Business Briefs: Clinic Visits and Evaluation and Management: Myths and Misperceptions

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information. However, HMP Communications and the author do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received. The ultimate responsibility for verifying coding, coverage, and payment information accuracy lies with the reader.

  At least once a week this author addresses a myth or a misperception pertaining to correct coding for 1) clinic visits by hospital-based outpatient wound care departments (HOPDs) or for 2) evaluation and management (E&M) services by physicians who are managing patients with chronic wounds. As you read some of the most common myths or misperceptions, reflect on your own wound care business to determine if you and/or your peers are working under these myths and misperceptions.

Myth/Misperception: Many of our patients do not like to change their own dressings. Therefore, we see them in the HOPD 3 times per week and bill for a 99211 low-level clinic visit/E&M service at each visit.

  FACT: Reporting 99211, when the patients are just coming in for dressing changes that the patients do not wish to change at home, will most likely not be covered by Medicare unless the physician has written an order and justified the medical necessity for these visits. If providers do not believe that the visits will be covered by Medicare, they should present the patients with Advanced Beneficiary Notices of Non-Coverage (ABNs).

Myth/Misperception: I am a busy physician and don’t have time to follow the complicated E&M guidelines. I just bill the E&M code based on the amount of money that I believe the visit was worth.

  FACT: Unfortunately, that business practice could back-fire on physicians when they are audited. The American Medical Association (AMA) created two sets of documentation guidelines that determine the E&M service level. The guidelines are known as the “1995 Documentation Guidelines for Evaluation and Management Services” and the “1997 Documentation Guidelines for Evaluation and Management Services” and can be found in the current year’s CPT®codebook. Physicians may use either version of the documentation guidelines for a patient encounter, but they cannot use a combination of the two guidelines. When payers conduct audits of physicians’ E&M services, they use the Documentation Guidelines that the physicians selected. If the physicians did not follow one of the Documentation Guidelines, the auditors will select the Documentation Guidelines, which they believe the physicians should have followed, to use during the audits. In either case physicians, who did not follow the AMA’s 1995 or 1997 Documentation Guidelines and did not adequately document the medical necessity of their work, may face repayment to payers when they are audited.

Myth/Misperception: I don’t have time to document in detail. In fact, documentation does not really matter, because I get paid no matter what I document.

  FACT: Because most claims are processed electronically, you may receive payment without appropriately documenting in the medical record. However, all wound care providers are required to document pertinent facts, findings, and observations about an individual’s health history including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element that contributes to high quality care. The medical record facilitates:

    • The physician and other healthcare professionals to evaluate and plan the patient’s immediate treatment, and to monitor his/her healthcare over time.
    • Communication and continuity of care among physicians and other healthcare professionals involved in the patient’s care
    • Accurate and timely claims review and payment
    • Appropriate utilization review and quality of care evaluations
    • Collection of data that may be useful for research and education

  Documentation for clinic visit/E&M services and procedures should be legible and should be written in the medical record for each date of service. The medical record should provide proof that the service was ordered and rendered. The medical record should also provide justification that supports medical necessity for each encounter by including:
    • The patient’s name and date of service
    • The reason for the encounter (Physicians must address the chief complaint and document appropriately. Physicians should not limit the chief complaint to “follow-up” without identifying the problem(s) being followed. )
    • HOPD staff notes (The nursing documentation should be independent and separately identifiable from the physician documentation. The nursing documentation should capture the appropriate nursing services provided during the visit when the clinic visit is separate and distinct. )
    • Appropriate history and physical exam including any relevant health risk factors (Every level of a clinic visit/E&M service requires a history of present illness)
    • Review of Systems (Document the Review of Systems appropriate for the clinical circumstances of the encounter. Do not record unnecessary information solely to meet requirements of a high-level service when the nature of the visit dictates that a lower-level service is medically appropriate.
    • The reason, results and review of diagnostic tests, X-rays, and laboratory tests. NOTE: Physicians should document the association between the diagnostic test and the diagnoses or potential diagnoses.
    • Consultation reports and the order or referral for the consultation
    • Patient assessment and a treatment plan, including a discharge plan (when appropriate). The written treatment plan should include: treatments and medications (specifying frequency and dosage); labs and tests; referrals and consultations; patient/family education; and specific follow-up instructions. NOTE: A list of established diagnoses or potential diagnosis is insufficient for coding purposes without indication(s) in the medical record of meaningful and necessary evaluation and management of each problem. Physicians should record relevant impressions, tentative diagnoses, confirmed diagnoses and all therapeutic options chosen related to every problem for which a clinic visit/E&M service is clearly demonstrated.
     •Physician’s progress notes
     • Physician’s orders
     • Complete procedure notes
     • Signatures/credentials of professional providing services. NOTE: Be sure to clearly identify and provide professional credentials of all professionals who contributed to the service and/or medical record.

  CAUTION: Regardless of the type of medical record (paper or electronic health record) used, each date of service should contain documentation to support the services provided at that encounter. For example: if the past, family, and/or social history reference another medical record on another date of service, the documentation is only sufficient if there is evidence that the physician reviewed and updated the previous information. The physician should describe any new past, family, and/or social history information or note that there has been no change in the information. In addition, the physician should note the date and location of the earlier past, family and/or social history. THE BOTTOM LINE: Providers should not record any unnecessary past, family, social history, or physical exam information solely to meet requirements of a high-level service when the nature of the visit dictates that a lower-level service is medically appropriate.

  When auditing, payers will compare the clinic visit/E&M service level billed and the procedure(s) performed and paid against your documentation. If the physician’s documentation does not meet the AMA 1995 or 1997 Documentation Guidelines and the Medicare contractor’s documentation guidelines for E&M services and procedures, and if the HOPD’s documentation does not meet their Clinic Visit Level Mapping System policy, as well as the Medicare contractor’s documentation guidelines for procedures, the payer can demand repayment and can impose additional fines.

  An appropriately documented medical record can reduce many of the hassles associated with claims processing, can reduce errors, and may serve as a legal document to verify the care provided.

Myth/Misperception: To make things consistent, our HOPD bills for the same clinic visit level as the physician’s E&M service level.

  FACT: Physicians and HOPDs are paid by different Medicare payment systems and have different rules for determining physician E&M service levels and HOPD clinic visit levels.

     • As stated above, physicians must follow either the AMA’s 1995 or 1997 Documentation Guidelines for documenting their work performed and for determining the E&M service level that should be billed.
    • Each HOPD should develop their own system for mapping the services furnished to the different levels of effort represented by the clinic visit codes. The Centers for Medicare & Medicaid Services (CMS) hold each HOPD accountable to follow its own clinic visit level mapping system. CMS has clearly stated that they do not expect to see a high degree of correlation between the E&M service code reported by the physician and the clinic visit code reported by the HOPD. When the HOPD uses the same clinic visit code as the physician’s E&M service code, the HOPD is telling CMS that the physician’s Documentation Guidelines for Evaluation and Management adequately describe the hospital resources. Because that is unlikely, HOPDs usually create their own clinic visit level mapping system.

Myth/Misperception: We assess the wound at each visit. Therefore, we bill for a clinic visit/E&M service at each visit, even when we perform minor procedures such as surgical debridements.

  FACT: When a minor procedure is performed, providers should only bill for a clinic visit/E&M service when 1) a significant, separately identifiable service [required by the beneficiary’s condition] above the usual pre-service and post-service care of the procedure is rendered by the same physician on the same day of the procedure and 2) is documented in the medical record.

  In general, wound care assessments (including removal of dressing, cleansing of the wound, wound measurement, photographs, anesthesia[if performed],specimen collections, topical hemostatic agents, topical ointments,reapplication of dressing, and discharge instructions) are an integral part of minor wound care procedures and are not separately billable as clinic visit/E&M services. In addition, payment for therapeutic procedures (code ranges 10021-69990, 70010-79999, and 90281-99199) includes taking the patient’s blood pressure, temperature, asking the patient how he/she feels and getting the consent form signed, in addition to assessing/evaluating for the procedure and performing the procedure. Since payment for these types of services is already included in the payment for the minor procedure, it is not appropriate to bill separately for a clinic visit/E&M service.

  If reporting a clinic visit/E&M service for the same visit when a minor procedure was performed is appropriate, add the modifier -25 significant separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service to the appropriate clinic visit/E&M service code.

  NOTE: Modifier -25 applies only to the clinic visit/E&M service code when performed on the same day as a procedure with a same-day or 10-day global period.

  The following primary considerations should be made by providers before they bill a clinic visit/E&M service with modifier -25 during the same encounter with a procedure:
     • Why is the physician seeing the patient?
        o If the patient exhibits symptoms from which the physician diagnoses the condition and begins treatment by performing a minor procedure on that same day, modifier -25 should be added to the correct level of clinic visit/E&M service code.
        o If the patient is present for the minor procedure only, modifier-25 does not apply.
        o If the clinic visit/E&M service was to familiarize the patient with the minor procedure immediately before the procedure, modifier -25 does not apply.
     • If the clinic visit/E&M service is related to the decision to perform a major procedure (90-day global), modifier -25 is not appropriate. The correct modifier is modifier -57, decision for surgery made within global surgery period.
     • When determining the level of clinic visit/E&M service to bill when modifier -25 is used, providers should consider only the content and time associated with the separate clinic visit/E&M service, not the content or time of the minor procedure and its pre-service and post-service work.

  CAUTION: The provider’s documentation must clearly indicate that a significant, separately identifiable clinic visit/E&M service beyond the pre-service and post-service work included in the procedure was performed. To double check that modifier -25 is applicable, wound care providers should be able to remove the documentation affiliated with the minor procedure and the remaining clinic visit/E&M service documentation should be able to stand on its own. In other words, all of the pre-service and post-service care that is part of the procedure MUST NOT BE INCLUDED IN THE CLINIC VISIT/E&M SERVICE CALCULATION. If the pre-service and post-service care is included in the clinic visit/E&M service calculation, payers and auditors typically view that as double billing.

  NOTE: Providers that are using an electronic health record should be sure that their system is programmed to remove the pre-service and post-service care affiliated with the minor procedure before calculating the clinic visit and/or E&M service level.

Summary:

  Like all other wound care services, there are numerous coding and coverage regulations and guidelines that HOPDs and physicians must consider before they bill for a clinic visit/E&M service. See Exhibit I for a few of the many reference sources that pertain to clinic visit/E&M service documentation and coding.

  Wound care providers should rely on CPT® coding guidelines and CMS coding, coverage, and documentation guidelines rather than following myths and misperceptions. Incorrectinformation may allow a claim to be paid. However, billed codes that are not supported by HOPD and physician documentation may not withstand audits and may eventually lead to repayments and possible fines. Keep in mind that clinic visit/E&M services account for approximately 40% of the benefit dollars paid under Part B of the Medicare program. Unfortunately, the Medicare claims payment error report, published by CMS each year, demonstrates that an unacceptably high percentage of benefit dollars for clinic visit/E&M services has been paid in error. HOPDs and physicians should do everything possible not to be part of those unpleasant statistics.

  CPT® is a registered trademark of the American Medical Association.

Kathleen D. Schaum, MS, is President and Founder of Kathleen D. Schaum & Associates, Inc. , Lake Worth, FL. Ms. Schaum can be reached for questions and consultations by calling 561-964-2470 or through her email address: kathleendschaum@bellsouth. net.