input needed on audits/doctors correcting notes

I have been asked to get some additional professional input on the way audits are handled.

An audit is performed prior to the claim being filed to insurance and it is discovered that the doctor has marked a 99215 but upon audit the level only meets a 99214. The doctor has received one on one training and it has been explained what constitutes a level 5 and the doctor has a copy of the requirements.

Once it has been identified that it does not meet a 99215 is it acceptable for the doctor to make amendments to the note so that they claim can be filed as a 99215 or should it be considered as a training opportunity and the 99214 should be billed without the doctor going in and amending the note?

Also, is it acceptable for a physician to consistently reach a level 5 by utilizing the option under amount and complexity of data reviewed to review and summarize old records and/or discussion with other health care provider? For example, any time a patient is seen as a follow up to a hospital or ER encounter the doctor summarizes the report, then typically orders lab and x-ray and then meets a high level on number of diagnosis and management options. This can result in 10 level 5's in the course of 3 days.

Thank you,

Cathy Satkus, CPC
Harvard Family Physicians
918-743-8200

Comments

  • We received requests for notes from Medicare for our 99215's and we don't bill very many of them! Request specifically stated 99215 was audited based on MEDICAL NECESSITY (i.e. risk) So even if all other documentation reached 99215 - unless the risk fell into the 99215 category e/m was reduced and paid at 99214. I might add, we had some fairly complex cases that I personally and strongly felt were 99215's but had to defer to their decision.

    Dawn Breithaupt CPC
    Preventive Medicine Associates

  • You've asked a couple of good questions.

    I personally have no problem with the doctor making amendments to the documentation prior to the claim filed. Heck - if they want to do that on every patient - I don't see a problem. Once the claim is filed - they can still make amendments. Once an audit has started by the carrier - I do not recommend amending the record.

    Now - to the 2nd one. Yes - the doctor may be doing a 99215 by using the highest level of MDM - as long as either the history or exam is a level 5 - but what is the medical necessity for that level? If the medical necessity does not support that level of MDM and exam or MDM and history - then the audit that invariably occur will result in recoupments, fines and possible penalties. Never forget the medical necessity is a whole different dog than the history, exam and mdm pack.

    Don


    Don Self & Associates, Inc

    305 Senter Ave, Whitehouse, TX 75791
    903 871-1172 fax 480-247-5650
    donself@donself.com web: www.donself.com
    free webinars at www.donself.com

    DISCLAIMER: This email has not been scanned for correct spelling, grammar or punctuation. It has been created in the language of Texan and may or may not be understood completely to those north of Kentucky.

  • Any time a medical record is changed, there must be a notation when it was changed and by whom. If there is addition of information the addendum should state date and by whom. Cross-outs or if paper chart, if are still being used or additions, follow the same rules and it is important. If an auditor consistently sees this happening, it is a red flag of sorts.

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    Maxine Lewis, CMM, CPC, CPC-I, CCS-P, CPMA
    Main: 513-771-7070
    Direct: 513-672-4363
    Fax: 513-326-7640
    200 Northland Blvd
    Cincinnati, OH 45246
    mlewis@scrogginsgrear.com
    www.scrogginsgrear.com

  • edited May 2017
    Thanks for everyone's input.
    Maxine, we use an EHR so it's very easy to see when the chart was amended and what was changed. It's almost like a beacon!

    Don, do you still think it's OK for notes to be added to meet the level 5 if the elements left off are ROS and EXAM?

    Thank you,

    Cathy Satkus, CPC
    Harvard Family Physicians
    918-743-8200

  • I was always told that you can amend a note to update ,correct or complete a chart, but not to meet a higher level of service.....


    Mindy L Dowd CPC,CPMA
    Denver Arthritis Clinic
    200 Spruce St
    Suite 100
    Denver,CO 80230
    (303)302-7433
    mdowd@dacdenver.com

  • Cathy,

    I am of the belief that a physician can amend his or her notes anytime with anything that is relevant and timely - meaning that if the data was omitted for whatever reason and needs to be added and if it is within a period of time that a reasonable person would remember the data. If the doctor remembers the ROS and exam elements and wishes to amend (again - noting when it was amended and by whom) the progress note before the claim is filed, I have no problem with it.

    Don

    Don Self & Associates, Inc

    305 Senter Ave, Whitehouse, TX 75791
    903 871-1172 fax 480-247-5650
    donself@donself.com web: www.donself.com
    free webinars at www.donself.com

    DISCLAIMER: This email has not been scanned for correct spelling, grammar or punctuation. It has been created in the language of Texan and may or may not be understood completely to those north of Kentucky.

  • edited May 2017
    Sorry if this is a duplicate.. I didn't see my message come through:

    When I audit, I give the provider an opportunity to amend his/her record when appropriate prior to filing the claim. The guidelines we follow are copied below.

    As for level 5’s based solely on data, I would say no most of the time. If the presenting problem(s) is/are not highly complex, level 5 would not usually be appropriate unless the provider is spending 40+ minutes w/ patient, greater than half counseling/coordinating care. I encourage providers to document time for all visits.

    Thanks,
    Erica

    Amendments to Medical Records

    Internal Guidelines:

    Amendments to and/or editing of a medical record can be done at any time it is necessary. Providers shall make corrections as soon as possible after an error/omission is discovered or when clarification is needed. However, coding staff will not change CPT/ICD-9 codes based on any changes made after the claim has been processed by the payor.

    Background Information / CMS Guidelines:
    Amendments to a medical record are legitimate occurrences in documentation of clinical services. However, these occurrences should only happen occasionally and should never be done to meet regulatory requirements or to later validate a CPT code that was down coded or denied due to lack of supporting documentation.

    Amendments must be made timely, preferably within a few days of the date of service (DOS) and rarely more than 30 days from the DOS. Medicare auditors shall give less weight when making review determinations to documentation created more than 30 calendar days following the DOS. If the auditors identify providers with patterns of making late (more than 30 calendar days past the DOS) entries in the medical documentation, they may refer the provider to other agencies for further review.

    Corrections to the medical record legally amended prior to claims submission and/or medical review will be considered in determining the validity of services billed. If these changes appear in the record following payment determination based on medical review, only the original record will be reviewed in determining payment of services billed to Medicare.

    References:
    “Amendments, Corrections, and Deletions in the Electronic Health Record: an American Health Information Management Association Toolkit”

    “Documentation Guidelines - Amended Records”

    “Medicare Program Integrity Manual”, Chapter 3



  • edited May 2017
    I agree with the guidelines you attached. If information was omitted or clarification was needed, I'm all for it. When the doctor has been provided the guidelines and the requirements for the ROS and EXAM have been provided for a 99215, but the doctor continues to not meet the level with enough EXAM and ROS and is using the main element of Data to determine the level 5, it begins to feel like we are not coding based on what was done, but what needs to be added to meet the level. At what point should the doctor have to follow the guidelines provided instead of depending on the coder to say you need more exam elements. If you are consistently leaving off exam, is it appropriate to have multiple claims amended for exam elements being added? I'm talking about 3-5 patients on one date for the same provider. Then it happens again the next day, and the next day.

    Cathy Satkus, CPC
    Harvard Family Physicians
    918-743-8200

  • Cathy - at some point either the doctor learns what needs to be put on there at the time of service or you start filing the claims with the level documented without amendments. You're absolutely right that it is ludicrous to do this over and over and over again. I thought you were talking about training the doctor as to what is required and in that case - yeah - I don't have a problem with amendments - but not on EVERY note and if his or her usage of level 5 is above the national average for his/her specialty - then the medical necessity of the level 5s really need to be discussed.

    Don


    Don Self & Associates, Inc

    305 Senter Ave, Whitehouse, TX 75791
    903 871-1172 fax 480-247-5650
    donself@donself.com web: www.donself.com
    free webinars at www.donself.com

  • edited May 2017
    No, that would not be acceptable to me. If I tell a provider documentation supports 99214 and they say but I spent 45 minutes with her discussing such and such…. Okay then go and document that. Or if they failed to document the severity of something (e.g. SEVER exacerbation vs. exacerbation), that’s okay to me, too. But to be constantly adding ROS and/or exam elements after the fact seems like they are just adding to meet the requirements. Why would you not document certain elements of a physical exam? Bordering on shady if you ask me. The coder should never say “you need more exam elements”. Instead they should say documentation does not support this level of service and bump them down. How many providers have five 99215s in one day? What kind of specialty is this? 99215s are generally pretty rare. Sounds like they are trying way too hard to manipulate the system and bill higher than what is medically necessary.

    From: Cathy Satkus [mailto:Cathy.Satkus@harvardfamily.com]
    Sent: Tuesday, October 04, 2016 4:57 PM
    To: Multiple recipients of list PARTB-L
    Subject: FW: [partb-l] input needed on audits/doctors correcting notes

  • In addition, the level of history and exam should be in line with the nature of the presenting problem(s). So just because they do and document a comprehensive history and exam on every patient, is it really medically necessary? The first column in the table of risk is where you should start your audit. I have down-coded many providers for this. For example, I had one doc billing 99204 for every single new patient. And sure, because of templates, the history and exam were always comprehensive. But if the diagnosis is a simple sprain or allergic rhinitis, no way.

    "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported."
  • edited May 2017
    It is Family Practice. I had advised the physician to not depend on the DATA reviewed section to meet the level 5's, that medical necessity should be a factor.
    In order to remain professional, I won't describe how I have been treated since that meeting! = )

    I immensely appreciate everyone's input. I can tackle this issue again with additional feedback and hopefully this will be more productive.

    Thank you,


    Cathy Satkus, CPC
    Harvard Family Physicians
    918-743-8200

  • edited May 2017
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    Not sure how much this helps, but it does reference the online manual, which
    might be helpful.





    http://www.wpsmedicare.com/j8macpartb/claims/submission/documentation-timeli
    nes.shtml



    I always believe it is a good idea to have a documentation timeliness and
    accuracy statement in your practice that identifies what is protocol, if a
    pre-claim audit is performed and doesn't match what was asked to be billed.
    It should outline the pathway steps to resolution for the claim to be sent.



    The same goes for a service that should be coded higher.



    Depending on the type of medicine the physician personally practices and the
    presenting problems of the patient, it could be possible to bill all 99215's
    in a day's work... Example: a group of physicians may give their highly
    complex patients to one provider in the group for an E/M. This physician
    might see less patients in a day, but it entirely humanly possible for a
    physician to see and document the particulars and medical necessity to meet
    that level.



    So, the number of 99215's in a day isn't the issue, it's whether the
    documentation can score to that - and meet medical necessity, which could
    only be determined by a licensed clinician.



    Your physician may need strength training on those presenting problems that
    drive the need for additional work that equates to the result of medical
    necessity.



    It is a complex process, but designed by their colleagues - which is
    something I remind them of when they decide to be way too wordy in the
    documentation - that doesn't move toward the need for intervention,
    decision-making, and a plan for the patient.



    Karen A. Hurley, BS, CMM, CPC, CNA

    President, HPMSI

    PO Box 409

    Parrish, FL 34219-0409

    Tel: (941) 776-4822

    Fax: (240) 368-0059

    Web: www.hpmsi.com



  • edited May 2017
    But............a simple sprain on a para-mobile paraplegic patient, or allergic rhinitis in the cystic fibrosis patient - could drive a higher thought process for the provider, especially if there is an issue with multiple medical problems and/or medications.

    And they deserve the right to be paid for their complexity of work.

    Every patient - every encounter - is different.

    Karen A. Hurley, BS, CMM, CPC, CNA
    President, HPMSI
    PO Box 409
    Parrish, FL 34219-0409
    Tel: (941) 776-4822
    Fax: (240) 368-0059
    Web: www.hpmsi.com

  • edited May 2017
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    Although I love computer programs to make our lives easier, I am still not a
    proponent of EMR's. They still aren't perfect enough for me to match the
    skill set of the physician mind and the need of the patient.



    When a physician has documentation problems, the best advice I can give is
    this:



    Write down what you saw, what the patient told you, your deductive process,
    and what you need to do (or did) to help the patient. Give a diagnosis to
    show your conclusion and the plan for the future. Make it clear enough that
    when you read it in 5-10 years in a courtroom, you know exactly what you
    did.



    This helps to remove the easy choices of EMR's.



    Karen A. Hurley, BS, CMM, CPC, CNA

    President, HPMSI

    PO Box 409

    Parrish, FL 34219-0409

    Tel: (941) 776-4822

    Fax: (240) 368-0059

    Web: www.hpmsi.com



  • edited May 2017
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    You would amend a note to record the accuracy of the event, it doesn't
    matter if it is a higher (or lower) level of service. This is a must for
    two reasons:



    -Continuity of care



    -If the record is pulled into a court of law.



    Karen A. Hurley, BS, CMM, CPC, CNA

    President, HPMSI

    PO Box 409

    Parrish, FL 34219-0409

    Tel: (941) 776-4822

    Fax: (240) 368-0059

    Web: www.hpmsi.com



    Since 1996, Celebrating 20 years of Service to Physicians



  • edited May 2017
    Exactly. Amendments should be to clarify care not to get a level of
    service only. And as someone else said.... MEDICAL NECESSITY must be met.
    99215 should not be the norm except in very exceptionally complicated
    specialties. Even then if the patient has no complications and everything is stable
    for the visit, 99215 is not likely.



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