In our new series, we will review the topics of compliance, auditing and coding. To kick off this series, we felt that the remarks made by Principal Deputy Inspector General Joanne Chiedi’s comments at Health Care Compliance Association (HCCA) 2019 Compliance Institute, April 8, 2019, were of value to simply repost.
HHS OIG presented a 2 page pdf covering the highlights of the Deputy Inspector General’s remarks. Here is an outline of the 2 pages for a fast read.
Oversight and Compliance at This Time of Disruptive Innovation in Healthcare
We cannot oversee what we do not understand.
Compliance must have a seat and a voice at the innovation table.
Give Compliance the data.
Compliance and innovation must advance together.
The Healthcare Ecosystem
PATIENTS AND FAMILIES are reimagining how and where they want to receive healthcare.
CLINICIANS, PROVIDERS, SUPPLIERS, AND PAYERS are rethinking how they deliver smart, quality care to consumers.
INNOVATORS AND SCIENTISTS are supporting the delivery of quality healthcare with new digital health technologies, new care delivery models, and new clinical treatments.
OVERSIGHT AND COMPLIANCE PROFESSIONALS are working to ensure that the rules of the road are followed, that dollars are well spent, and that patients are protected.
Strategies for Forward-Focused Oversight and Compliance
Agility and Adaptability
Continuous Prioritization
Compliance Leadership
Strategic Partnerships
SpringSoft Medical is in the business of disruptive innovation in healthcare. Come see what we are doing.
This week we’ll look at how the various authoritative sites describe Number and Complexity of Problems Addressed.
First let’s look at the AMA’s definition in the now familiar document “cpt-office-prolonged-svs-code-changes.pdf”, titled CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes.
Page 3: Number and Complexity of Problems Addressed at the Encounter says
… Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management. The final diagnosis for a condition does not in itself determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition. Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction. ….
In a prior posting, we provided an E/M documentation tip from WPS GHA. In their introduction of documentation tips for E/M coding, WPS GHA reminds the reader (bold font is theirs) “Evaluation and Management (E/M) Services Documentation must support the level of service billed and the medical necessity for the level billed.“
“Medicare requires a face-to-face encounter with a patient consisting of elements of both evaluation and management
The evaluation portion is substantiated when the record includes documentation of a clinically relevant and necessary exchange of information between provider and patient
The management portion is substantiated when the record demonstrates an influence on patient care (ex.; medical decision making, patient education, etc.).”
Effective for dates of service on and after January 1, 2021, the “Number of Diagnoses and Management Options” has been changed to “Number and Complexity of Problems Addressed at the Encounter.”
One element in the level of code selection for an office or other outpatient service is the number and complexity of the problems that are addressed at an encounter. Multiple new or established conditions may be addressed at the same time and may affect medical decision making. Symptoms may cluster around a specific diagnosis and each symptom is not necessarily a unique condition. Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management. The final diagnosis for a condition does not in itself determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition. Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction.
The number and complexity of problem(s) that are addressed during the encounter
This section allows you to identify the office or other outpatient service level which corresponds to the number and complexity of the problems that are addressed at an encounter. Multiple new or established conditions may be addressed at the same time and may affect medical decision making. Symptoms may cluster around a specific diagnosis and each symptom is not necessarily a unique condition.
You can find Novitas’ FAQ on the 2021 E/M at this link.
Some key thoughts from these descriptions are:
Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management.
Questions to consider:
Does the documentation identify the conditions addressed?
Does it demonstrate the influence on the patient’s care?
The final diagnosis for a condition does not in itself determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition.
Questions to consider:
Does the documentation describe the risk of morbidity/mortality for the conditions addressed?
Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction.
Questions to consider:
Does the documentation describe the risk of morbidity/mortality of the conditions’ comorbidities?
We’ve been seeing this question posted searching for authoritative references.
My clinic bills the 81003 for a UA done in house and A1C and prothrombin. My understanding is that it can NOT be counted as a unique test ordered under current guidance but I can’t find where the AMA says this.
Here is what the AMA 2021 CPT(R) Manual says.
Any specifically identifiable procedure or service (ie, identified with a specific CPT code) performed on the date of E/M services may be reported separately.The actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when reported separately.
Dr. Vinita Magoon, DO, JD, MBA, MPH, CMQ replies to similar questions in his 2021 outpatient office E/M changes FAQ (Nov 6, 2020) n the AAFP’s FPM Journal.
Is use of over-the-counter (OTC) medications automatically considered low risk (as it was under previous guidelines)?
OTC drugs are not necessarily without risk and therefore are not necessarily considered low risk for purposes of MDM. For example, recommending an OTC medication to a patient with several co-morbidities may still result in a detailed discussion of risk. Therefore each instance should be evaluated individually and not automatically characterized as low risk.
If I order a test during one visit and review the same test during the next visit, can I count this as a data point for both visits?
No, you can only get one point for this lab, so the order and review of results is part of the data ordered/reviewed during the first visit. It is not considered a unique data point in a subsequent encounter. When you order a test it is assumed you will review it, therefore both the ordering and the reviewing is attached to the first visit.
If I review a previous A1c and order a new A1c during the same encounter, does this count as two points under data reviewed?
No. Each unique test will count as one point and a unique test is defined by its CPT code. Since this is the same test with the same CPT code, the reviewing of the previous test and ordering of the new one will together count only as one point.
15. Can the independent visualization of a test be counted in the medical decision making if the physician is also billing for the test?
Per AMA, the actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the level of E/M service when reported separately. Physician performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code. The physician’s interpretation of the results of diagnostic tests/studies (i.e., professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code and, if required, with modifier 26 appended. If a test/study is independently interpreted in order to manage the patient as part of the E/M service but is not separately reported; it is part of medical decision making.
In anarticle for AAOS, Margaret M. Maley, BSN, MS of KarenZupko & Associates, Inc. (KZA) writes:
Data are divided into three types:
tests, documents, orders, or independent historian(s) (with each unique test, order, or document counted to meet a threshold number)
independent interpretation of tests
discussion of management or test interpretation with external physician or other QHP or appropriate source
Data include information obtained from multiple sources, interprofessional communications, and interpretation of unique tests. To be considered part of MDM, these data elements cannot be reported separately with a CPT code for reimbursement. [bold font is our emphasis]
For example, if reporting the professional component of a radiologic service, you cannot also count the independent interpretation of the radiograph as a data element in MDM—no double-dipping. A unique test is imaging, laboratory, psychometric, or physiologic data defined by a CPT code. For example, when you order radiographs, three views of the hip and three views of the knee would be considered ordering two unique tests, as each of those radiologic series has its own CPT code.
What other complex scenarios are you running into?
As you have trained, researched, debated and questioned how to use the 2021 E/M Guidelines, what are the key changes you plan to train your providers on?
One of our expert auditors, Jill Young, CEMA, CPC, CEDC, CIMC has suggested that a narrative note could be very effective to a) tell the story of the patient, b) be concise and clinical, documenting and showing the intensity of care considered and provided and c) justify medical necessity of the level of service provided.
“Do you remember the last time you read an excellent physician note? If it was similar to any of the gems I’ve discovered, it was well organized and included the pertinent data from the encounter, all the while keeping the patient at the center of the dialogue. Good notes facilitate continuity of care, since many physicians gather background information in the electronic medical record (EMR) prior to meeting a new patient.”
As one of our event participants stated, the 2021 E/M coding guidelines can be supported by a return to documenting as a SOAP note. To support outpatient E/M services, the note should document the intensity of service, the intensity of assessment and treatment plan.
There are a myriad of articles on the topic of writing good visit notes. There is also a growing interest by patients and caregivers to be involved in their care.
So how should you educate your providers to write their notes in today’s world of patient portals and provider / patient communication?
Here is one commentary by Jared W. Klein, MD, MPH, et al in The American Journal of Medicine, Vol 129, No 10, October 2016.
Be clear and succinct
Directly and respectfully address concerns
Use supportive language
Include patients in the note-writing process
Encourage all patients to read their notes
Ask for and utilize feedback
Be familiar with how to amend notes
Hannah Chimowitz and Leonor Fernandez, MD, recommend in their article “Sharing Visit Notes: Getting Patients and Physicians on the Same Page” in AAFP’s Family Practice Management. 2016 Nov-Dec;23(6):10-13.
Be transparent.
Minimize jargon and abbreviations, especially any that patients might easily misinterpret.
Briefly define or simplify medical terms, such as short of breath, rather than SOB or dyspneic.
Highlight the patient’s strengths and achievements in addition to his or her symptoms.
Describe behaviors
Additional guidance may be found on your MAC’s website. Here are some documentation tips from WPS GHA. In their introduction of documentation tips for E/M coding, WPS GHA reminds the reader (bold font is theirs) “Evaluation and Management (E/M) Services Documentation must support the level of service billed and the medical necessity for the level billed.“
Medicare requires a face-to-face encounter with a patient consisting of elements of both evaluation and management.
– The evaluation portion is substantiated when the record includes documentation of a clinically relevant and necessary exchange of information between provider and patient.
– The management portion is substantiated when the record demonstrates an influence on patient care (ex.; medical decision making, patient education, etc.).
8. Is the documentation of history and examination required when scoring office/outpatient services under the revised 2021 guidelines?
The approved revisions do not materially change the three current MDM elements, but instead provide extensive edits to the elements for code selection and revised or created numerous clarifying definitions in the E/M guidelines.
While the provider’s work in capturing the patient’s pertinent history and performing a relevant physical exam contributes to both the time and medical decision making, these elements alone should not determine the appropriate code level.
The revised code descriptors state a “medically appropriate history and/or examination” is required.
An additional benefit to a clear note that supports the medical necessity for the service – is that it can help to improve coding the encounter – whether you are new to the field of coding or a highly experienced auditor.
What are your thoughts on using this type of encounter documentation?
Our goal in this blog series is to provide a forum regarding topics around the 2021 E/M Guidelines and to encourage community conversation on how the new guidelines might be applied. We’ll provide scenarios and expert opinion for your consideration, and we hope you’ll feel free to contribute to the thoughts and ideas presented by fellow auditors, coders, billers, CDI professionals, compliance professionals, payment integrity and risk managers.
The AMA has provided a definition for “Problem addressed” in the 2021 AMA CPT(R) Manual.
“Problem addressed: A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service. This includes consideration of further testing or treatment that may not be elected by virtue of risk/benefit analysis or patient/parent/guardian/surrogate choice.”
More importantly, the definition includes this statement.
“Notation in the patient’s medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service.”
Many EHR patient records systems automatically pull the patient’s “problem list” and their complete “medication list” into a new encounter. This information may not be considered in the EHR’s 2021 guidelines unless notation is made about an evaluation or treatment of the problem(s), additional assessment needed or care coordination of the issue.
Though the new encounter may have a complete “problem list,” sufficient documentation is needed to note which problem(s) affects the MDM for the encounter, and what the risk of morbidity is. In a list of problems or multiple providers, which problem(s) are being managed by the provider during the encounter?
The medication list is another area that could draw questions. Experts recommend there should be notes indicating who is managing which medications in the case of multiple providers managing care. Specifically, it is best to show which medication is being managed by the physician for the encounter. The statement “continue meds” is not a sufficient indication of management.
Taken together, these elements may impact the risk associated with the care provided by the provider to manage the patient’s condition(s). These elements support the basis for the level of service provided during the encounter and the E/M code billed.
Is your provider’s documentation clear enough to note the problems addressed and the intensity of service provided in the encounter?
What types of changes would you recommend to the provider?
