If your medical record documentation is lacking, you likely cannot support a higher Evaluation and Management (E&M) level of service—which may lead to lost revenue for orthopedic services. And although the Centers for Medicare & Medicaid Services (CMS) is pondering a major makeover for E&M coding and documentation, you still need to ensure that you can pass an audit today.
When correctly selecting an E&M level of service, documentation is crucial, according to coding and compliance guru Margie Scalley Vaught in her 2019 Coding Updates Virtual Boot Camp for Orthopedics. And now the HHS Office of Inspector General (OIG) and Recovery Audit Contractors (RACs) are closely scrutinizing your claims to root out “cloning” and other issues to prevent improper payments.
Double-Check Basic Patient Info
Part of your E&M documentation is the basic patient information—and although this portion may not seem particularly essential to claims audits, it actually is. You’ll need ensure that all the patient information is correct and not transposed in error.
Second look: Palmetto GBA advises that you double-check the following basic E&M claim info:
- E&M service (type/place of service)
- Examination guidelines (1995 versus 1997)
- Beneficiary’s first initial of first name
- Beneficiary’s last name
- Diagnosis
- Date of Service (DOS)
- Chief complaint (or reason for encounter)
- History of Present Illness (HPI), or status of three or more chronic/inactive conditions
Tool: If you need help, you can also use Palmetto’s E&M review checklist and score sheet tool for established patients.
Avoid Cloning in ROS
Electronic medical records (EMRs) have revolutionized the healthcare industry, but one of the big dangers is the temptation is click through a review of organ systems (ROS) template haphazardly.
Example: The patient presents with back pain, but the exam of the musculoskeletal system states “Negative” or “Normal” in the ROS, Terry Fletcher illustrated in an article for ICD10Monitor.com. Auditors will look for these types of red flags, which will prompt them to look for other inconsistencies in the documentation.
Hidden trap: Another red flag for auditors is different typesetting or fonts within the EMR, which could indicate copying-and-pasting, Fletcher warned. If the standard or generic electronic font is changed and the physician’s actual free type is added, this can look to an auditor as if the only work actually performed was what the physician free-typed.
Depending on your payer and EMR system, you would click “None” or “N/A” if the ROS is not obtained, Palmetto instructed. Otherwise, make sure that at least one system was assessed if you’re selecting “All Other Neg” or “All Other N/A.”
Also, if the patient is unable to provide information, make sure the following documentation is present in the medical record:
- Reason why the patient is unable to provide the history
- The source(s) used to obtain the information
- Information obtained from these sources
Understand MDM vs. Medical Necessity
Another hot spot for auditors is the Medical Decision-Making (MDM), which is often considered the trickiest E&M component, according to a blog post by Grant Huang for Doctors Management. CMS is considering revamping its E&M rules, and one idea in the proposed rule is to determine the E&M code level based solely on the level of MDM.
Significance: The history, exam, and ROS E&M components are fairly simple to understand, while MDM is a more complex concept, Huang noted. MDM aims to quantify the amount of “cognitive labor” required to evaluate and treat the patient’s problems, and payers typically view MDM as the most important E&M component.
And MDM is not the same as “medical necessity,” which is the requirement that a service be “reasonable and necessary.” MDM, on the other hand, answers the crucial question of whether the service’s cost was a justifiable use of resources given the patient’s condition. For MDM, the documentation must illustrate the number and nature of problems, the amount and complexity of diagnostic data review, and overall risk to the patient.
Bottom line: When it comes to audits of your orthopedic E&M notes, you must understand what’s required in an HPI, ROS, and MDM, Vaught stressed. Learn how often you need to perform and/or update the complete ROS and how to spot the MDM essentials—the “meat and potatoes” of your full E&M documentation. This is the fine-tuning you must do on top of the annual task of learning all the new orthopedics CPT® code changes and ICD-10 code changes for 2019.
