Recent communications with an auditor at one of Indiana's health plans answered several questions from ISMA members over the last year. Some of these examples may help practices avoid automatic downcoding of higher-level visits or decrease time in prepayment review.
More Level 4 E/M services are justified if documented correctly
Auditors agree! It is easier to support a Level 4 E/M visit with the
AMA’s 2023 CPT® Evaluation and Management (E/M) Code and Guideline changes. Two or more stable chronic illnesses, three data elements ordered or reviewed, and/or prescription drug management occurs frequently. These elements support a Level 4 visit when at least
two of three Medical Decision Making (MDM) components are documented. However, documentation must support the requirements outlined in the 2023 guidelines. Many of the previous definitions have either changed or been clarified and should be reviewed periodically. Sometimes, subtle word changes can improve a chart note to support a Level 4 service rather than a Level 3. Some examples of each of the three MDM elements are included here:
1) PROBLEMS ADDRESSED: Documentation does not often indicate an “exacerbated” condition or a “severely exacerbated” condition. A condition documented as “worsening” or “not at goal” would support a Level 4 service under Problems Addressed, and the word “severe” may support a Level 5 service. Remember that a problem is not considered “stable” unless it meets the goals, but what are the goals? Make sure to document them.
2) DATA ORDERED or REVIEWED: Abnormal lab tests are either not documented or not clearly associated with multiple conditions being treated when the note only states “labs reviewed.”
- This statement does not support the required data element for a Level 4 visit unless three unique lab tests or data points are indicated separately in the documentation. A panel only counts as one data element per CPT code. Count data when tests are ordered if you are not also billing for the test; reviewing data is part of the order and is not counted again.
- A patient who presents with URI symptoms. A COVID test, strep, and flu swabs are obtained and billed by the hospital lab. The physician writes a new prescription. If properly documented, this will support a Level 4 visit. When physicians forget to document the tests ordered or reviewed, the documentation only supports the URI or general symptoms and the prescription, which would only support a Level 3 visit. This may seem like the same diagnosis being paid for one claim and denied for another, but in the Assessment and Plan, one physician documents specific tests reviewed while the other documents only the presenting problem(s) and prescription ordered.
- Remember to document and count an independent historian as one of the three data points when they provide information relevant to your medical decision-making.
3) RISK LEVELS: Using words from the AMA’s MDM table is extremely helpful in helping an auditor make the connection. What risk level do the treatment options discussed put each individual patient in on that date of service? Prescription drugs are not automatically a Level 4. Risk levels include Minimal, Low, Moderate, or High and the level could change over time.
- Prescribing a new medication could put any patient at higher risk for side effects than refilling the same medication for a patient with no adverse effects in two years.
- An OTC NSAID could put one patient at much higher risk than a patient given a prescription medication depending on comorbidities.
- High-risk medications being monitored for toxicity would be better identified if documentation indicates what is being monitored and why. Monitoring the effect of a drug or treatment is not the same thing as measuring for toxicity. Explain the rationale to make it clear and support the frequency requirements.
Inpatient errors
A significant problem with inpatient E/M services is that physicians carry over or copy forward their notes from day to day; they do not document new discussions or new results reviewed in a way that clearly shows what happened at the encounter on each date of service. Every note looks identical, and yet the same level of service is billed every day until the patient is discharged. Is the condition improving or are patients being discharged who are still in critical condition? The levels of service should decrease from the time of admission until discharge as the patient improves.
Physicians on prepay review
One common error is not responding appropriately to initial requests for documentation. Letters sent from the payers are often overlooked. Many reviews are triggered by utilization data, but when there is no response to initial documentation requests, this initiates the need for a prepayment review. Many prepayment reviews could be avoided if initial requests for records were responded to within the time-frame indicated in the letters.
Documentation is often returned to the payer without a date of service or a physician’s signature. Sometimes, pages are missing from the chart note, or 100 pages are sent back for review. This only delays the process and correct payment of claims as no auditor will look through 100 pages to find the one thing they need to know to approve the claim. Many physicians return the same chart note repeatedly without any amendments or additional information, expecting a different result.
Helpful hints
- Make sure your billing and mailing addresses are updated with all payers so you do not miss any payer request letters.
- Someone in your office needs to monitor all incoming mail from payers frequently and ensure that requests for documentation are addressed in a timely manner.
- Remember that sending the same chart note repeatedly without making any changes or highlighting key elements will not get claims paid any faster, and maybe not at all.
Some physicians have been on prepay review for years, and others have only been on for 60 days. It all depends on the improvement seen in the documentation. Some physicians go on review for a range of CPT codes, and as they demonstrate improvement, certain codes will drop off the list while other “problem codes” remain. For example, Level 3 to Level 5 E/M codes are initially put in review. In the first month, they show 80 to 90% improvement for Level 3, so that code is taken off while Levels 4 and 5 continue to be reviewed until similar improvement is seen.
The percentage of appeals overturned and required to end a prepay review varies depending on the type of errors and which line of business is being reviewed (e.g., commercial, Medicare or Medicaid). Communication with provider reps and auditors should clear up any confusion about the expectations if they are not documented in the initial request letter.
If you have questions about claim denials that you feel are not adjudicated correctly, please seek an outside certified auditor to review the chart and give their unbiased professional opinion. Sometimes having another set of eyes look at your documentation will reveal something minor that could save you and your billing staff valuable time and keep your hard-earned dollars in your pocket. Consultants can also provide E/M training for your organization online or in person. Reach out to the ISMA for more information.