Moving forward with implementation means your participation is vital.
If you thought the introduction of the electronic health record (EHR) would change coding, you were absolutely right. The days of sitting in the back office, appending ICD-9-CM codes to paper fee tickets and manually posting charges is, for some practices, in the distant past. Modern offices expect you to transform your coding knowledge into the fundamental tools used for EHR software development and compliance auditing. With a systematic plan, the right resources, and reasonably sophisticated EHR software, you can be a vital resource in their implementation.
Get Ahead of the Learning Curve
To participate in the development of compliant documentation templates, you must understand how an EHR is designed and how software is modified.
Overall, the EHR should interface with a billing or practice management software so patient demographics data attach to the medical record to avoid ‘wrong patient’ issues. Most EHR software is designed with pre-created templates used to capture patient medical data, document visits and procedures, order prescriptions, and document patient/provider communication—all seamlessly linked to the patient demographics. These templates are designed so providers can enter data through several methods. They can click check boxes or select radio buttons, and choose items from drop down menus to determine the information they want to document in the patient chart. The provider can type additional data within a text box, which displays this information exactly as it’s entered. Other patient data, such as chronic conditions, past medical history, and medication lists can be pre-loaded.
In some sophisticated software, templates can be set up to require some sort of action—almost like an internal email that alerts nursing staff to contact the patient regarding lab results. Other templates can be developed to order a prescription that automatically faxes to the pharmacy. These methods of selection and documentation are elements of a “user interface,” which is a behind-the-scenes mapping of how and where the information is displayed. Taking the time to learn about the behind-the-scenes default “language” that is all part of the EHR package’s user interface will help you determine whether there are options for clear and concise documentation, or if the documentation is limited to certain canned phrases and verbiage.
All EHR software arrives “out of the box” with default data lists that are used to populate the templates to drop pre-determined verbiage into a formatted document based on the provider’s selection. These data lists can include CPT® and ICD-9-CM codes, and place of service (POS) indicators, as well as more customized and editable lists such as office locations, special charges, and fee schedules. Data is typically selected through a drop-down menu.
In all cases, successful EHR implementation depends on the ability to understand, customize, test, and audit the capability and compliance of the EHR software. Coders, today, need to understand the concepts of a user interface, billing rules, and clinical documentation standards, and be able to translate coding and documentation guidelines for successful and compliant software development.
Test the EHR Before Going “Live”
A good software package will provide you with a test environment. When the practice decides to “go live” with a new EHR, there is a period during which the electronically-generated medical record should be systematically audited within a test environment to identify errors or bugs. These problems should be corrected prior to using the EHR in a “live” environment.
By comparing the computer generated notes against an approved audit tool, you can see where the software might be “double-dipping” (counting the same elements twice), pulling forward (bringing arbitrary documentation from another, unrelated note), or creating “bugs,” such as documenting both male and female system reviews for all patients. The completed EHR should meet all of the criteria for a legal medical document. This kind of testing is most effective if planned and implemented in a methodical manner, using test patients that you create, name, and run through the workflow process with varying visit types and medical scenarios.
Using a spreadsheet or database to capture and compare this analysis process is helpful, and can keep the project organized. Some scenarios to consider include:
- Are the templates for physical examinations age/sex appropriate?
- Are there opportunities to document all elements of the history of present illness (HPI)? The review of systems (ROS)?
- Are the examination templates set up to record based on 1997 or 1995 guidelines?
- Can your medical record be locked for security after a certain length of time? What is your addendum process?
- Can you import data such as lab results that are relevant to your current note? Is your note readable? Do consecutive notes appear to be copied, or cut and pasted?
- Do surgical/procedural templates allow for informed consent documentation?
- Is there space to document adverse effects or complications?
- Does your finger stick glucose lab template always default to a diabetes diagnosis? This should not be the case: Not everyone is diabetic!
- Does your wart destruction template allow for both benign and malignant lesion reporting?
Much of this developing and testing should be handled by your practice’s information technology (IT) department, but savvy coders, such as yourself, may want to develop super-user status. You can participate in pre-implementation activities, where you act as patients while the providers learn the software. During this time, make recommendations regarding coding compliance to the physicians, as well as the IT team.
EHR Software Works Best when Customized
The features that make an EHR easy to use, such as pre-filled templates, automatic code drop, and pre-determined diagnosis codes are the very things that cause compliance concerns. Think of the EHR as a tool that has to be sharpened and honed. It’s very effective if used correctly, but you have to learn how to use it safely, or you’re going to get hurt.
Most EHR software comes with pre-loaded E/M templates, which vendors probably will tell you are of the “plug and play” variety. Information systems experts and coders know that this is not necessarily the case. The Centers for Medicare & Medicaid Services (CMS) has not changed the E/M guidelines since 1997; however, the way the EHR captures data to support the levels of service has most definitely changed. Usually, the EHR configures the E/M templates in a manner similar to an audit tool, with a section for each of the key components: the chief complaint; HPI; ROS; past, family, and social history (PFSH); exam; and medical decision making (MDM). By working systematically, you and your IT staff can approach the development and customization of these templates in a way that ensures easy use and compliance within the final documentation.
Most EHR programs also have the capability to import documents. Scanning allows you to import a photo image of a document, to be stored in the patient’s chart. Establishing a direct interface between a lab or radiology department to import diagnostic results is a very efficient way to receive medical information into the patient chart. Having a consistent method of importing and cataloging these documents is important because it allows records to be easily identified and located at a later date. To meet compliance and patient care standards, all imported documentation must be reviewed and noted by the ordering physician before being stored in the electronic chart. Take it upon yourself to ensure that this is being done effectively and consistently.
Much of the custom work will be the IT department’s responsibility, with you acting as the compliance consultant. In smaller practice settings, your software vendor can be extremely helpful with the implementation process. Some EHR products offer users groups, which are online chat rooms offering a place for IT people, coders, and practice managers to post questions and discuss known issues. The bigger software companies provide seminars, conferences, and workshops on best-practice concepts and new initiatives. There is also an EHR discussion thread on the AAPC website where coders who are using the same EHR can “meet” and discuss.
Additional EHR Concerns to Address
Who Did What? Most EHRs have some “auditing” capability, where a behind-the-scenes look can identify which employee or clinician entered or edited which pieces of information. This allows you to see who is accessing the medical record (for instance, in case of privacy concerns), who is actually placing orders for medications and diagnostics, and where data entry errors might be occurring (to identify training opportunities). All EHRs should have signature and date recording ability for physicians and performing clinicians to meet the regulatory requirements of a legal medical record. This is one area where you can assist in workflow planning for compliance.
Procedure Templates: Most EHR software allows for easy documentation of office and surgical procedures. Templates should be designed to capture common elements of any given procedure, including anesthesia, informed consent, procedural elements, and follow-up instructions. When using these templates in a test environment, make sure the resulting procedure note makes sense, and your software default choices match the procedure that actually took place. For example, if your provider performs and documents a lesion excision, make sure your resulting note doesn’t document lesion destruction.
Annual Updates: Many of the EHR’s data lists, such as CPT® and ICD-9 codes, can be updated annually by the vendor, but often the vendor can provide only new codes. Frequently, the deleted and revised codes have to be edited individually and manually by you, or someone in IT, to ensure providers do not select invalid or deleted codes. One common issue in an EHR is that old diagnosis codes that are related to previous encounters remain in the patient’s list of chronic conditions, so the invalid codes can inadvertently be chosen again and again to appear on a claim form. Claim edits should be set up to prevent this from happening.
As you move forward with your implementation, other issues may present themselves. It’s critical for documentation compliance that you perform concurrent audits to review the EHR for completeness and accuracy as codes change, software is upgraded, and new providers begin to use the EHR. Having a comprehensive plan for EHR implementation that includes your participation in creating compliant EHR templates is essential. This implementation must include a comprehensive workflow evaluation to ensure that the EHR system your practice is using is configured in the best possible format as a legal medical record.
Pam Brooks, CPC, PCS, is physician services coding supervisor with Wentworth-Douglass Hospital in Dover, N.H.
April 4th, 2013
By Penny Osmon Bahr, BA, CPC, CPC-I, CHC, PCS
The 2013 Medicare Physician Fee Schedule (MPFS) final rule makes several changes to the Physician Quality Reporting System (PQRS). Providers who begin reporting now in accordance with these changes stand to gain incentive payments, while those who don’t will soon suffer economic consequences.
Incentives: The Good, the Bad, and the Ugly
The Good: Successful participation in the 2013 PQRS earns providers a 0.5 percent incentive on all original Medicare Part B allowed charges billed in the reporting period (whether six or 12 months). This incentive continues through 2014.
An additional 0.5 percent incentive is also available through 2014 for eligible providers (EPs) who submit data on quality measures through a Maintenance of Certification® (MOC) program operated by a specialty body of the American Board of Medical Specialties (ABMS). In addition to reporting PQRS data successfully for one year (submitted through a MOC program), the physician must participate in and successfully complete a MOC program. Board certification status may require more frequent reporting.
The Bad: Effective Jan. 1, 2015, EPs who do not successfully report PQRS quality measures will incur a negative 1.5 percent adjustment to all professional services reimbursed under the Medicare Part B fee schedule, based on 2013 program year data, per section 3002(b) of the Affordable Care Act (ACA).
The Ugly: Beginning in 2016, the negative adjustment to payments for nonparticipating EPs increases to 2 percent.
Subtle Changes to Traditional Reporting
The first step to successful PQRS participation is choosing “how” to report quality measures. An EP has two options: Either as an individual or as a group practice under the Group Practice Reporting Option (GPRO).
The 2013 MPFS final rule expands the definition of “group practice” from 25 or more EPs to two or more National Provider Identifiers (NPI) assigned to a single Tax Identification Number (TIN). Participation in the GPRO requires self-nomination. For 2013, GPRO reporters have until Oct. 15, 2013 to select and change their initial reporting method.
Individual EP Reporting of Individual Measures
EPs choosing to report as individuals must decide if they will report on individual measures or measures groups. Self-nomination is not required if an EP chooses individual reporting, regardless of the method of measure submission.
As shown in Table A on the next page, EPs choosing to report individual measures under their individual NPI may still choose from the following reporting mechanisms:
- Qualified direct electronic health record (EHR)
- Qualified EHR data submission vendor
Per the final rule, published in the Federal Register last Nov. 16, there are 259 measures for 2013, including 241 reportable through claims or registries.
Aligning Quality Initiatives
There are a number of quality improvement initiatives running concurrently that affect physician payments under Fee-for-Service Medicare, including the EHR incentive programs, Million Hearts Campaign, eRx program, Medicare Shared Savings Program (MSSP), and more. The 2013 MPFS final rule outlines PQRS changes intended to align quality-reporting requirements across these programs, thereby making it easier for EPs to earn incentives.
“We believe that alignment of CMS quality improvement programs will decrease the burden of participation on physicians and allow them to spend more time and resources caring for beneficiaries.”
— 2013 Medicare Physician Fee Schedule Final Rule
In 2012, the Centers for Medicare & Medicaid Services (CMS) began offering EPs attesting to meaningful EHR use the ability to “pilot” PQRS clinical quality measures reporting on the same sample of beneficiaries used for pursuing an EHR incentive payment. To participate in the EHR pilot program, EPs must indicate this intention through their meaningful use incentive program attestation.
As shown in Table B on the next page, EPs may choose to report the same six clinical quality measures for PQRS incentive purposes as they are reporting for meaningful EHR use. The six measures must include three core or alternate core EHR clinical quality measures and three additional EHR incentive program clinical quality measures. The clinical quality measures must be reported through direct EHR submission, or via a qualified data submission vendor. The pilot effectively allows “double dipping,” as EPs are able to capture one set of measures for use across two separate CMS quality incentive programs.
An EP choosing the EHR pilot must report on a full year of quality data and must be in his or her second year of meaningful use.
Individual EP Reporting of Measures Groups
EPs who opt for measures groups may submit through claims or a registry. A significant change to measures group reporting is the reduction of the patient sample threshold to 20 Medicare Part B FFS beneficiaries (down from 30).
There are 22 measures groups for 2013, including a new measures group for oncology, focused on measurement of breast and colon cancer screening. The community acquired pneumonia (CAP) measures group was retired. The final measures groups are:
- Diabetes Mellitus
- Chronic Kidney Disease
- Coronary Artery Bypass Graft (CABG)
- Preventive Care
- Rheumatoid Arthritis
- Perioperative Care
- Back Pain
- Coronary Artery Disease (CAD)
- Heart Failure
- Ischemic Vascular Disease (IVD)
- Hepatitis C
- Chronic Obstructive Pulmonary Disease (COPD)
- Sleep Apnea
- Irritable Bowel Disease (IBD)
- Cardiovascular Prevention
CMS also finalized its intent to add Osteoporosis, Total Knee Replacement, Radiation Dose Optimization, and Preventive Cardiology as measures groups for reporting in 2014.
Group Practice Reporting
CMS finalized the proposal for groups of two or more NPIs to nominate and report under GPRO for 2013 quality reporting, providing greater opportunity for smaller clinics to participate in “system-based” reporting. Group practice size is determined during the active participation of reporting and not at the time of nomination.
Groups of two to 24 EPs looking to self-nominate under the GPRO must report on at least three measures through a registry on at least 80 percent of all Medicare FFS patients seen during the reporting period. The more common “web interface” reporting methodology associated with GPRO (more detail below) is not designed for smaller groups. CMS will not assign beneficiaries to groups of two to 24 that opt for GPRO reporting in 2013.
Registry reporting is a new reporting option for groups of 25-99 and 100+ EPs participating in GPRO for 2013. CMS will post a comprehensive list of quality registries on its website by summer 2013. When the registry reporting mechanism is selected, groups will choose three measures and report on 80 percent of all Medicare Part B FFS patients seen during the reporting period (Jan. 1, 2013 to Dec. 31, 2013).
Web interface is an alternative reporting mechanism with the number of assigned beneficiaries adjusted respective to group size. Groups of 25-99 will be assigned a Medicare patient sample of 218. Groups of 100 or more EPs will be assigned 411 patients. To continue alignment with other quality initiatives, CMS has adopted the Medicare Shared Saving Program (MSSP) method of patient assignment and sampling (For additional information on the MSSP program, go to www.federalregister.gov/articles/2011/11/02/2011-27461/medicare-program-
medicare-shared-savings-program-accountable-care-organizations). If either group fails to meet the sample threshold, they must report on 100 percent of the patient sample.
Regardless of size, if a group has chosen the web interface methodology, it must report on all 22 quality measures and seven disease modules: Care Coordination/Patient Safety, Preventive Care, Coronary Artery Disease, Diabetes Mellitus, Heart Failure, Hypertension, and Ischemic Vascular Disease.
If EPs are actively participating in a CMS Accountable Care Organization (ACO), they must report clinical quality measures through the GPRO web interface according to the ACO reporting criteria; they would not self-nominate for PQRS reporting through GPRO.
As CMS takes continued steps toward the public reporting of clinical quality data, EPs who actively report PQRS measures through the GPRO mechanism in 2013 will have their group level performance data posted on the Physician Compare website (www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/PhysicianReview-ICN904144.pdf).
There’s Still Time to Act
Through the final rule, CMS offers opportunities for EPs to successfully avoid the negative adjustment in 2015 and to prepare for the impact of the Value-based Payment Modifier, a provision of the ACA also mandated for implementation in 2015 (You can find additional information on the VBM at: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html).
Avoiding the PQRS Negative Adjustment
CMS is offering a temporary, less stringent data submission methodology for 2013, created to assist EPs in avoiding the 2015 PQRS negative adjustment. Unlike traditional clinical quality reporting, this methodology does not require EPs to submit any clinical quality data codes on Medicare Part B claims. Instead, CMS will analyze administrative claims data for 14 preventive and chronic care measures.
If EPs opt for the administrative claims methodology, they are required to self-nominate on the CMS website beginning summer 2013 (and no later than Oct. 15, 2013). Choosing the administrative claims option provides a mechanism for EPs to avoid the negative adjustment in 2015, but does not satisfy the reporting requirements for the PQRS incentive in 2013.
CMS provides EPs with three options for avoiding the 2015 PQRS payment adjustment:
- Satisfactorily report and earn the 2013 incentive of 0.5 percent.
- Report one valid measure or measures group using a traditional reporting methodology of claims, registry, or EHR.
- Self-nominate for analysis by CMS under the administrative claims-based reporting methodology.
The Push for Better Care and Outcomes
CMS has moved again to better align quality-reporting requirements in an effort to minimize duplication and administrative burden and, ultimately, to increase participation rates. CMS will continue to modify and evolve quality initiatives like PQRS to collect accurate and meaningful data that will empower physicians, health care systems, and patients through information for the purpose of affecting overall care delivery and outcomes, and to influence the shift of paying for “value” vs. “volume.”
Penny Osmon Bahr, BA, CPC, CPC-I, CHC, PCS, is director of health care solutions and specializes in health care reimbursement and practice management. She has more than 18 years of health care experience with a strong background in Medicare compliance, coding and billing, regulatory interpretation, curriculum development, and health information management (HIM). Ms. Osmon Bahr provides strategic guidance and solutions for revenue cycle, ICD-10, risk management, and HIM for health care clients throughout Wisconsin and the Midwest, emphasizing waste reduction, risk mitigation, and quality improvement. She is an author and speaker. Ms. Osmon Bahr is a founding member of the Wisconsin ICD-10 task force (WICD-10), sits on the HIMSS national ICD-10 Task Force, and is a member of the Medical Group Management Association.
April 1st, 2013
By Ronda Tews, CPC, CHC, CCS-P
Most emergency department (ED) visits are stressful for the patient, but too often they are also stressful for the coder or physician responsible for choosing the evaluation and management (E/M) level to report to the payer. At first glance, choosing a service level shouldn’t be hard: There are only five levels to choose from, with no distinction between new and established patients in the ED, and there are insightful documentation requirements for each ED level in the CPT® codebook. So what’s the problem?
It’s Harder than You Think
Take a closer look at the ED documentation requirements, however, and you’ll see where the difficulty for selecting an E/M level lies:
- A problem focused history;
- A problem focused examination; and
- Straightforward medical decision making.
- An expanded problem focused history;
- An expanded problem focused examination; and
- Medical decision making of low complexity.
- An expanded problem focused history;
- An expanded problem focused examination; and
- Medical decision making of moderate complexity.
- A detailed history;
- A detailed examination; and
- Medical decision making of moderate complexity.
- A comprehensive history;
- A comprehensive examination; and
- Medical decision making of high complexity.
The bold text shows that different codes contain some of the same requirements, which means selecting a level is not always straightforward. Consider also:
- History of Presenting Illness (HPI) requires one to three elements to be problem focused or expanded problem focused; and four or more elements to be detailed or comprehensive.
- Examination requires two to seven systems to be expanded problem focused or detailed.
- Medical decision making (MDM) is challenging when it comes to moderate complexity because this is the requirement for 99283 and 99284.
These overlapping requirements allow for gray areas, making the appropriate ED level choice very challenging. To add to this dilemma, the use of documentation templates in the electronic health record (EHR) is becoming more widespread. To save time, the physician often creates his or her own template for a review of systems (ROS) and physical examination, which are usually comprehensive. Every patient encounter ends up with a comprehensive history and a comprehensive examination, with the final determination of the ED level dependent on MDM.
But remember: Moderate MDM is required for 99283 and 99284.
The American Medical Association’s 2012 CPT® Professional codebook includes the following clinical examples in Appendix C, which may provide some guidance:
- Emergency department visit for a well-appearing 8-year-old who has a fever, diarrhea, and abdominal cramps, is tolerating oral fluids and is not vomiting.
- Emergency department visit for a healthy, young adult patient who sustained a blunt head injury with local swelling and bruising without subsequent confusion, loss of consciousness or memory deficit.
- Emergency department visit for a 4-year-old who fell off a bike sustaining a head injury with brief loss of consciousness.
- Emergency department visit for a patient with flank pain and hematuria.
- Emergency department visit for a female presenting with lower abdominal pain and a vaginal discharge.
The clinical examples are of little use, however, if you are questioning an ED case that has a comprehensive history, comprehensive exam, and moderate complexity MDM. Unless the example exactly matches your case, you are left to determine the appropriate ED level based solely on your opinion and experience.
If the history and exam are both comprehensive, many coders would lean toward 99284; but keep in mind the templates being used in the EHR, where every patient has a comprehensive history and a comprehensive exam. That would mean 99283 would never be billed.
Tackle the Gray Areas
I have several recommendations to deal with these difficult areas:
- Share your concerns with physicians. Show them the clinical examples in CPT® and ask for their input on how a given service might be reported. It’s only appropriate for the physician, whose name is on the claim, to have the final say on what he or she feels is the most appropriate ED level under the circumstances.
- Put in place a coding policy to assist coders in determining the most appropriate ED level when “bean counting” isn’t enough. The policy should be as specific as possible, so the coder can determine the number of elements needed for an “expanded problem focused” history and “expanded problem focused” exam when choosing between 99282 and 99283, as well as for moderate complexity MDM when choosing between 99283 and 99284. This will alleviate confusion for the coder and set a baseline for your organization so everyone is on the same page.
- Stay away from “one-size-fits-all” guidelines, such as “report 99284 whenever there is a comprehensive history or comprehensive exam.” Determine the appropriate service level on a case-by-case basis.
- Lastly, remember that medical necessity, above all else, should drive the clinical process and, by extension, coding and billing. Per the Medicare Claims Processing Manual, chapter 12, section 30.6, paragraph A:
“Medical necessity of a service is THE overarching criterion for payment in addition to the individual requirements of a code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted.”
Ronda Tews, CPC, CHC, CCS-P, is a senior financial analyst in revenue compliance for Mercy. She conducts E/M audits for all Mercy providers in Oklahoma, and also teaches coding and documentation to physician assistant students at Missouri State University. Ms. Tews has been in the health care industry for over 20 years, and has served as secretary and president of her local AAPC chapter.
By Carol Olson, CPC, CPC-H, CPC-I, CEMC, CCS, CCS-P, CCDS
Medicare Advantage (MA) reimbursement can trip you up in ways you didn’t expect. If you are seeing MA patients, be mindful of opportunities and pitfalls.
MA health plans are reimbursed based on beneficiaries’ chronic conditions. Submitting an inaccurate diagnosis, or a diagnosis resulting in a different hierarchical condition category (HCC), is a compliance risk. Any change in the HCC could mean you are receiving too much or too little revenue. Either way, the code would not be validated and would be considered discrepant.
There are opportunities for you to capture a more appropriate HCC code. Consider this list of the top 10 coding errors for risk adjustment:
- The record does not contain a legible signature with credential.
- The electronic health record (EHR) was unauthenticated (not electronically signed).
- The highest degree of specificity was not assigned the most precise ICD-9-CM code to fully explain the narrative description of the symptom or diagnosis in the medical chart.
- A discrepancy was found between the diagnosis codes being billed versus the actual written description in the medical record. If the record indicates depression, NOS (311 Depressive disorder, not elsewhere classified), but the diagnosis code written on the encounter document is major depression (296.20 Major depressive affective disorder, single episode, unspecified), these codes do not match; they map to a different HCC category. The diagnosis code and the description should mirror each other.
- Documentation does not indicate the diagnoses are being monitored, evaluated, assessed/addressed, or treated (MEAT).
- Status of cancer is unclear. Treatment is not documented.
- Chronic conditions, such as hepatitis or renal insufficiency, are not documented as chronic.
- Lack of specificity (e.g., an unspecified arrhythmia is coded rather than the specific type of arrhythmia).
- Chronic conditions or status codes aren’t documented in the medical record at least once per year.
- A link or cause relationship is missing for a diabetic complication, or there is a failure to report a mandatory manifestation code.
Regardless of where you find shortcomings in your facility, you should consider ways to improve clinical documentation. Develop a compliance plan and implement prospective and retrospective, internal and external chart reviews with ongoing monitoring and feedback. Be sure to review records based on official coding guidelines.
March 20th, 2013