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LIVE BLOG: Coding & E&M – Which Modifiers and When to Apply? With John Bishop, PA-C, CPC

In the second segment of Live Blogs on Coding, John Bishop shares on the importance of proper billing and coding for procedures, as well as the dangers (and inevitability) of audits.  
 
Some Coding Caveats to Remember!
 
If you didn’t write it down, you didn’t do it
If you did write it down but incorrectly, you didn’t do it
If we can’t read it, you didn’t do it
If you can’t produce a dictated copy of whatever you said you did (OR ER ASC), you didn’t do it
If you can’t justify the medical necessity of what you dictated or wrote down, you didn’t do it
If you code it incorrectly, you still didn’t do it
 
Dermatology Problem Areas
According to Mr. Bishop, auditors are looking for practices with EHRs, specifically targeting PAs with the E&M choices that they are making. 
 
Risk Areas of Coding and Billing
+Services not rendered or provided
+Double Billing
+Known misuse of PIN
+Unnecessary service and tests
 
–> You who work with Mohs: You are under high suppression for this year and 2013 for being audited
 
+Up-coding
You willfully disobey the rules of coding and billing.
You will not see a Level 5 office visit in your derm. clinic
 
+Down-coding
You don’t know the rules.
Don’t bill every visit as a Level 3 visit.  You are doing flatline billing and coding.
 
+Inaccurate documentation
If you don’t know how to document, you shouldn’t be doing it, or you need to pay the scribe to document what you are talking to your patient about
You are missing out of revenue if you don’t do this
 
+Lack of ICD-9 specificity 
What type of lesion?
Mole, Nevus: benign 216
 
The days of non-specific coding are long past us and should well be
If you don’t know what specific diagnosis is, why don’t you know that?  Are you 
choosing the right area of code?
 
+Submitting claims for unnecessary or unreasonable services and supplies
 
 
Problem Areas in CPT Coding
 
EHRs
When you are using electronic health records, the vendors designed these under the Electronic Health Records were designed under the old way of teaching E&M and that was by counting bullets, body parts, organ systems and said to everyone: if you hit these boxes you can bill E&M. 
 
Here is the problem: It’s not true and it’s even fairly illegal.  
 
Here is why: You are cloning with templates and electronic health records.  
 
If you are seeing a patient today that you saw 3 months ago, if your record is designed to bring everything forward electronically that took place in the last visit, ask yourself: Why did you bring all that information forward?
 
What information are you getting today that is different from what you got 3 months ago?  What purpose does it serve for your decision making it today?
 
Even if it was “the machine” that brought the information forward, it is still your fault, and it is still fraud.
 
 
New Patient vs Established Patient
 
A new patient is one that hasn’t received any professional services from physician or another physician of the same specialty (and NPPs).  If you are covering for another physician or NPP, you must bill like that physician would have billed in their practice.
 
Example:
If Mrs. Jones follows you from your old practice to your new practice, and saw someone working in your new office, then Mrs. Jones is an ESTABLISHED patient, not a new patient!  
 
 
Audit Checklist
+ Patient ID
+ Provider ID
+ Date of service
+ Medical reason for the encounter/eval
+ Intensity of medically appropriate history
+ Intensity of medically appropriate examination
+ Complexity of decision making process
+ Legibility
 
–  FEDERAL LAW has a fine of $1000+ for illegible medical handwriting
 
– Can someone out of your medical practice read your handwriting?
 
– If your handwriting is bad, hear the warning, if you get audited, they will be all 
over you.
 
“Incident To” Story
Dr. Smith meets with Mrs. Jones, does a work up: “I think you have this, I’m going to prescribe you this for that, run a test on this, and let’s check back in 2 weeks.”  Mrs. Jones comes back in and while Dr. Smith is in house, Mrs. Jones is on your book.
 
You meet with Mrs. Jones, “Here are your test results.  Is that medication alright for you?  Let’s get you a refill.”  You haven’t changed anything from Dr. Smith’s original note and there is no need to talk to the doctors in the clinic.  
 
Today, that visit gets billed under DR.SMITH’s NPI number and not yours.  Dr. Smith takes legal responsibility for that visit.
 
 
New: OIG work Plan for 2012
 
The OIG is now looking back as far as 9 years into practice records. This is something everyone should  be aware of… for when they come and audit the practice (Note: Bishop argues that this is *when* they come, not *if* they come). 
 
Medicare contractors have noted an increased frequency of medical records with identical documentation across all services, ie. cloning.  Be aware of this and look for cloning when you go back through your records.
 

[Image by Koen Vereeken]




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