NAMAS Webinar Q&A: Hands On Inpatient E&M Services

Post here your questions regarding auditing ,coding, documentation, and compliance. Also, join in on the conversation- help your fellow auditors and compliance professionals in the industry.

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These questions have been answered by the webinar presenter, Kathy Pride, RHIT, CPC, CCS-P, CPMA

1. For the first example, what if the Dr. believes that this is a high level of severity for the patient's age? and have the doc for high level.
Keep in mind the Table of Risk provides only examples. The patient’s age is not listed in the Table of Risk as a contributing factor; however, in the “real world” we know that a patient’s age can affect the risk level. That said, this is one of those gray / subjective areas of auditing. My thought process for this case was based on the documentation “Etiology of patient symptoms likely infections gastroenteritis (viral) or UTI. Clinically better today, vomiting resolved, stools are closer to baseline,” it appears the patient is out of the critical phase and is improving from when he/she was seen in the ED prior to admission. One thing that is important to keep in mind is the risk is determined by the patient’s condition between the current encounter and the next encounter. For example, the patient is improving, so is the patient still at a high risk? Remember our Nature of Presenting problem guide states high risk for an inpatient is “admitting problem is still requiring major adjustment to try to reach a more stable state.” Based on the documentation, this patient is not requiring major adjustments to the regimen at the time of the encounter. I also do not see documentation to support the patient is in a critical state which is posing an immediate threat to life. I see this as a complicated, acute problem which falls into the Moderate level of Nature of Presenting Problem.

2. With combination diagnosis codes, are you able to count 2 diagnosis? example diabetes with diabetic polyneuropathy
Yes, if the provider is treating or considering both diagnoses as part of his/her medical decision making. Remember that just listing a diagnosis is not sufficient to count as part of the MDM. The provider must provide a status / assessment demonstrating they are either treating or considering the diagnosis in their assessment of the patient and treatment plan.

3. Does documentation stating "patient here today unaccompanied" count towards social history?
I would not count that as social history.

4. What is considered additional workup in the inpatient setting?
Additional workup is if the provider ordered new diagnostic studies during that day’s encounter.

5. for ulcers can you count every one as different so for example can you give 2 points for different locations on the same leg or just 1 for an stable ulcer?
I would not, as they are generally a manifestation of the same condition, just manifesting in different locations of the skin. Other auditors may have differing opinions as this is not specifically addressed in the guidelines.

6. Can the chief complaint be taken from the hospital course in the history?
Be careful with this. Subsequent hospital visits lead the pack for the visit type with the most denials due to improper payments, and missing a chief complaint was one of the biggest contributors to the high number of improper payments. The provider should give a very brief statement as to why they are seeing the patient that day and it should not be assumed it is the reason the patient is admitted to the hospital. Often times there are multiple specialties following a patient. They may be in the hospital for a hip replacement, but the hospitalist is following them for hypotension resulting from the hip surgery. In this case the CC is hypotension, not hip replacement. The history often does not state which physician is following them for which condition, and specifically if they are seeing them on that DOS for that specific condition. The history is generally a listing of all conditions as part of the patient’s past medical history.

7. "Just want to confirm that ALL teaching physicians should have GC mod on their claims? My providers are not employed by the hospital (been told we don’t need it). Also, GC applied to all payers or Medicare only?"
GC is a Medicare only modifier and should only be used if your physician is a teaching physician in an approved Graduate Medical Education (GME) program who involves residents in the care of his/her patients on claims. Claims must comply with requirements in the General Documentation Guidelines and E/M Documentation guidelines. Per Medicare’s Guidelines for Teaching Physicians, Interns, and Residents Guide, claims must include the GC modifier and an attestation statement demonstrating the teaching physician’s involvement in the encounter. I was not able to find any documentation to support GC should only be used if the teaching physician is an employee of the hospital.

8. Is there a risk when a provider documents time on every visit even when documentation supports the E/M?
Yes. If the key components support the level of service, there is no reason to document the time. The risk is when the time element is actually lower than the key components. For example if the provider documents they spent 20 minutes the time element becomes the “controlling factor.” In this scenario, this would be a 99213. Let’s say the provider has documented a detailed history and the MDM = moderate. That yields a 99214. However, because the provider has documented the time, they now must code the 99213 as time has become the controlling factor. It is not required they spend 25 minutes with the patient to yield a 99214. According to the CPT guidelines “times expressed in the visit code descriptors are averages and, therefore, represent a range of times that may be higher or lower depending on actual clinical documentation.” However, if they chose to use the time element, they must use the time they documented.

The other risk is documenting time is ensuring they are not documenting more time than they are actually seeing the patient. The time can only include their face-to-face time in an office visit. This differs with inpatient’s as they can count time on the floor reviewing test results, speaking with other providers, nurses, technicians, etc., and writing notes in the chart. I have noticed that many of the EMR’s will give them the exact number of minutes needed to meet the level of service. What is the chance that every single patient with a 99214 took exactly 25 minutes. And if the provider saw 25 patients in the office that day, all with time documented as 25 minutes, that means they worked >10 hours with no breaks. Providers have been investigated by CMS/OIG for this very reason.
An inpatient example is a 99223 (Initial hospital visit) requires 70 minutes total time to use time as the controlling factor. However, it may not take 70 minutes for the provider to perform the service, and the chart reflects a comprehensive history, exam and high MDM. It may have only taken them 60 minutes to do that work. If they document 60 minutes, then it is automatically down-coded to a 99222. But, if they are using a macro from the EMR that gives them the exact number of hours each time for the level of service, they would be inaccurately documenting their time, and that may come back to haunt them one day (if you get my drift).

9. So you can count diagnosis as established in box A for a new patient admission?
A diagnosis should only be counted as “new” if it is new to that provider.

10. Would oxycodone be considered high risk in box C for MDM?
Good question, and I have heard conflicting advice on this. There is no list of “high risk” drugs. In my humble opinion, I think anything that is a schedule II narcotic with a high potential for abuse is a high risk. According to the Controlled Substance Act (CSA), oxycodone is a schedule II drug. Keep in mind the high-risk category states “parenteral controlled substances” which by definition must be administered IM, SQ, or IV. This does not include oral (PO). That said, if the physician is a pain management specialist and is monitoring the patient’s toxicity of the high-risk drug, then they would qualify for High Risk. Yes, if the provider is actively managing the prescription for the oxycodone. If it is prescribed by another provider who is managing the oxycodone (i.e. pain management physician), and your provider is seeing the patient for diabetes management, then I would not count it towards MDM.
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