Whether performing an audit or providing education, when it comes to evaluation and management (E/M) coding, your first consideration should be accurate, compliant information and results.

Choose Reliable Resources

Our reliable resources are the Centers for Medicare & Medicaid Services (CMS) 1995 and 1997 Documentation Guidelines for Evaluation and Management Services, the Office of Inspector General (OIG) website for compliance guidance, and the CPT® and ICD-9-CM codebooks for specific coding rules. Medicare administrative contractors (MACs) are also good resources for finding information unique to each geographic area.

Why are these recourses so important? If you choose to educate or audit without these stated rules, you’ll impart your opinions in a very crucial area where there is no place for opinions.

Compliance Supersedes Coding

Audits and education for E/M services should go beyond determining the level of service. Many compliance issues can cause the documentation of an E/M service to fail an auditor’s review. The resources noted above will outline key areas where provider documentation will be at risk for non-compliance, even when the level of service is supported by the documentation. When reviewing E/M documentation, remember the items that make the documentation “complete,” as defined by CMS and the OIG.

Focus on Complete Records

Let’s take a look at the areas that continually threaten the completeness of the medical record:

Relevant History: Each record must state the reason for the encounter, any relevant history, and the exam. The chief complaint must be clearly indicated and the relevant history of the condition(s) that warranted the visit must be documented. In other words, the documented history should have some relationship to the reason why the patient is being seen. Too often the history bears no relevancy on the date of service, and instead reads like a past medical history of many problems not addressed at that visit.

Documentation of the History: The only part of the history that may be documented by a nurse, student, ancillary staff, or the patient is the review of systems (ROS) and/or past, family, and social histories (PFSH). The provider (doctor of medicine (MD), doctor of osteopathy (DO), nurse practitioner (NP), physician assistant (PA), etc.) must document the chief complaint and history of the present illness (HPI).

If someone else documents the ROS or PFSH, there must be a notation supplementing or confirming that the provider reviewed the information. If that confirmation is not a part of the record—even if the patient information supports the level of service—the documentation does not meet the compliance rules, and does not count.

Orders for Diagnostic Tests: If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred. This seems simple enough, and yet it can cause many problems. Compliance issues normally arise in paper records more than in electronic records, where orders for diagnostic tests are often linked to a particular diagnosis.

From a compliance standpoint, an auditor must be able to determine that the provider made the decision to order a diagnostic test. Documentation that supports the order provides data when determining the level of medical decision-making. Without documentation showing the provider ordered the test—and even if the test results are documented—an auditor may infer that ancillary staff ordered the test.

Signatures: Per CMS, a signature is “a mark or sign by an individual on a document to signify knowledge, approval, acceptance, or obligation.” This statement does not indicate the signature must be a complete name. In the event of an audit, a provider may provide a signature log to reflect the signature with a typed name. In the instance where a medical record is submitted without a signature, an attestation can be submitted as proof that the provider saw the Medicare beneficiary on that date of service.

Signatures are crucial to validate who saw and participated in the care of the patient. Regardless of the caregiver (e.g., nurse, medical assistant (MA), certified medical assistant (CMA), NP, MD), there must be a signature showing this health professional documented an encounter in the patient’s medical record. Auditors look carefully at who is signing notes and how the notes are signed, which can provide insight into noncompliant practices. Signatures (or the lack of signatures) can reflect who is performing services, versus who is supposed to be performing services.

A good resource for additional signature guidance is your MAC.

Participation of Medical Students: This often comes up in an E/M audit, and goes back to who is allowed to document and perform certain parts of the patient encounter. A medical student may document only the ROS or PFSH, and the provider must confirm that information. Because this is a teaching situation and the student may be asked to take a history and/or perform an exam, as well as document his or her findings, it’s important to understand how that documentation can be used, if at all. The teaching physician must re-perform and re-document his or her own history and exam. Only the work and documentation of the teaching physician will be used for determining the level of service.

Make Sure Guidelines Are Met

When auditing or educating for E/M services, it is crucial to look beyond the level of service to determe if guidelines have been met. Much goes into determining if the medical record is complete. Read the tools and resources and consider each encounter note carefully to determine if the documentation can withstand both coding and compliance audits.

Jaci Johnson, CPC, CPC-H, CEMC, CPMA, CPC-I, is president of Practice Integrity, LLC. She has worked in medical coding and auditing for 24 years and has been a Certified Professional Coder (CPC^®) since 1994. Ms. Johnson has expertise in coding for family practice, urgent care, OB/GYN, general surgery, and Medicare’s Teaching Physician Guidelines, with a particular emphasis on E/M guideline compliance. She serves on the AAPC National Advisory Board (NAB), and is past president of her AAPC local chapter. She was also recognized as Virginia’s 2006 Coder of the Year.

Benchmarking Shows How Your Practice Stacks Up

To paraphrase Wikipedia, “benchmarking is comparing one’s performance metrics to industry bests, and involves management comparing the results and processes in the targets to one’s own results.” Operating under the theory of “no surprises,” sharpening your benchmarking skills should be at the top of your priority list.

When benchmarking performance (whether it be for collection metrics or coding), you may discover that you are an “outlier” in some categories. Wikipedia defines an outlier as “an observation that is numerically distant from the rest of the data.”

If a physician is an outlier on an E/M benchmark comparison—for instance, because he or she uses more consultation codes or more upper level codes—it’s not necessarily a bad thing. In many cases, the variation can be explained because a specialist, such as a neuro-otologist, is compared to general ear, nose, and throat (ENT) specialists due to Medicare’s specialty classifications; or, a spine surgeon who only sees patients on referral is compared to general orthopaedic surgeons. Nevertheless, being an outlier will prompt inquiring minds to ask questions. Hopefully, you will have good answers to explain the deviation, supported by excellent documentation.

Keep an Eye on Your Curves

From any payer’s perspective, graphing code usage produces a distribution curve to use as a basis for comparison. This is especially true for Medicare, which paid $25 billion for E/M services (totaling 19 percent of all Medicare Part B payments) in 2009, according to the 2011 Office of Inspector General (OIG) Work Plan. Comprehensive Error Rate Testing (CERT) audits also revealed a national Medicare fee-for-service error rate for the November 2009 reporting period of 8 percent (up from 6 percent in 2008), which equates to $24.1 billion in erroneous payments. Medicare’s recovery audit contractors (RACs), CERT contractors, and zone program integrity contractors (ZPICs) are out to recoup money paid to those outliers, and they have been successful in collecting.

Knowing how you compare to other practices on a physician-to-physician basis is critical. Ignore those who tell you that your coding pattern should look like the proverbial “bell shaped curve.” Your coding should instead represent the level of care and documentation in your records. Your subspecialty or other unique aspects of your practice, your patient population, and your level of automation will influence your coding, E/M distribution, and variations from the “norm.”

Implement Benchmarking in Your Practice

You can use various tools to benchmark your code use. For example, Karen Zupko & Associates’ (KZA) E&M Profile Analyzer™ uses Medicare paid claims data to compare doctors in the same specialty and state with one another using a graphic format.

The chart on the preceding page is an example of a benchmarking graph (with specialty and state concealed). What you see here is a physician’s distribution pattern for new patient visits that is significantly different than other members of his group. His volume and intensity of services differs from his colleagues in the state and nationally, as well.

To find out why the physician’s distribution pattern deviates from others, you would:

• Audit a sample of 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; medical decision making of low complexity. Verify that the medical necessity and documentation support the volume of level-III visits. If you identify any issues, address them through internal education.

• Look at the other levels of service. Both the physician and practice are outliers in undercoding. Undercoding equals lost revenue to the practice, and might even raise concern that Medicare beneficiaries aren’t receiving appropriate care.

The next steps include:

1. Running a frequency report for new, established, consultation, and inpatient codes by the physician.
2. Reviewing reports from the E&M Profile Analyzer, or a comparable product. The E&M Profile Analyzer, for example, allows you to access monthly or quarterly reports.
3. Using the above results to audit E/M records that represent outlier status (over- or under-utilization).
4. Making sure someone with solid qualifications performs the audit, such as a certified coder with relevant experience in your specialty. The auditor must be able to command the physicians’ attention and respect.
5. Developing an internal compliance plan (if you don’t have one), identifying both coding and billing process risks.

Tip: Use the E&M Profile Analyzer, or a similar tool, as part of your internal compliance plan to pinpoint documentation reviews. Rather than pulling random numbers or types of charts, you can focus on outliers who are likely to attract an auditor’s interest.

Double Check E/M in EHRs

Using an electronic health record (EHR) doesn’t mean that everything is OK with your E/M utilization. In fact, the OIG 2011 Work Plan has a special callout for EHR generated notes. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. It’s advisable to review multiple E/M services for the same providers and beneficiaries to identify EHR documentation practices associated with potentially improper payments.

Never assume EHR logic is perfect—few, if any, systems can accurately calculate medical necessity; and cloning is often a significant problem. For instance, it’s a good idea to review all EHR generated 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity visits after about six weeks of use.

Mary LeGrand, RN, MA, CPC, CCS-P, is a senior practice management consultant with Chicago-based KarenZupko & Associates. Ms. LeGrand specializes in E/M and surgical coding education, reimbursement analysis, and compliance/auditing. She is a coding and reimbursement expert in specialties such as orthopaedics, spine surgery, otolaryngology, and general surgery.