It’s every physician’s worst nightmare: Receive payment for services rendered, but then a payer identifies an aberrant pattern in claims data, audits the records, decides it has overpaid the practice, and recoups those funds. That money you already allocated for overhead, staff salaries, bonuses, or new medical equipment? Gone. With one post-payment audit, you now owe thousands of dollars or more. The good news is, physicians can take steps to focus on accurate billing and avoid costly recoupments. This article explores five billing vulnerabilities
and provides tips to maintain compliance.
E/M coding: Four tips to select the correct level
Payers don’t usually deny evaluation and management (E/M) codes on the front end, says Toni Elhoms, CCS, CPC, a provider coding and education consultant in Denver. It isn’t until they look at the totality of the data retrospectively—long after physicians are paid—that financial penalties ensue, she adds.
“Payers are like the IRS,” says Elhoms. “You don’t want them on your back because recoupments are insidious. They come out of nowhere.”
Consider the difference in reimbursement for established patient office visits levels 2 versus 3 (i.e., CPT codes 99212 and 99213)—approximately $29. Let’s say 10 to 20 times per week over a year, a physician bills 99213 when their documentation only supports 99212. They’ll be paid initially, but likely have a $15,000-$30,000 recoupment on their hands if a payer uncovers the error during a post-payment audit.
Here are four tips to help physicians avoid denials due to incorrect E/M levels:
1. Ensure the E/M code supports
the specific patient encounter.
Not every patient with asthma, for example, will justify reporting CPT code 99213, says Elhoms. Some cases may be exacerbated and/or require medication management and referrals to specialists while others may be relatively straightforward and controlled.
2. Refer to the E/M guidelines
Assigning an E/M code is not a subjective process. Instead, physicians should refer to the 1995 or ‘97 E/M guidelines that include specific requirements for time-based billing as well as billing based on the three key components: history, exam, and medical decision-making, says Elhoms. She says the most common mistake physicians make when applying these guidelines is under-documenting E/M level 4 and 5 visits for new patients. More specifically, they omit one or more systems in the requisite general multi-system exam or they omit a complete past family and social history.
3. Use copy and paste
functionality with caution.
Copy and paste can save time, but it can also cause serious compliance problems, says Elhoms. That’s because when physicians automatically bring historical information from a previous encounter forward into their current note, they may inadvertently inflate the E/M level. Best practice is to validate any information copied forward to ensure it’s accurate and relevant to the current encounter—or turn off the functionality altogether, she adds.
4. Watch out for pre-populated EHR templates.
Pre-populated templates not only lead to upcoding (e.g., if certain body systems are always indicated as having been reviewed even when they’re not relevant to the current encounter), they can also lead to contradictions that raise red flags with payers, says Elhoms. For example, a physician diagnoses a patient with strep throat. If the template defaults to a normal exam for ear, nose, and throat, this could open the door for a post-payment audit. Physicians should ensure their documentation is aligned with the patient’s diagnosis even if it means manually unchecking certain boxes in the template.