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Solving Your 9 Biggest Billing Blunders


Coding is hard. It’s tedious. Yet it is how you get paid for the services you perform. So we asked the experts where things go wrong most of the time - and how to fix them.

Coding can be a dense and Byzantine process. Doctors hate it. The worst of it is that every payer seems to have its own take on coding.

But you can't bill for services without coding for them. And as Medicare's pay-for-performance program catches on and private payers follow, correct coding and documentation are more important than ever.

Bottom line: If you want to get paid correctly for the work that you do, you must understand the rules.

We turned to several procedural coding professionals - experts who advise physicians, medical practices, hospitals, and other providers - and asked two questions:

First, what are physicians doing most often to undermine their own coding and documentation efforts? In response, our experts offered nine big coding blunders that physicians could and should fix today.

"I see many physicians stuck in the mind-set that what they learned about coding 10 years ago is all they need to know," says Rhonda Buckholtz, vice president of business and member development for the American Academy of Professional Coders. "A lot of times their knowledge of coding is outdated."

Second, we asked them to describe the emerging trends and possible coding rule-changes likely to affect physicians' lives in the future. (See textbox "Trends.")

Straight from the experts, then, here are the tips, peeves, and predictions we heard most often.

1. Failing to note negatives

There's far more to assessing a patient than listing the chief complaint. Noting the pertinent negative findings - ruling out what's not involved - is a fundamental part of the diagnostic process. So why not get paid for it? Unfortunately, physicians can slip up when documenting this aspect of their thought process, says Margie Scalley Vaught, a coding consultant based in Chehalis, Wash.

"To give the proper CPT code for the office visit, it comes down to what did you touch and what was the result," Vaught says. "If you leave out some of the negatives you could end up with a lower-coded visit even though you spent the time and did perform an exam that deserved the higher code."

Let's say you've seen a patient who complains of knee pain and limited range of motion. Your examination finds no lesions or rashes, no signs of injury, neurological impairment, or pain to the touch. If you state in the record merely, "knee pain and limited ROM (MS)," you've just cost yourself money. That short recitation of just the positive findings is a problem-focused exam covering just one organ system, which is a lower-level code.

"When it comes to coding and billing, both positives and negatives are at work," Vaught says. "You have to go beyond saying 'patient has limited range of motion and pain with palpation,' and mention the other aspects of the knee and other areas that you examined but had negative findings."

No payer, or coder for that matter, will just assume that you also checked the patient's pulse, sensation, or looked for a rash or lesion. That's three more organ systems - a detailed exam under the 1995 rules or an expanded exam under the 1997 rules. All you had to do was describe those pertinent negatives in the record as something like: "negative for rashes or lesions" (Integ), "no effusions," "normal pulses" (CV), and "normal sensation" (Neuro). Presto: The proper code for the appropriate exam level you did is applied.

2. Skimping on substance

Vaught urges physicians to be especially wary of unintentionally downcoding follow-up visits for established patients. That patient's knee-injury follow-up would be a 99212 if your note says: "I'm seeing Ellen back today regarding the left knee injury three weeks ago. She's been going to physical therapy, has no complaints. We're going to see her back in a month."

It's an adequate note, but was that really all you did? What about your assessment that supports your treatment plan? Mentioning them would lead to a note like this: "Ellen's been going to physical therapy and icing her knee as instructed. She's used the brace as recommended for the past three weeks with no complaints. She is going to continue physical therapy, bracing, and using over-the-counter medications as needed for pain, and she'll call us if she has any problems."

OK, it's a bit wordy but isn't that what you did? If so, you've got a 99213 visit.

Vaught also sees oversimplification happen when physicians interpret other physicians' records or tests they've ordered. An assessment and medical plan in the patient's record should state your diagnosis and the rationale for your treatment plan, test, therapy, or other orders.
"Put it in the note if you discussed options with the patient or what you intend to do next, whether it's therapy, or continue watching, or discussing surgery," Vaught says.

3. Use of "noncontributory"

Don't say "noncontributory" unless you really mean "it wasn't worth mentioning," says Melody Irvine of CareerCoders. And certainly not if you intend that phrase to support your medical decision making in Evaluation and Management (E&M) visits.

"'Noncontributory' doesn't tell me, as a coder, that an organ isn't related to the condition or the existing problem; it's saying that you didn't consider whether it could be a factor," Irvine says.

True, a family history of heart disease and early death from myocardial infarction might not be your primary consideration when your 93-year-old patient reports chest pain, but reaching higher-level E&M codes requires that you consider whether or not it was a contributing factor.

"Mentioning the elderly patient's family history of heart disease in the record doesn't mean you concluded it was important to the current illness; it's just saying that you gave it consideration as a factor before deciding it wasn't," Irvine says.

Trends: What's Next in Coding?

What's coming in the next three to five years that will affect physicians? Experts expect change in three major areas:

ICD-10 will be here in 2013 and when it arrives, specificity will be a key to coding success, says the AAPC's Rhonda Buckholtz. "Bilaterals will be huge in ICD-10," she says. "You won't be able to assign a diagnosis code unless you say it is left or right ear or right or left abdomen, and so on."

Prepare now by getting into the habit of specificity and get psyched up to start using your specialty's share of ICD-10's 68,000 diagnosis codes to support your CPT coding.

And start saving for the switch, too. The Medical Group Management Association estimates that between training, software upgrades, clogs in the insurance claim pipeline, and higher documentation costs, adapting to ICD-10 could cost a three-doctor practice about $84,000.

Medicare's Physician Quality Reporting Initiative, (PQRI), aka pay-for-performance, hasn't been a runaway hit but don't expect it to go away. And private carriers will continue pursuing their own takes on quality through pay-for-performance programs that sometimes pay better bonuses than Medicare's PQRI.

The meaningful-use criteria that physicians must report to qualify for Medicare or Medicaid bonuses under the federal EHR stimulus program aren't a twin to the PQRI program requirements, but don't be surprised if there are attempts to align the two.

Medical necessity: Medicare and its carriers are getting tough here, says coding consultant Nancy Enos. "They are going to challenge physicians more often on extent of service, not just documentation of service, which means coders must be more clinically minded to determine what's medically appropriate."

4. Stuck in the middle

A middle-of-the-road coding level - 99213 - for E&M visits must sound like a safe way to stay below the radar of zealous payer auditors, the Office of the Inspector General, and everyone else looking over your shoulder these days. It seems to be the most popular code. But no code is a good bet unless it's justified, says Buckholtz.

"I stress to the doctors that they shouldn't be afraid to code or bill anything that they do," she says. "If they did it and they documented it, they need to code it and get paid for it."

To get off autopilot, revisit proper 99213 documentation. Buckholtz recommends a two-step recovery plan:

First, know what a 99213 really is. Medicare's Documentation Guidelines for Evaluation and Management Services says a level 3 established patient office visit must meet two of the following three criteria:

• An expanded problem-focused history;

• An expanded problem-focused exam; and/or

• Low-complexity medical decision making.

If coding the visit based on time - you spent more than half the total visit counseling the patient face to face - then you'd need 15 minutes to reach the 99213 level.

The second step to getting out of your 99213 rut is to understand that a 99214 visit requires at least two of the following three components:

• A detailed history;

• A detailed examination; and/or

• Medical decision making of moderate complexity.

Examples of "moderate complexity" are a new complaint that could become serious if left untreated, three or more old problems, a new problem requiring a prescription, three stable problems that require medication refills, or a stable problem plus an inadequately controlled problem requiring medication refills or adjustments.

In dollars and cents, routine undercoding of what should be a 99214 represents a lot of lost revenue. The Medicare national allowable is $65.67 for a 99213 visit vs. $98.51 for a 99214. For commercial payers, the average allowables are $65.49 and $91.37, respectively, according to the Physicians Practice 2009 Fee Schedule Survey. Undercode just two of your Medicare patients -a week, and it will cost you more than $10,000 in a year.

Buckholtz's advice: "Learn how to document properly; you can grasp correct E&M coding pretty quickly."

5. Cloning patients

It may not have happened yet in a biomedical research laboratory, but physicians are already cloning patients in their offices - via their EHR systems, that is. The result can be a disarming and costly similarity of medical records from patient to patient - disarming to payers and auditors, costly to you.

It's cloning when the documentation in every patient's medical record is worded exactly (or almost exactly) like the previous entries. Vaught says lazy template design often creates the problem.

"Even though you may do the same type of exam for every patient, the symptoms and duration of symptoms are going to be different from patient to patient," Vaught says. "Focus on the chief complaint and don't get overly focused on getting everything under the sun in just to reach the higher-level code."

Cloning is one of several EHR-related coding problems that the professionals say they're seeing more often as the systems become more widespread. It's true that an EHR, preloaded with templates and coding intelligence, can make the process simpler by automating it. But with that automation comes the danger that physicians will rely too heavily on their EHRs, experts say.

"If you're looking for an electronic medical record to solve your coding worries, understand that there's no system that can code for you," says Buckholtz.

Help Is on the Way

There are many places to get coding help. Here are guides and resources suggested by the coding experts interviewed in this article:


"EncoderPro" by Ingenix

"Custom Coder" by Decision Health

"The Field Guide to Physician Coding," by Betsy Nicoletti

Web sites:

CMS Web site

The Medicare Claims Processing Manual: click on "100-04"

• Medicare's "Documentation Guidelines for Evaluation and Management Services":


Medicare Carrier Web sites

6. Electronic over-documenting

Closely related to the cloning problem is over-documentation, also called "exploding notes." If your EHR template inserts: "abdomen no tenderness, rebound or masses," into every patient's record, then you'll appear to be disregarding medical necessity. Coding consultant Nancy Enos calls it "the EHR effect."

"With one click on the template, physicians can make every system automatically negative and then go back and just put in what's positive, which leads to over-documentation because you aren't really reviewing every system for a sore throat," Enos says.

Over-documentation also can be a sign of overusing the EHR's auto-populating feature, says Buckholtz.

"We used to tell doctors they weren't documenting enough. Now, it's at the other extreme," she says. "And (insurance) carriers are starting to take notice."

The surest sign of EHR-caused over-documentation? Your visit records jump from one page to three or more pages after you implement the system. The solution, Buckholtz says, is to take care in building templates. A cardiologist should not use the same exam template for a 50-year-old male with chest pains and a pediatric patient with a possible congenital heart condition. Also, make sure that your templates allow you to easily mark off things you aren't doing in the exam.

7. Overlooking CPT updates

Along with introducing new codes and retiring others, annual updates to the AMA's "Current Procedural Terminology" (CPT) frequently add details to required documentation. Enos points to the several dozen codes OB/GYNs and orthopedists use to describe soft tissue. In the latest CPT update, 41 new codes describe size prior to excision or removal.

"The code description now requires more details in the operative note, but I see many physicians who haven't gotten the message yet, so their coders are forced to default to the lower-level code when there's nothing in the record about size," Enos says.

For example, a vaginal hysterectomy of a uterus greater than 250 grams can be coded as CPT 58290 (added in 2003), which pays a Medicare physician $1,127.28 (national average). Neglect to record the weight in your note and you'll likely get the lower code, a 58260, which pays $320.07 less. Failing to note whether a tumor or vascular malformation is more or less than 1.5 centimeters before removing it from the soft tissue on a finger or hand could cost you $79.02, the difference between a 26115 (1.5 centimeters or larger) and a 26111 (smaller than 1.5 centimeters), Enos says.@pagebreak@

8. Confusing the coder

Most coders are not clinicians, says Kim Snyder, corporate director of coding at Zotec Partners. So it's crucial to accurately document the service or procedure you perform. Until your coder is experienced in your specialty, document with the CPT's take on things in mind. For example, an inexperienced coder would struggle to translate a radiologist's note about a "magnetic resonance cholangiopancreatogram procedure without contrast" into a 74181. The CPT guide describes that only as "Magnetic resonance (e.g., proton) imaging, abdomen; without contrast material(s)," saying nothing about cholangiopancreatography.

Snyder, whose firm provides electronic billing and practice management software, says complete documentation is critical to support the application of the appropriate CPT codes that will avoid unintentional downcoding.

Coming Soon to an Audit Near You

Want to know what Medicare's auditors will be looking out for each year? You need only read the Department of Health and Human Services' Office of Inspector General's (OIG) annual work plan. In this document, the OIG details which types of healthcare-related frauds, abuses, and errors it plans to focus on during the federal fiscal year (which starts in October). Here's a sampling from the FY 2010 plan, available at the agency's Web site:

Place-of-service errors. The OIG wants to determine whether physicians are properly coding for services provided in outpatient departments, such as ambulatory surgical centers, which, when facility fees are added, may pay physicians more than inpatient services.

E&M services during global surgery periods. The government wants to know whether the number of E&M services provided during the global surgery period has changed since the global fee concept - under which physicians are paid a lump sum for providing the various services considered part of the global period - was developed in 1992.

Medicare billings with modifier GY. Modifier GY is used to code for services that are statutorily excluded or do not meet the definition of a covered service. Beneficiaries or their secondary insurance plans are responsible for paying these charges. Citing the more than 75 million claims (totaling $820 million) that Medicare received in FY 2008 with a modifier GY, the OIG says it will look for patterns and trends in how physicians and suppliers are using the modifier.

9. Audit aversion

Audits help uncover gaps between what you document and what you code, which is one reason why the Department of Health and Human Services Office of Inspector General recommends regular chart audits. Yet many practices neglect auditing, says Cindy Dunn, a consultant with MGMA Health Care Consulting Group.

"Even when a practice does these audits, I don't always see them done well, nor do I see them doing anything to follow up, which means they'll just keep repeating their mistakes," Dunn says.

She suggests that each year, you review at least five notes for each of your government payers, or 10 notes selected at random. Make sure to conduct audits for each physician and make sure each of your practice sites is represented. A basic audit compares documentation with the codes submitted on the claim form. Look for discrepancies and study up on where you find weakness.

Coders like Vaught suggest using the data to make a simple graph showing, for example, how many level 3 and 4, new and established patients you are coding compared with the national average of Medicare data for your specialty.

Want to get your practice partner's attention to take audit findings seriously? Try extrapolating the results of your small-scale audit to a full year of income lost by undercoding or gained inappropriately by overcoding. After all, that's similar to the way the feds figure fines for overcoding.

Robert Redling is a freelance writer based in Tacoma, Wash. He has been practice management editor for Physicians Practice, Web content editor and senior writer for the Medical Group Management Association, and a speechwriter for the American Academy of Family Physicians. He can be reached via

This article originally appeared in the May 2010 issue of Physicians Practice.


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