impact on hospital revenue physician documentation & billing
TRANSCRIPT
• H O S P I TA L S H AV E B E E N A C Q U I R I N G P H Y S I C I A N P R A C T I C E S .
• H O S P I TA L S H AV E B E E N E S TA B L I S H I N G J O I N T V E N T U R E S W I T H P H Y S I C I A N S .
• H O S P I TA L S H AV E B E E N F O R M I N G A F F I L I AT I O N S W I T H P H Y S I C I A N S
Trends in Healthcare
• P H Y S I C I A N B I L L I N G S F R O M A F F I L I AT E D P R A C T I C E S N O W I M PA C T H O S P I TA L R E V E N U E .
• P H Y S I C I A N B I L L I N G E R R O R S C A N N O W C R E AT E C O M P L I A N C E I S S U E S F O R T H E PA R E N T H O S P I TA L .
• R A C A U D I TO R S A R E N O W F O C U S I N G O N E / M B I L L I N G S
The Effect on the Hospital Revenue Cycle
WHY YOU SHOULD BE CONCERNEDReason #1
Medicare Carrier Finds 50-90% Error Rate for E/M Codes Written by Leigh Page | February 22, 2011
Tags: claims | error rates | Medicare | Part BA random survey of claims by the Medicare Part B carrier in five
states has uncovered average error rates of 50-90 percent for E/M codes, according to a report by Part B News.
TrailBlazer, the carrier in Colorado, New Mexico, Oklahoma, Texas and Virginia, said the most common cause was "documentation
errors." TrailBlazer also cited some obvious errors, such as the reason for encounter was to receive lab results, which doesn't count as an
E/M and also some not so obvious ones, such as that the frequency of E/Ms billed per beneficiary exceeded documented needs for
management of stable, chronic conditions.
"I could see maybe 20 percent (error rate) or a little higher. But 90 percent I just haven't seen before," said Seth Canterbury, an education specialist for the University of Florida Jacksonville
Physicians.
OUR EXPERIENCE IN AUDITING THE DOCUMENTATION AND BILLING RECORDS FOR OVER 200 PHYSICIANS
WE HAVE SEEN AVERAGE ERROR RATES BETWEEN 35% AND 70% WITH SOME MUCH HIGHER.
WE FOUND BOTH UNDER CHARGED AND OVER CHARGED ERRORS.
MOST ERRORS WERE CAUSED BY POOR OR INADEQUATE DOCUMENTATION BY THE PHYSICIANS.
WHY YOU SHOULD BE CONCERNEDReason #2
RACs Expand into Physician Practices, Adding Pressure to Existing Audit Burden Written by Lori Brocato | Thursday, December 20, 2012
HDI and Connolly Make First Strides Two RACs recently mentioned upcoming reviews of physician practices and medical groups. One is taking a generic approach, while the other will hone in on specific issues sorted by provider type. Regardless of the methodology used, however, we predict that other RACs will follow suit.
WHAT YOU CAN DO:
1. Install sophisticated electronic medical documentation and billing systems in all affiliated physicians’ offices.(Can be expensive and will be effective only if physicians properly use it)
2. Hire medical scribes to assist each affiliated physician.(Very expensive and depends on the training of the scribes)
3. Teach the physicians to properly document and correctly bill for services.(A reasonably priced alternative that will be effective with most physicians)
E & M BILLING
THE OVERWHELMING MAJORITY OF PHYSICIAN BILLING IS FOR EVALUATION AND MANAGEMENT (E & M) SERVICES.
THERE ARE CLEARLY DEFINED PROTOCOLS FOR THE PROPER DOCUMENTATION AND CORRECT BILLING OF E & M SERVICES.
THERE ARE PUBLISHED AUDIT GUIDELINES FOR ESTABLISHING THE ACCURACY OF E & M BILLING.
YET MANY PHYSICIANS ARE UNAWARE OF THESE PROTOCOLS AND GUIDELINES.
EVALUATION & MANAGEMENT PROCESS
E&M Encounter
Take Patient History
Document History
Perform Examination
Make Clinical Decision
Code & Bill
E & M Documentation
Clear and concise medical documentation is required to provide patients with quality care, and is critical to receive accurate and timely payment. It is also necessary to ensure that a service is consistent with the patient’s insurance coverage and to validate the following:
The medical necessity and appropriateness of the diagnostic or therapeutic services provided
The site of service That services furnished have been
accurately reported
E & M General Principles
The documentation of each patient encounter should be legible and include:
• Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results
• Assessment, clinical impression, or diagnosis
• Medical plan of care
• Date and legible identity of the observer
Defining the levels of E & M services
Key components:I. Patient HistoryII. ExaminationIII. Medical decision making
Contributory components
• Nature of presenting problem
• Time
• Counseling
• Coordination of care
PATIENT HISTORY
History includes some or all of the following elements: Chief Complaint (CC) is required for any level of service and
validates the medical necessity of the service. It should be a concise statement describing the symptoms, problem,
condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter. It is usually stated in the patient’s own words.
History of present Illness (HPI) or Status of Chronic Conditions is required for any level of service and Must be documented by the MD.
Review of Systems (ROS)* Past Family and/or Social History (PFSH)*
*Must include Physician Notation, MD signature and date
The extent of the history documented should depend on the nature of the problem
HISTORY DOCUMENTATION SUMMARY
Type of History History of Present Illness(HPI)
Review of Systems(ROS)
Past Family and/or Social History
(PFSH)
Problem Focused (PF)
Brief1 – 3 elements
N/A N/A
Expanded Problem Focused
(EPF)
Brief1 – 3 elements
Problem Pertinent1 system
N/A
Detailed(D)
Extended4+ elements
Extended2 – 9 systems
Pertinent1 area
Comprehensive(C)
Extended4+ elements
Complete9+ systems
Complete3 areas
PHYSICAL EXAMINATION
The extent of examinations performed and documented is dependent upon clinical judgment and the nature of the presenting problem. They range from limited examinations of single body areas to general multi-system or complete single-organ system examinations.
PHYSICAL EXAMINATION DOCUMENTATION
The body areas:• Head, including face• Back, including spine• Chest including breasts and axillae• Abdomen• Neck• Genitalia, groin, buttocks• Each extremity
The organ systems:• Constitutional• Eyes• Ears, nose, mouth, throat• Cardiovascular• Respiratory• GI• GU• Musculoskeletal• Neurological• Skin• Psychiatric• Hem/lymph/imm
4 LEVELS OF EXAMINATION - CPT
Problem Focused (PF): a limited examination of the affected body area or organ system.
Expanded Problem Focused (EPF): a limited examination of the affected body area or organ system and other symptomatic or related organ systems.
Detailed (D): an extended examination of the affected body area and other symptomatic or related organ systems.
Comprehensive (C): a general multi-system examination or complete examination of a single organ system.
MEDICAL DECISION MAKING
1. Number of possible diagnoses and/or number of management options considered;
2. Amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed;
3. Risk of significant complications, morbidity and/or mortality as well as comorbidities associated with the patient’s presenting problems, diagnostic procedures, and/or possible management options.
Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option, determined by considering the following factors:
To qualify for a given type of medical decision making, two of the three above elements must be met or exceeded.
MEDICAL DECISION MAKINGSCORING FOR COMPLEXITY
ANumber of diagnoses and treatment options
1Minimal
2Limited
3Moderate
4Extensive
BAmount and Complexity of Data
1Minimal/Low
2Limited
3Multiple
4Extensive
C Highest Risk Minimal Low Moderate High
Type of Decision Making
Straightforward
LowComplexity
ModerateComplexity
HighComplexity
If no column contains more than one entry, choose “Low Complexity”
BILLING E&M SERVICES
When billing for patient visits, select the codes that best represent the services furnished during the visit.
It is the provider’s responsibility to ensure that the submitted claim accurately reflects the service provided.
Do not use the volume of documentation to determine which specific level of service to bill.
In order to receive payment from Medicare, the service must also be considered reasonable and necessary.
New Patient Office Visit (All 3 key components met or exceeded)
Level History Exam Medical Decision
99201Problem Focused
Chief Complaint Brief history of present illness(1 – 3 HPI elements)
Exam of affected body area/organ system (1995 guidelines – At least 1 system with 1 element or 1 comment)
Straight-forward
99202Expanded Problem Focused
Chief Complaint brief Hx of present illness (1 – 3 HPI) Problem pertinent system review (1 ROS)
Exam of affected body area/organ system Exam of other symptomatic or related body area/organ system (At least 2 systems with at least 1 element or 1 comment)
Straight-forward
99203Detailed
Chief complaint Extended HPI (4 or more elements) Extended system review (2 – 9 ROS) One pertinent PFSH
Extended exam of affected body area/organ system Extended exam of other symptomatic or related body area/organ system(At least 4 systems with at least 4 elements or 4 comments - 4 X 4 rule)
Low
99204Complete
Chief complaint Extended HPI (4+ elem) Complete ROS (10+) Complete PFSH (all 3)
Complete single system specialty exam orComplete multi-system exam (1995 guidelines – at least 9 systems with 1 element or 1 comment)
Moderate complexity
99205Complex or
Severe
Chief complaint Extended HPI (4+ elem) Complete ROS (10+) Complete PFSH (all 3)
Complete single system specialty exam or Complete multi-system exam (1995 guidelines – same as Level 4 above)
High complexity
Established Patient Office Visit (2 key components met or exceeded)
Level History Exam Medical Decision
99211Problem Focused
Does not require presence of a physician
Presenting problems are minimal
99212Expanded Problem Focused
Chief Complaint Brief history of present illness (1 – 3 elements)
Exam of affected body area/organ system(1995 guidelines – At least 1 system with 1 element or 1 comment)
Straight-forward
99213Detailed
Chief complaint Brief history of present illness (1 - 3 elements) Problem pertinent system review (1 ROS)
Exam of affected body area/organ systemExam of other symptomatic or related body area/organ system (At least 2 systems with at least 1 element or 1 comment)
Low
99214Complete
Chief complaint Extended HPI (4+ elements) Extended ROS (2 – 9 ROS) Pertinent PFSH (1 PFSH)
Detailed exam (At least 4 systems with at least 4 elements or 4 comments – 4X4 rule)
Moderate complexity
99215Complex or
Severe
Chief complaint Extended HPI (4+ elements) Complete ROS (10+ ROS) Complete PFSH (2 of 3 PFSH for complete)
Complete single system specialty exam or Complete multi-system exam (1995 guidelines – at least 8 systems with 1 element or 1 comment)
High complexity
Evaluating E & MDocumentation
How others will judgeThe quality of your
Documentation
1. The patient history2. The Exam3. The complexity of
your decision making
Copy of the Marshfield ClinicAudit Worksheet commonly usedTo evaluate E & M documentation
THE TRAINING APPROACH
Electronic medical documentation and the use of scribes can be effective methods to reduce the problem of physician billing errors, but they are expensive to install and maintain.
Physician documentation/billing training is a less-expensive alternative that can produce significant documentation improvements, increased revenue and reduced risk of compliance errors and RAC vulnerability.
PHYSICIAN TRAINING
I. Group training for Physicians and practice support staff.
II. Sample audits of the billings and documentation for each Physician.
III. One-on-one training with each physician.
IV. Remedial follow-up audits and training at regular intervals.
I. GROUP TRAINING
All physicians, billers and support staff attend a 2 – 4 hour training session covering the following:A. A detailed explanation of how to correctly document an E
& M encounter with relevant examples. B. Instruction on standard billing protocol and proper
selection of the appropriate E & M code.C. Introduction to the standard audit worksheet used by
outside auditors to evaluate the quality of the physician documentation and the accuracy of the billing.
II. AUDIT OF SAMPLE BILLINGS
A sample of 20 to 30 E & M bills are randomly selected for each physician.
Each bill is carefully audited, using standard audit protocols, to confirm the accuracy of the bill and the completeness of the documentation
Every error and inadequacy is clearly explained with indication of the correct or more appropriate choice.
A report is prepared outlining the accuracy and completeness of the billings for each physician.
III. ONE-ON-ONE PHYSICIAN TRAINING
A qualified trainer meets with each physician for an individual one-hour post-audit training session.
The audit report is presented and explained so the physician clearly understands every error or inadequacy and the correct way to document and bill.
M. LECO & ASSOCIATESABC MEDICAL PRACTICE
PROVIDER E/M AUDIT RESULTS SUMMARY
Provider Audit Date Post Audit Final Report Under Over Correct Total Error Revenue Interview Coded Coded Audited Rate Impact
DR. A 10/3/2012 10/8/2012 10/10/2012 15 2 5 22 77.3% $787.00DR. B 10/4/2012 10/18/2012 10/29/2012 7 3 10 20 50.0% 210.00DR. C 10/31/2012 11/15/2012 11/19/2012 3 0 17 20 15.0% 258.00DR. D 10/31/2012 11/15/2012 11/19/2012 5 0 15 20 25.0% 410.00DR. E 10/23/2012 11/15/2012 11/19/2012 0 9 6 15 60.0% -505.00DR. F 11/7/2012 12/13/2012 12/14/2012 1 0 19 20 5.0% 20.00DR. G 10/22/2012 12/13/2012 12/14/2012 4 2 14 20 30.0% 50.00DR. H 11/7/2012 12/13/2012 12/14/2012 6 1 13 20 35.0% 140.00DR. I 11/7/2012 12/19/2012 12/20/2012 8 0 12 20 40.0% 220.00DR. J 11/7/2012 12/19/2012 12/19/2012 5 0 15 20 25.0% 145.00DR. K 10/31/2012 12/19/2012 12/20/2012 6 1 12 19 36.8% 10.00DR. L 11/7/2012 12/21/2012 12/21/2012 3 0 17 20 15.0% 90.00DR. M 12/18/2012 1/5/2013 1/7/2013 6 1 13 20 35.0% 200.00DR. N 11/29/2012 1/8/2013 1/9/2013 0 6 14 20 30.0% -246.00DR. O 12/19/2012 1/8/2013 1/9/2013 11 2 7 20 65.0% 316.00DR. P 12/18/2012 1/9/2013 1/9/2013 0 4 16 20 20.0% -160.00DR. Q 12/19/2012 1/10/2013 1/15/2013 14 0 6 20 70.0% 420.00DR. R 11/30/2012 1/11/2013 1/15/2013 7 0 13 20 35.0% 370.00DR. S 12/4/2012 1/17/2013 1/18/2013 3 0 17 20 15.0% 120.00
TOTALS 104 31 241 376 35.9% 2,855.00
SAMPLE OF ACTUAL AUDIT RESULTS
Typical report presented along with narrative to management staff
THE POTENTIAL BENEFITS
Most physicians under code and under bill because of compliance concerns.
Most physicians could code higher if they adequately documented.
The average physician is under coding and under billing about $5 to $10 per patient encounter.
Physicians can typically handle 20 – 40 encounters per day (approximately 500 per month or 6000 per year)
That could mean $30,000 to $60,000 of under billing per year per physician.
100 physicians = $3 million to $6 million per year!
RESULTS OF TRAINING
1. Most physicians significantly improve the quality of their documentation and the accuracy of their billing.
2. Most physicians greatly reduce the risk of billing non-compliance because their improved documentation now supports their billing choice.
3. Many physicians increase their average amounts billed because the improved documentation adequately supports higher billing levels.
99201 99202 99203 99204 992050
5
10
15
20
25
30
35
40
45
50
2
13
3735
13
2010 AVERAGE E/M CODE DISTRIBUTIONFOR NEW PATIENT OFFICE VISITS
E/M CODE
PERC
ENTA
GE
Department of Health and Human Services Publication: "Coding Trends of MedicareEvaluation and Management Services"; May 2012
ACCURATE E/M BILLING
99211 99212 99213 99214 992150
5
10
15
20
25
30
35
40
45
50
4
9
46
36
5
2010 AVERAGE E/M CODE DISTRIBUTIONFOR ESTABLISHED PATIENT OFFICE VISITS
E/M CODE
PERC
ENTA
GE
Department of Health and Human Services Publication: "Coding Trends of MedicareEvaluation and Management Services"; May 2012