In 1997, the American Medical Association (AMA) added codes to the echocardiology section of the CPT® codebook to further define echocardiograms when performed with a confirmed congenital anomaly. Although the intent was to identify a special situation that does not fall into the normal echocardiology realm, the additions caused confusion for cardiologists and coders in assigning codes for suspected cardiac anomalies.

Proper application of CPT® codes 93303 Transthoracic echocardiography for congenital cardiac anomalies; complete versus 93306 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography has resulted in numerous debates. Coding guidance often appears conflicting, even within the same document.

Set the Record Straight

When a patient presents with a suspected, unconfirmed congenital anomaly and an echocardiogram is performed, many cardiologists believe that the proper code is 93303 because the stated reason for the study is either to confirm or rule out a cardiac anomaly. In actuality, 93303 is only for confirmed anomalies.

A basic rule of thumb is that when a congenital echo is ordered, but a congenital anomaly is not detected, use the regular echo code (93306). If a congenital echo is ordered and a defect is detected, use the congenital code (93303). Conversely, when a regular echocardiogram is ordered and a congenital anomaly is detected, turn to the congenital code (93303).

Support for coding congenital echocardiograms can be found in the AMA’s CPT® Assistant, December 1997, which states, “The Congenital Heart Disease (CHD) codes should not be used when suspected CHD is not confirmed by the echo exam.” The American College of Cardiology also recommends that  the congenital heart disease echo codes be used when CHD is known to be present or is detected on the exam. In absence of a CHD diagnosis, report the regular echocardiogram codes.

Complete Vs. Limited

There are additional questions regarding the difference between a complete congenital study and a limited congenital study. A complete congenital study requires an evaluation of the aorta and pericardium, which is often lacking in the clinical documentation. Based on CPT® criteria:

“… a complete transthoracic echocardiogram requires 2-dimensional and, when performed, selected M-mode examination of the left and right atria, left and right ventricles, the aortic, mitral and tricuspid valves, the pericardium and adjacent portions of the aorta. (Note that while M-mode exam is usually performed, it is not required in order to assign a complete echo code.) If it is impossible to image all of the listed structures, the report must indicate the reason. A limited transthoracic echocardiogram should be billed if the report does not evaluate or attempt to evaluate all of the structures listed above.”

Consider the following examples of proper coding:

• A pediatrician refers a newborn because, upon routine examination, she thought she detected a heart murmur. Your cardiologist performs a congenital echocardiogram, but the results do not reveal a congenital defect. Report the standard echo codes (93306, 93307, 93308, 93312-93314).
• Your cardiologist performs a normal echo on a patient who is not suspected of having CHD; however, upon assessment, it’s discovered the patient has a defect. Regardless of whether the defect is significant enough to warrant treatment, the congenital codes (93303, 93304, 93315-93317) now apply.
• A 15-year-old male patient presents to the cardiologist for a follow-up exam. He was last seen one year ago for an evaluation of a suspected heart murmur due to a positive family history of the same. His primary care physician detected what appeared to be a murmur the previous year. Your cardiologist performs a complete congenital echocardiogram at that time. He does not find any evidence of CHD, but suggests follow up in one year. At this time, a follow-up study for congenital cardiac anomalies is performed, which again shows no evidence of CHD. Your cardiologist documents in the medical record “well male patient.” Report the standard follow-up code 93308 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study.

Always Check Carrier Guidelines

Always check with your Medicare administrative contractors (MACs) and individual payers in your area, as reimbursement guidelines can vary dramatically from one insurance company to another, and each payer may have specific documentation/medical necessity requirements for various services.

Janice G. Jacobs, CPA, CPC, CPCO, CCS, ROCC, is a director at IMA Consulting and has over 25 years of health care and consulting experience. During her consulting career she has worked on numerous ambulatory payment classifications (APCs), diagnosis-related groups (DRGs), physician billing and coding projects, and chargemaster (CDM) reviews and various interim-staffing engagements such as billing office manager and director of compliance at a major west coast academic medical center. Ms. Jacobs owned and managed a full-service, multi-specialty medical billing company. She is a Certified Public Accountant licensed in Pennsylvania, with experience in hospital accounting, auditing, and cost reporting.

“Compliance” often conjures up images of boring lectures, law enforcement, huge fines, scary “I’m from the government and I’m here to help” mentality, and worse. In reality, compliance is an integral part of the health field. And with health care reform and the Patient Protection and Affordable Care Act (ACA), compliance programs are mandatory.

Compliance is also inextricably linked to coding. With health care reform putting pressure on accurate documentation, coding, and billing, there are many benefits to having strong and accurate coding skills, a positive coding-compliance team, and an effective compliance program to ensure correct reimbursement. Having good partnerships may also strengthen an organization’s overall compliance program by increasing a hospital or medical practice’s revenue. Finally, coding and compliance working together can support audit or recoupment efforts and quality measurements; and cooperation can help meet electronic health record (EHR) meaningful use requirements.

Fraud. Waste. Abuse.

These three little words form the government’s mantra for audits and legal actions conducted by the Office of Inspector General (OIG), the U.S. Department of Justice (DOJ), the Office of Civil Rights (OCR), and the Centers for Medicare & Medicaid Services (CMS). As these government agencies look for ways to prevent fraud, waste, and abuse, there are four important federal laws that form the framework for an effective compliance program. Appropriate and effective coding is tied to each of them:

• False Claims Act (31 USC§3729).
  This Civil War era statute has been revised over the years to strengthen the legal underpinnings and penalties for any individual or entity that presents a false (i.e., inaccurate or wrong) claim to the government (i.e., Medicare or Medicaid or other federal health insurance program). When a submitted claim from a hospital is inaccurate, there is the potential that the False Claims Act is being violated.

• Anti-kickback Statute (42 USC§1320a). This law prohibits offering, paying, soliciting, or receiving anything of value to induce or reward referrals or generate federal health care program business. This law directly affects referrals from physicians to hospitals for services and patient care.
• Stark law (42 USC§1395) or the physician self-referral law. Stark law is named after the California congressman who spearheaded the massive legislation. This law prohibits a physician from referring Medicare patients for designated health services to an entity with which the physician (or an immediate family member) has a financial relationship. Given the breadth of this law, any hospital referrals from a physician who receives any form of compensation from that hospital need to be regulated and monitored. Because hospitals, clinics, and physicians are inextricably linked, it is critical to meet the safe harbors, or exceptions, provided in these comprehensive laws regulating provider-hospital relationships. Huge fines, penalties, Corporate Integrity Agreements (CIAs), exclusion from Medicare, and jail are consequences of violation. Although typically not directly involved in physician financial arrangements, coders should at a minimum have confidence that all physician/hospital financial arrangements are appropriate. Coders are often the first to see irregular patterns of referrals, elevated service levels, and inappropriate orders—all possible signs of violations. You can ask managers, compliance officers, and legal departments how physician financial arrangements are monitored. When necessary, question any inappropriate or excessive referrals from a particular provider.
• Health Insurance Portability and Accountability Act (HIPAA) (45 CFR Parts 160, 162, and 164). This law, familiar to all coders, governs the transmission of medical records containing important medical information. HIPAA—under the purview of the OCR—also regulates the disclosure of patient protected health information (PHI). Professional coders know the importance of adhering to strict confidentiality when dealing with the thousands of bits of private medical information coming across their desks each day. With implementation of EHRs, HIPAA kicks in with full force. The Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009 increased regulations and requirements for preventing and reporting PHI breaches. For instance, a PHI breach affecting more than 500 patients in one geographical area requires notification to the U.S. Department of Health & Human Services (HHS), notification to affected patients within 60 days of learning about the breach, establishing a specific hotline number for patients to call, and other possible consequences. Data nationally indicates the cost for mitigating and responding to each breach is over $200 per record. Any misuse of patient PHI can cause the OCR to audit, investigate, and fine the perpetrator. The OCR has initiated over 100 HIPAA audits in 2012 to review practices of hospitals, clinics, and physicians across the United States. More HIPAA audits are probably on the horizon.

These four main laws, along with Medicare and Medicaid rules and regulations, and other state and federal laws, provide tools to guide effective compliance and coding practices. These laws also provide the leverage for the government to audit and review coding practices, patterns, and claims.

You Can’t Stick Your Head in the Sand

Historically, coders have said, “I just code what is given me; compliance is not my concern.” And in the past, perhaps, knowledge or awareness of some of the aforementioned compliance laws were not on the coder’s radar.

The landscape has changed. As these laws are revised and updated, deliberate knowledge is being removed as a requirement for violation. Laws now contain the verbiage “known or should have known.” For instance, the Anti-kickback Statute is an “intent-based” statute. This means that specific intent to violate the Anti-kickback Statute must be shown to prove a violation. Historically, however, federal courts have interpreted this statute broadly, ruling, for instance, that intent to violate this statute may be inferred from other circumstances.

Conversely, the Stark law is a “strict liability” law. This means that under Stark, lack of deliberate intent or knowledge is not an excuse and proof of intent is not necessary. If there is an improper or illegal physician financial arrangement in place, every referral from that physician is affected as long as the arrangement was noncompliant, and all claims coded and submitted by that physician are suspect.

The False Claims Act was modified in 2009 to make it clearly illegal—defining it as “fraud”—for a hospital or physician to knowingly keep overpayments or money paid to them due to a billing error or wrong payment (i.e., “credit balance”). Entities now have 60 days to repay an overpayment after they know, or should have known, about the improper payment.

In a nutshell: Ignorance of compliance in the changing health care landscape is not bliss. Compliance offices will need to work closely with coding and billing offices to ensure systems and practices are in place to adhere to strict law compliance.

The Government Is Watching

Hospitals and physician practices have seen an exponential increase in government audits and claim reviews. Coders will often be the front end of defense and offense when government auditors review and audit health claims.

The Recovery Audit Contractor (RAC) program is perhaps the most familiar these days, but Medicaid integrity contractors (MICs), Zone Program integrity contractors (ZPICs), Medicare administrative contractors (MACs), and the Comprehensive Error Rate Testing (CERT) program are closely related. All are designed to help the government discern fraud, waste, and abuse—and to recoup federal health care dollars that have been improperly paid.

The U.S. government has repeatedly reported that incorrect claims cost the taxpayers billions of dollars. Consequently, over the past several congressional sessions (both Republican and Democrat led), the OIG enforcement budget has increased dramatically. Government data shows that every dollar invested in compliance recoups anywhere from six to 10 dollars for the government.

The same holds true for third-party payers who have increased their scrutiny of claims, instigating their own independent reviews and audits. From a taxpayer viewpoint, RAC, MIC, MAC, ZPIC, OIG enforcement, etc. are all good ways to ensure Medicare/Medicaid dollars are being paid accurately. But from a hospital or physician practice viewpoint, these programs have added huge administrative burden and costs.

Good News for Coders

The “good news” for professional coders is that these governmental and third-party payer audits reinforce the importance of accurate coding, professional coding standards, and the involvement of coding in an entity’s overall compliance program.

One of the key seven elements of an effective compliance program, according to the OIG, is to have regular auditing and monitoring in place. The basis for most audits of claims is the medical documentation, underlying medical necessity, and then how that translates into the codes and the bill. Coders should increasingly be called upon to help review coding internally, set up effective coding practices, protocols, and procedures, and meet accurate coding benchmarks.

David Lane, PhD, CHC, CPC, CAPPM, is chief compliance and privacy officer at Hawaii Health Systems Corporation.

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.