CPT vs CMS E/M

Hi list, is there anyone out there that has had experience with a billing company that has no framework for which to audit E/M for non government payers? They do not audit non-government payer charts unless they get a request from a payor. All coding and auditing is performed offshore, the vendors are auditing there own coders.

When I say no framework, I mean nothing, the tell docs it is ok to document 1 -3 HPI elements and that is counted as comprehensive. There are no guidelines for the exam, docs can put whatever they want.

Everything is driven from the MDM for which they have a proprietary tool.

Am I crazy thinking this is hurricane waiting to happen?

Getting nowhere
Thanks

Comments

  • edited May 2017
    I am a billing company, one of the first certified coders with AAPC - and I
    do not provide coding advice to my clients.

    I recommend modifier use only, and explain when and how that might be able
    to affect documentation and payment.

    The decision is left up to the physician as to what code(s) to report.

    What I believe I am reading below is that it may be a billing company that
    uses/offers and EMR that extracts information and 'codes.'

    That is one area I predicted years ago would be hugely problematic when CMS
    started offering incentives for EMR conversion. I have found so many
    weaknesses in automatic code selection that I keep my billing company
    separate from any EMR use.

    Am I guessing correctly? I know my opinion is my own, but I have always
    been very leery of the documentation / billing connection - other than
    notification of completion.

    Would be interested if that's how their company provides services.

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

  • Thank you Karen,

    This company has sold it’s business on making life easier for the physician. They do not have to code the company takes full responsibly for the coding. All charts are sent offshore to be coded by coders in India, the Philippines. The auditors are employed by the vendors. The only charts that get looked at stateside are for downcoding ordinals.

    There are a few stateside coders but they are audited by the same untrained auditors in India.

    For government payers they use E/M guidelines, for all non government payer the providers are told they can document what they want as long as the MDM supports a high level they are good

    In addition, coders are told to pick a diagnostic code that will allow for the billing of the highest E/D level. So if a patient comes in with chest pain and after study the physician writes his impression (they have been told not to write diagnosis) is GERD

    The coders are to code the chest pain because supports the medical necessity of a level 5 E/D service and GERD would only support a 3 or 4.

    This is all performed by human beings.

    Operations requested a review of the guidelines from a consultant that they do business with. The consultants first report agreed with me that there should be some framework that could be audited against, operations did not like the fact that the consultant had agreed with me so he e-mailed and had a call with him. We receive a second report from the consultant agreeing with what the company is doing.

    This smells funny

    M


  • edited May 2017
    Totally agree with you on the EMR. Well said.

    Ruby Woodward
    Sent from my iPhone

  • edited May 2017
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    I know this is a somewhat separate subject from my issue but computer
    coding is also a storm waiting to happen. computer cannot match findings to
    the indication. basic issue that they cannot master. frustrating

    sharon


  • edited May 2017
    Interesting.

    Diagnosis codes equating out to a certain level of service can only really be determined by colleagues of the provider as it would be based on the written word, and if the words written to define the work was medically justified.

    It has always been a challenge to define whether we code from the chief complaint or the findings, which sometimes can't be determined until the results are back from ordered testing.

    It's why I always steer clear of 'medical necessity' - (I have even written AAPC about their offering of classes to train on that, it is not within scope of a coder). I just transcribe the words in the record to numbers.

    I agree with you, there needs to be a framework - and you already have it, the CPT book. :-)

    If a payer or provider decides not to follow the CMS DG's, they can support their stance through CPT, but if it isn't meeting that, there's a big problem. Of course, that only reflects the E/M's and other CPT's - not the diagnosis, but it’s a place to start.

    Good luck.......always difficult to convey the message on coding and the required documentation.

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

  • edited May 2017
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    Indeed !



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

    President, HPMSI

    PO Box 409

    Parrish, FL 34219

    Tel: (941) 776-4822

    Fax: (240) 368-0059

    Web: www.hpmsi.com





    I know this is a somewhat separate subject from my issue but computer coding
    is also a storm waiting to happen. computer cannot match findings to the
    indication. basic issue that they cannot master. frustrating



    sharon



  • edited May 2017
    This may help:

    CMS 30.61 "For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnoses documented in the interpretation. Do not code related signs & symptoms as additional diagnoses".
    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 should not pose any visual, auditory or sensory defects in the average reader. If you are now or have been dead or stupid in the past, this email will probably not help you. If you know anyone reading this email who is not from earth - you should immediately seek medical attention. If you have been or plan to be an imbecile in the future, please do not read this disclaimer. These warnings are not valid in the state of Hawaii, Alaska or New Hampshire.

  • edited May 2017
    amen!

    The computer program may or may not have the right algorithms in it. For instance, the software may include algorithms that come from a clearinghouse owned by one of the largest insurance carriers in the country and when doctors use it - they end up under-coding. it could be that the system is designed to not count all of the bullet points in the medical decision making areas that might have increased the level of code from a 3 to a 4 or from a 4 to a 5, thereby saving the insurance carriers hundreds of millions per year.

    Of course - I didn't mention any names of carriers or software as my wife is tired of me being sued - even though I have won each time I've gone against an insurance carrier. Of course - my attorney loves it as he still gets paid even when I win in defense.

    Don



  • I also run a billing service. This is such a disservice to the physician. This is one of the reasons I got into the business.

    Thank you,

    Renee Gillam, CPMA, CMOM, CMC
    Avalon Practice Management Solution,LLC
    Cell Ph:
  • edited May 2017
    And from Official Coding Guidelines - Section IV - Diagnostic coding for
    outpatient services- such as xrays-and office visits.
    Letter G - Icd 10-CM code for the diagnosis, condition, problem or other
    reason for encounter /visit- List first the ICD10cm code -----shown to be
    chiefly responsible for the services provided.In some cases the first listed
    may be a symptom when a diagnosis has not been established (confirmed) by
    the physician.

    Sharon Cohen


  • edited May 2017
    I hope they realize they have professional liability for giving out this kind of bad/incorrect information.

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