and social histories. Documentation of past, family, and social histories (PFSH) involves data obtained about the patient’s previous illness or medical conditions/therapies, family occurrences with illness, and relevant patient activities. An auditor credits the physician for a single comment correlated to each history for the PFSH. Using the term “noncontributory” (N/C) with any of the histories can result in downcoding. Many contractors do not allow this statement due to previous misunderstandings over its use.

• Incomplete PFSH example: “Patient is status-post cholecystectomy in August 2013; family history N/C; patient is former smoker” (Note: “family history N/C” is not accepted by most contractors).
• Better PFSH example: “Patient currently on Prilosec 20 mg daily; family history of Barrett’s Esophagus; no tobacco or alcohol use.”

PFSH data can also be documented by anyone, including the patient, and the physician must reference the PFSH information in his own progress note. Re-documenting the PFSH is not necessary unless a revision is required. PFSH documentation is only required for initial care services (i.e., initial hospital care, initial observation care, consultations). It is not required for subsequent care services, unless additional pertinent information that impacts care is obtained during the hospital stay.

Common Problems to Avoid

Information cannot be obtained. Some contractors will not penalize the physician for the inability to ascertain complete historical information as long as there is evidenced documentation of an attempt to obtain the information. When the physician cannot extract historical information from the patient directly and no other source is available, the physician documents that he is “unable to obtain” the history. Additionally, the physician must provide a comment to explain why the information is unobtainable (e.g. patient confused, no caregiver present) along with the available information from the limited resources (e.g. emergency medical technicians, records from previous hospitalizations at the same facility).

Previous information referenced. When referencing items from a previous encounter, be sure to include the referenced information when documentation is requested by the payer. Per CMS guidelines, the ROS and/or PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. The review and update may be documented by either describing any new ROS and/or PFSH information or noting that there has been no change in the information and noting the date and location of the earlier ROS and/or PFSH.²

Pre-op clearance and HPI deficiencies. HPI is typically not as deficient as the ROS or family history elements; however, HPI underdocumentation is mostly associated with encounters for pre-op clearance. The physician may state that “patient requires pre-op clearance for left knee repair.” In the absence of any comorbidities or acute illness, HPI documentation may be missing. The physician should remember to identify the details of the presenting problem: “Patient runs five miles daily. Knee felt unstable after running two weeks ago. Swelling and intermittent sharp pain 7/10. Patient has been taking ibuprofen daily without relief.”

Not medically necessary. Remember not to document any elements for the purpose of “getting paid.” Only document information that is clinically relevant, lends to the quality of care provided, or demonstrates the delivery of healthcare services. This prevents accusations of fraud and abuse, promotes billing compliance, and supports medical necessity for the services provided.

Varying levels of history. E/M services are selected based on the content of the three “key” components: history, exam, and decision-making (or visit time). If counseling and/or coordination of care does not encompass >50% of the physician’s total visit time or the service is not exclusively designated as a time-based service (e.g. critical care and discharge day management), the physician’s service time is not considered.

Documentation for each of the three key components must support the reported visit level when reporting initial hospital care and consultations (for those payers who still recognize consultation codes). Subsequent hospital care (e.g. 99233) only requires supportive documentation from two key components. Medical decision-making should be one of the two supporting components in order to demonstrate the medical necessity and nature of the presenting problem; the other supporting component can be history or exam.

Each visit category (e.g. initial hospital care or subsequent hospital care) and service level (e.g. 99221-99233) identifies corresponding documentation requirements. Failure to document any essential element in a given visit level (e.g. family history required for a comprehensive history when billing for 99222 and 99223) may result in service denial or downcoding (e.g. 99221). Be aware of what an auditor expects when reviewing patient history (see Table 1).

There are four levels of history: problem-focused, expanded problem-focused, detailed, and comprehensive. An auditor determines the number of history elements documented in the progress note (see Table 2). The history level corresponds to the lowest documented element. For example, if physician documentation includes four HPI elements, eight ROS, and a comment in each of the PFSHs, the history level is equivalent to “detailed.” The history would support initial hospital care 99221 or subsequent hospital care 99233.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Levinson DR. Department of Health and Human Services, Office of Inspector General: Coding Trends of Medicare Evaluation and Management Services. May 2012. Available at: oig.hhs.gov/oei/reports/oei-04-10-00180.pdf. Accessed October 4, 2014.
2. Centers for Medicare and Medicaid Services. 1995 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf. Accessed October 4, 2014.
3. Abraham M, Ahlman J, Boudreau A, Connelly J, Levreau-Davis L. CPT 2013 Professional Edition (Current Procedural Terminology). Chicago: American Medical Association Press; 2012:4-10.
4. Centers for Medicare and Medicaid Services. 1997 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf. Accessed October 4, 2014.
5. Noridian Healthcare Solutions. Medicare Part B: Evaluation and Management Workshop Questions and Answers. Available at: www.noridianmedicare.com/cgi-bin/coranto/viewnews.cgi?id=EkZpEVAyylqZyOfqel&tmpl=part_b_viewnews&style=part_ab_viewnews Accessed on October 4, 2014.
6. WPS Medicare Health Insurance. J5 MAC Part B: Documentation (Q&As). Available at: www.wpsmedicare.com/j5macpartb/resources/provider_types/evalmngmntqa.shtml. Accessed October 4, 2014.
7. NHIC, Corp. Building Your Medicare Knowledge: Advanced Building Blocks. Available at: www.medicarenhic.com/providers/pubs/AdvdBuildBlocks061212.pdf.
8. Palmetto GBA. Jurisdiction 11 Part B: History Component. Available at: www.palmettogba.com/Palmetto/Providers.nsf/docsCat/Jurisdiction%2011%20Part%20B~EM%20Help%20Center~General%20Articles~History%20Component?open&Expand=1. Accessed October 4, 2014.
9. Novitas Solutions. Frequently Asked Questions: Evaluation and Management Services (Part B). Available at: https://www.novitas-solutions.com/faq/partb/pet/lpet-evaluation_management_services.html. Accessed October 4, 2014.