Due to federal regulations and the variety of audits that now exist, the ACR has developed an overview of guidelines and identified a list of resources to keep handy to ensure all current guidelines are strictly followed.
Evaluation and Management Guidelines Overview
There are two guidelines for coding an evaluation and management service: 1995 and 1997. Either guideline is permissible to use from visit to visit; however, use only one guideline during an individual visit because there are subtle, yet important, differences in each style.
History documentation: Under the 1995 guidelines, a provider is allowed to document the status of three or more chronic or inactive issues to reach an extended level for the History of Present Illness, while the 1997 version requires at least four of the eight elements of the illness to be documented:
- Location
- Severity
- Timing
- Modifying factors
- Quality
- Duration
- Context
- Associated signs and symptoms
Examination documentation: At first glance, the 1995 version appears to have easier and less tedious documentation requirements, but a practice can leave itself open to an auditor’s interpretation of what is documented. The 1997 version is very specific and rigid in its requirements for documentation. It is broken down into the different organ systems, and each system is broken down by bulleted sections that must be met in order for that organ to count as being examined.
MDM Documentation: Medical decision making (MDM) is the driving force to establish the medical necessity of a visit, and both versions have the same guidelines.
Carrier Medical Policy Resources
First and foremost, coding and billing staff must know which E/M style—1995 or 1997—is being used in the documentation so that the service is billed correctly.
Secondly, staff must know how the insurance carrier requires a serviced to be billed. This information can be found in the medical policy on the carrier’s website. These policies should not contradict coding guidelines. Carriers usually provide online articles and payment policies to give additional information on medical policies.
The three main areas of a medical policy to review are:
- Diagnoses (e.g., codes to support the medical necessity of the service);
- Frequency guidelines (e.g., monthly, every other year, allowed three times a year); and
- Patient specifications (e.g., weight, sex, age).
Types of Audits
A provider can be audited by a private carrier, Medicare carrier, or a federal entity. It is important to know who is auditing your practice because there are different time constraints issued by the type of carrier that is performing the audit.
- Private carriers will typically farm out auditing work to third-party auditing firms. Your staff should always verify who is actually requesting records if it is not clear.
- Medicare carriers can audit a practice in many ways. Here are examples of the different types of audits:
- Comprehensive Error Rate Testing (CERT)—CERT audit contractors will audit procedures that have been flagged as having high rates of improper payments.
- Recovery Audit Contractors (RAC)—RAC only assess overpayments or underpayments and look at coding and billing guidelines such as frequency or units.
- Zone Program Integrity Contractors (ZPIC)—ZPIC audits are fee-based audits. This means they are looking at unusual billing patterns. If your practice receives a notice of a ZPIC audit, there is a suspicion of fraud.
- Office of Inspector General (OIG)—The OIG’s function is to supervise and guard the integrity of the Department of Health and Human Services (HHS) programs as well as protect the beneficiaries of these programs. This federal office will audit a practice when there is any suspicion of fraud from both private and federal healthcare plans.
Coding Guidelines Resources
- Current coding manuals—CPT, ICD-9, and HCPCS—are coders’ main resources. For in-depth information about these manuals and the anatomy of their codes, refer to The Rheumatologist article, “The Anatomy of Coding” (June 2011, p. 17).
- ACR Rheumatology Coding Manual—an adjunct rheumatology-specific guide to the AMA’s CPT manual that provides an overview of the codes most applicable to rheumatology practices as well as their effective and appropriate use.
If you have any additional questions concerning coding or billing guidelines contact Melesia Tillman at (404) 633-3777, ext. 820, or mtillman@rheumatology.org.