You’ve received a request for medical records from a payer, who is going to conduct an audit on your claims. Your EHR is tight, the notes are voluminous, your providers are well versed at coding. If anything, you under code. You provide excellent care for your patients. No one has ever given you any trouble before. Nothing to worry about, right?
Several months pass, and you get a letter from the payer. It’s the results from your audit. You open it up, and see………”…medical necessity not supported”……..”….notes are cloned”……….”…..records include conflicting data”. It also says you owe an astronomical amount of money due to overpaid claims related to these citations, and, they’re putting you on prepayment review until things improve.
What just happened? Why are they doing this? CAN they do this??
Welcome to the world of billing and coding, where black and white is often eclipsed by gray, where the obvious isn’t always quite so obvious, and where sometimes, less is more.
The electronic health record is supposed make your life easier. It provides accurate, up to date information about the patient. It facilitates coordinated access and information sharing. It helps providers more efficiently diagnose patients, reduces errors, provides safer care, facilitates quality. And oh by the way, it does a bang up job of capturing essential billing elements. Pop in the right template, maybe tweak it a little, and you’re good to go. So, where do things go astray?
To understand how something like this can happen, you first need to understand how the patients medical record influences medical necessity. Per CMS, medical necessity is the overarching criterion for payment. Inaccurate information in the chart, especially when carried forward from a previous service date or entry without necessary editing, often does not afford an auditor the ability to understand if you needed to see that patient, perform that test, order that script, etc. “Copy/paste” type operations that occur without needed modifications to content is a process infamously known as ‘cloning’. And that doesn’t just refer to the entire progress note as a whole; it can refer to pieces of a progress note that are inaccurate. Those pieces could be integral to billing a distinct procedure, or a crucial element associated with an office visit code. If one or more pieces never or almost never change from one visit to the next, the auditor doesn’t know if the information simply didn’t change, or may have changed but just wasn’t edited. Lately, auditors seem to assume the latter.
The presence of conflicting information is another giant red flag. If the history indicates the patient has severe dementia, but the review of systems template indicates “All systems were reviewed and negative”, well, that could be a problem. One error of this nature can lead to a reviewer to cast aspersions on the integrity of your note. “What else could be wrong with this chart?”, says the auditors thought bubble.
Truth be told, these are usually just innocuous mistakes which do not represent any intent to commit billing fraud. The payers don’t see it that way. They don’t know if you forgot to revise that ROS because you’re up until 11:30 PM signing off on your notes, or if you’re trying to pad the record with billing elements. All they know there is a conflict or redundancy which could represent something fraudulent.
Another pitfall that may come back to haunt you is the overstuffed progress note. This occurs when the sheer quantity of the displayed items seems wildly disproportionate to the nature of the presenting problems. Taken at face value, it would seem that a single, self-limiting medical condition would not normally warrant a complete review of past medical, family, and social history, full review of systems and comprehensive exam. Although there may be times when circumstances do require a more intensive evaluation than meets the eye, the payers expect this would be the exception, not the norm.
All of this leads to a presumption that the information in your charts is questionable. Once that notion is planted in an auditors head, it colors their perspective. If you happen to be a ‘high volume’ provider with excessive billing of any particular code or modifier, the notion that there “must” be something disingenuous going on becomes solidified. This thinly veiled ethical challenge can be insulting and infuriating to hard working providers who never in a million years would intentionally submit an unsupported health claim.
So, what on earth can be done…….
A gift horse arrived January 1, 2021, and its name is the 2021 Evaluation & Management (E/M) Guidelines. These are new rules, created by the AMA and adapted by CMS and other payers, for outpatient office visit codes (99202-99215 only). The guidelines effectively remove those preexisting requirements to ‘quantify’ the history and physical examination: you no longer need to worry about having ‘enough’ of that ROS anymore. (However, you should continue to document those aspects of history and exam that lend support to your clinical decision making and any tests or treatments ordered.)
E/M coding has historically been associated with EHR misuse, in part due to the confusing and onerous documentation requirements imposed by CMS. The new rules allow physicians to document the most salient points relevant to the medical decision making, or time spent. Its coding, so sure, there are some charting nuances you still need to know. But this is an enormous step in the right direction.
Another very simple rule to bear in mind is: change what changes. Your notes should always have an interval HPI. The history of the problem is what it is, but there is usually something unique to say about the patients status covering the span of time between the last appointment and the current one. And label it “Interval HPI”, don’t blend it in with the other history because that combination of new and old data sometimes doesn’t set well together. You want unique documentation for each encounter, and it should stand out in your progress note.
Taking the Interval HPI concept one step further, understand that encounter specific charting is king. With the E/M changes comes a flexibility that has not existed in many years. The rigidity of cookie-cutter, awkward appearing templating is, from a billing standpoint, now inferior to an old-school 1985-ish free text paragraph or two (yep, I remember those). Everything has come around full circle. Less is more.
To be clear, the E/M documentation changes do not apply to all CPT codes. Certain services, such as wellness visits, chronic care, transitional care, etc, require more rigidity in capturing essential elements. However, you do want to infuse encounter/patient specificity into those templates too. Despite the redundancies, you still need to personalize those notes so as to render them unique to the patient. A little TLC goes a long way.
Finally, in the unfortunate event that you do receive one of those nasty overpayment demand letters someday, don’t acquiesce without conducting an analysis first. Lets face it: they call them “procedure” codes because there are commonalities. Certain things may not change (or change much) from one service date to another. If you’ve changed the things that change, and still got dinged in an audit, there may be sufficient basis to challenge the results. There is absolutely no requirement to rephrase verbiage in your charts just for the sake of making it look different. That’s a level of insanity I hope we’ll never arrive at.
So, spend an extra 5-10 minutes proofing those notes before you close them. As my mom once said, “An ounce of prevention is worth a pound of cure”. The immense benefits of such diligence can truly be worth its weight in gold.