Says Ms. Jimenez, “Medical necessity and medical decision making are often confused or considered one [and] the same, and that is not the case. … When it comes to E/M services, the level of care billed must be medically necessary for the conditions treated, managed or diagnosed during the encounter.”
Coding Accuracy
One potential pitfall with billing is related to relative value units (RVUs), which are related to how the CMS reimburses physicians. Ms. Jimenez explains, “If providers are measured based on number of RVUs billed each month, it can incentivize providers to code for higher level[s] of E/M [services] that might not be supported.”
To avoid “up-coding” or “down-coding,” Ms. Jimenez says physicians should respectively ensure medical necessity is supported and document patient encounters completely.
Coding to the highest level of specificity will become even more important as of October 2016, given that the one-year grace period for implementation of the International Classification of Diseases, 10th Revision (ICD-10) is expiring.
“In order for providers to have confidence in the coding of E/M services, a [self-]audit is recommended to identify any opportunities to improve documentation to support the services rendered. … If the provider does not have certified coders on staff to complete the audits, an external audit can be performed by a certified contractor,” Ms. Jimenez says. “After completion of an audit, the auditor can provide feedback to the provider to improve any deficiencies found.”
You can also contact the ACR’s certified professional coders at [email protected] for additional questions about billing and coding guidelines, modifiers and coverage determinations.
Kimberly J. Retzlaff is a freelance medical journalist based in Denver.
