By Michael Calahan Federal auditors promise to assail providers through a variety of initiatives.  Paradoxically, the recent annulment of consultation CPT codes by Medicare forces physicians to improve evaluation and management (E/M) reporting strategies.  This drastic change leverages the more flexible and ubiquitous E/M codes for office and hospital inpatient visits by discounting the stringent consultation criteria.  It also increases the impact of E/M services on practice revenue.  Thus, to ensure accurate reimbursement and fewer improper payments E/M services will become a larger target for federal programs such as the Comprehensive Error Rate testing (CERT) and Recovery Audit Contractor (RAC) initiatives. With heated efforts focused on E/M services, what should providers do in the face of this scrutiny?  The first order of business is to ascertain which audit findings yield valuable opportunities for clinical documentation improvement as well as coding and billing fortification.  Here’s a “Top 10” inventory of recent audit findings:

1. Non-response to ADRs: The number one reason for physician and nonphysician practitioner (NPP) services being downcoded or denied by auditors is non-response to Additional Documentation Requests (ADRs).  Federal reviewers will query providers via written medical record (MR) requests or ADRs; these are simple documentation demands to verify services billed. Survival Tips: Absent any tenable excuses for not replying to these queries, to avoid denials every provider’s office should log the receipt of, track the processing of and confirm the fulfillment of these requests.
2. Unsigned, illegible and/or indeterminate authorship of MRs: Unsigned MRs, illegible provider signatures and/or the federal reviewer’s inability to differentiate ancillary staff notes from treating provider’s notes accounts for a preponderance of audit findings. Survival Tips: Legible signatures are required to certify services; illegible signatures submitted without evidence of proof-of-signature are adjudged as “indeterminate” and equated to unsigned documentation.  Likewise, mixing ancillary staff/scribe notes in the body of the clinical note without signature clarification is tantamount to uncertified records.  These services are denied as “unable to be verified as being rendered by the billing provider.”  Providers and ancillary staff/scribes should sign and date their clinical note contributions so authorship of every annotation detailing the patient encounter is clear.  Excluding certain hospice notes, facsimile stamped signatures are no longer valid.
3. Review of Systems (ROS) missing or poorly documented for the E/M service reported: Recording the history portion of E/M services is, by audit, the weakest area of provider documentation.  Easily the most overlooked element of the history is the ROS which, when poorly documented or not recorded, severely limits the level of E/M service legitimately billed.  This is ironic as the ROS, like the PFSH, can be efficiently obtained by ancillary staff and reviewed/certified by the treating provider.  Examples of poorly documented ROS include those with statements such as “all systems unremarkable.”  Many Carriers do not allow such blanket statements. Survival Tips: There are few reasons why the ROS cannot be thoroughly obtained, unless it is not medically necessary.  If the ROS is obtained on a separate form or questionnaire and subsequently verified by the provider, the form should be signed/dated, i.e., certify the ROS document is germane to the current visit.
4. Undocumented or poorly documented services for E/M code 99211: CPT code 99211 is designed for minimal problems requiring “quick” visits carried out by ancillary staff, supervised by the reporting provider.  Adequately substantiated in the MR documentation 99211 can be reported for myriad services.  Errors in reporting 99211 range from inadequate or no MR documentation to reporting 99211 in an automatic manner, e.g., CERT auditors point to “99211 automatic reporting” for various staff services like Bp check, PPD reading, specimen collection, shot administration, etc., without cognitive services performed and/or documented. Survival Tips: CPT code 99211 represents a true E/M service therefore the MR documentation must convey both evaluation and management facets, e.g., (a) clinical information is provided or exchanged necessary to the patient’s condition or problem-related inquiries and (b) therapy, management or a treatment plan in some form is rendered/provided.  Both actions must be documented to substantiate the cognitive service.  Since 99211 is typically furnished by ancillary staff under the provider’s direct supervision, it is reported as “incident to” and the provider must certify the chart notes.
5. Time used as the key component for the E/M service but no times are documented: Providers can report non-time based E/M services using ‘time’ as the key component (instead of the 3-key components of history, physical exam [PE] and medical decision making [MDM]) when counseling and/or coordination of care (CoC) constitute 50% or greater of the total face-to-face time.  Federal auditors find numerous instances of missing or poorly documented time(s) when the provider clearly intended to use time as the singular key component. Survival Tips: Document two strata of ‘time’ when relying on it as the key component: (1) total face-to-face time for the entire encounter and (2) total time spent in counseling and/or CoC.  The second stratum demonstrates the >50% rule; the first stratum creates the frame of reference for stratum #2.  For outpatient services non face-to-face time (i.e., time expended in pre-/post-visit work) cannot be included in the total time calculated; inpatient services, however, can include non face-to-face unit/floor time spent in the care of the patient.  Content of counseling/CoC must be fully documented.
6. Modifier -25 mis-billed: By definition, modifier -25 is reported with an E/M code when significant, separately identifiable E/M services are rendered by the same physician on the same day of a procedure or other service.   Two common problems identified by federal auditors are: (1) modifier -25 was incorrectly reported on a non-E/M service, e.g., 93000-25 for EKG, and (2) modifier -25 was reported with an E/M code when the patient presented solely for a minor procedure, e.g., joint injection, however, the E/M service was not documented or was not medically necessary. Survival Tips: Modifier -25 is designed to allow certain non-allowed E/M services to bypass system edits.  The MCPM, 100-04, Chapter 12, addresses monitoring of modifier -25, for example at §40.2.A.8: “When Carriers have conducted a specific medical review process and determined … an individual/group has high statistics … of the use of modifier "-25," have done a case-by-case review …  to verify that the use of modifier “-25” was inappropriate, and have educated the individual/group as to the proper use of this modifier …” the Carrier may impose prepayment screens or documentation reviews.
7. “4x4 Rule” - Distinctions between expanded problem focused (EPF) and detailed physical exams: Confusion surrounds these specific exam levels because the official 1995 and 1997 E/M Documentation Guidelines (DGs) are ambiguous for both EPF and detailed exams by stating both must contain “2-7 elements,” specifying the EPF level requires a “limited” exam and detailed requires an “extended” exam.  Both must address “the affected areas/systems and any other symptomatic or related areas/systems, up to 7.”  The vague definitions for “limited” and “extended” have caused provider misinterpretation and allowed for a predominant auditor finding of “insufficient documentation for detailed exams.” Survival Tips: Know the “4x4 rule,” which comprises four elements/items examined within four body areas/organ systems, fully documented.  For providers, the “4x4 rule” is a quick and uncomplicated method to avoid misinterpretation.  For auditors, it allows an efficient assessment of the exam and more exact level differentiation.  Providers should check with their Carrier to ascertain the guidelines for EPF and detailed exam levels.  Carrier reviewers are tasked with referencing both sets of DGs - 1995 and 1997 - adjudging each case so final assessments best benefit the provider.  Even when the “4x4 rule” is not officially promulgated, it remains a useful tool.
8. CPT code 99499 (Unlisted E/M Service) reported in error: CMS addresses CPT code 99499 billing (Medicare Claims Processing Manual [MCPM] 100-04, Chapter 12, §30), stating “the Carrier has the discretion to value the service.”   In effect, the Carrier is in control and many maintain that 99499 should be reported in rare instances.  “Rare” is the operative term and used repeatedly in official literature.  This is because adjudicators must review associated documentation and apply individual consideration (IC) protocols for appropriate pricing. Survival Tips: Report 99499 in rare circumstances and only per Carrier instructions.  An example by a local MAC follows: “If documentation criteria for initial inpatient hospital services 99221-99223 cannot be met and if … even a 99221 cannot be met, but the documentation does meet the criteria for subsequent inpatient hospital services 99231-99233, then code appropriately even though it is chronologically an admission. However, if the documentation “does not even meet the criteria for a 99231, then code 99499."
9. E/M services misreported with modifier -24 during a global surgery period: When reporting E/M services during the global surgical period of a major procedure (90 days) or during the global period of a minor procedure (up to 10 days), the appropriate documentation must support the service and the E/M code must be appended with modifier -24 to circumvent system edits.  Documentation must detail why an E/M service should be paid outside the global period.  According to the MCPM, 100-04, Chapter 12, §40.2.A.7, “services submitted with modifier “-24” must be sufficiently documented to establish that the visit was unrelated to the surgery. An ICD-9-CM code that clearly indicates the reason for the encounter was unrelated to the surgery is acceptable documentation.” Survival Tips: This is one of the few E/M services included in the 2010 Office of the Inspector General (OIG) Annual Work Plan.  Providers must implement steps to prevent inadvertent reporting of E/M services as separately payable when the patient is in a post-surgical status.  Coders/billers should have solid knowledge of global surgery periods and modifiers which legitimately sidestep system edits.
10. Key components of the E/M service not fully documented or missing: This “Top 10” mention is the last-listed but in aggregate is the most prevalent of all audit findings.  For most E/M services 3-key components govern code selection: (1) history, (2) PE and (3) MDM.  Germane to this article, these key components must be included in the documentation for new office visits and initial inpatient services.  If only 2-key components are required to be documented, e.g., for 99212-99215 or 99231-99233, at least two of the components must meet the service’s lowest threshold requirements.  “Survival Tips” are interspersed:

(a) History:  Missing or lack of recorded data including chief complaint (CC), past medical, family/social history (PFSH), and history of present illness (HPI).  Contradictory data between these elements is also a common error, e.g., CC states one reason for the visit but the HPI details a different problem.  Some Carriers require the CC and HPI to be documented by the treating provider only.  Terms like “noncontributory” under the PFSH or ROS may be invalid; know Carrier preferences. (b) PE:  Missing or insufficient information. A common PE statement is “no change from prior visit.”  When 3-key components are required this brief statement is inadequate.  “Negative” and “WNL” notations are acceptable forms of documentation for unaffected areas/organ systems but are unacceptable for affected areas/organ systems. (c) MDM:  Truncated or disorganized data.  MDM information conveys the complexity/risk of the service.  Disorganized MDM data can cause mistakes in copying the requested MRs.  This is easily remedied when the provider creates a data bridge between the body of the visit text and other supporting visit documents.  The data bridge is critical when the provider has reviewed old MRs, ordered tests/studies, carried forward or revised diagnoses and medications, etc.  If overlooked and not submitted to reviewers, the service will be downcoded or denied.  This also relates to history elements, e.g., the ROS, when obtained on separate forms.  Empower office personnel tasked with processing MR requests by educating them on assembling a complete response package for the auditors. Michael Calahan, PA, MBA, CCS, CCS-P is an independent executive healthcare consultant working in compliance, coding and revenue cycle management in the physician and facility inpatient/outpatient arenas.  He can be contacted at mikiecal@hotmail.com for questions or comments.