NAMAS Webinar Q&A: Hands-on Examples of 2021 E&M Auditing, 08/24/2021

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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Below are the questions received during our recent webinar, Hands-on Examples of 2021 E&M Auditing, originally presented on August 24, 2021. These questions have been answered by the webinar presenter, Brenda Edwards, CPC, CDEO, CPB, CPMA, CPC-I, CEMC, CRC, CPMS, CMCS, CMRS

Question 1:
Our struggle is Doctors adding time statements as a safety nets. Most of the time is lower than MDM coders struggle with that.
Answer 1:
Providers do not need to document time when they are coding from MDM.

Question 2:
Workers compensation in NY does not accept the new E&M guidelines so it's a struggle for providers to go back and forth
Answer 2:
That is a struggle as well as the different categories of codes that do not yet use 2021 guidelines.

Question 3:
Knowing what problems addressed and what is just being listed as an existing diagnosis that may or may not be treated or addressed... UGH!!
Answer 3:
I like to use MEAT (monitor, evaluate, assess, treat) to help providers understand that simply listing a condition is not sufficient to report a diagnosis.

Question 4:
So they can count the time spent dictating into the chart when its on the same date correct?
Answer 4:
As long as it is the same calendar day, yes.

Question 5:
I have recently run into things such as where do you put risk for ordering medical marijuana or a CPAP machine?
Answer 5:
I would consider both of these under prescription drug management.

Question 6:
When there are TWO Acute, uncomplicated illnesses ( acute otis media and conjunctivitis, and there is medication management for each condition, is this a 99214?
Answer 6:
You would need to look at all three columns - Column A acute uncomplicated (low), if there is anything to count for Column B and then prescription drug management for Column C. If there is nothing in column B, I would count it as 99213.

Question 7:
What is a good example of a time statement?
Answer 7:
I would avoid vague statements, such as greater than 50%. I would prefer to see "I spent approximately __ minutes" and ensure documentation supports what occurred during that time.

Question 8:
My question is there reference for time statements?
Answer 8:
None that I am aware of

Question 9:
if the 2021 GL allow for counseling and care coordination why cant use 50%?
Answer 9:
Because time is not strictly tied to counseling and/or coordination of care. It includes all services on that given date of service.

Question 10:
another one is when a provider reports an outpatient consult code based on time, which time requirements are they supposed to follow?
Answer 10:
They follow 95/97 guidelines. 2021 Guidelines only apply to 99202-99215.

Question 11:
When giving data credit for independent interpretation, does that only get counted if the radiologist interp is not ready when the physician interprets the image?
Answer 11:
Only one provider can get credit for the interpretation.

Question 12:
I feel like the provider is going for a basic metabolic panel, so I would give credit for that.
Answer 12:
If not clearly indicated, we cannot make an assumption.

Question 13:
If I see time mentioned in a note, should I go with that instead of a regular level of service?
Answer 13:
If time is greater than MDM, yes use time.

Question 14:
what are your thoughts on the ultrasound conducted at a later date unknown if it's done at that facility or not. would you give credit for the ordering of the u/s in today's visit even if it is conducted and billed global at the office on a later date? Would this be double dipping?
Answer 14:
You could only give credit at one visit or it would be double dipping.

Question 15:
Provider is billing for US done today, but is ordering one to be done at future visit. They get the point for ordering, correct?
Answer 15:
Yes, credit today or at a future date, but not both.

Question 16:
Where is credit given for the discussion provided by the daughter?
Answer 16:
Independent historian in column B

Question 17:
Do you have any suggestions when determining if labs are part of a panel or note- ? having a cheatsheet when auditing?
Answer 17:
I would refer to CPT lab section where panels are outlined.

Question 18:
How do you know that the independent historian was required?
Answer 18:
It is an individual who provides a history in addition to a history provided by the patient. It is supplemental to what the provider stated.

Question 19:
should you count independent historian when a spouse or family member volunteers information?
Answer 19:
Yes you can if it is giving additional information to the provider.

Question 20:
Do you have to meet 3 of the 4 "bullets" under Category 1 in order to count Category 1 as one of the 3 categories?
Answer 20:
No, you can have multiple things under one bullet.

Question 21:
What is your thought for independent historian for a pediatric patient that can not speak for themselves due to age (example 6 months or 2 years)?
Answer 21:
According to AMA, that counts as an independent historian.

Question 22:
In the pediatric setting and the parent is always with the youth, assuming no disability, at what age do stop using the independent historian?
Answer 22:
There is no age indicated.

Question 23:
Please clarify: If test is performed in the office, we get points for both ordering and reviewing the results on the same encounter?
Answer 23:
No, credit for either ordering or reviewing the same test, but not both.

Question 24:
If a patient is going to be scheduled for a cath by cardiologist, is it a level 5 if risks are documented?
Answer 24:
It could be; it will be dependent on the documentation for each patient.

Question 25:
Can you please explain if there is a max number of points allowed for review of prior notes, review of the results of each unique test, ordering of each unique test?
Answer 25:
You only need a total of 2 bullets in Category 1 and they do not have to be from different bullets.

Question 26:
Opinion on "decision" vs. "discussed" admitting. Patient decides not to go in for surgery, but provider wants a surgery.
Answer 26:
The provider should get credit for discussing and going over options.

Question 27:
When that listener said she leans to AMA to review whether its acute or chronic? Is this just their website? I have a hard time finding specific questions on the AMA website? Any recommendations?
Answer 27:
I would refer to the AMAs EM guidelines section for any guidance.

Question 28:
Looking for your opinion on when there is no risk documented and none of the examples from mod or high risk are documented. Do you default to minimal risk? One of the MACs (NMS) directs us to do this, but I audit for multiple clients across all MACs. What is your stance when performing an audit? Obviously provider education would be requirement for follow-up.
Answer 28:
I would follow each specific MAC since one seems to be more stringent than others.

Question 29:These are good notes but what if we have a patient that has Diabetes but we see nothing addressed in note other than the Dx in Assessment so can we count anything for number/complexity problems addressed?, if they didn't have anything in column 2 Data reviewed, and under Risk they are managing Rx Drugs but can you count that if we don't have any problems addressed. Would you consider this note not billable. I would like to send you some of our notes to use for this session? LOL
Answer 29:
The old adage still applies "if it's not documented, it's not done". So without supporting documentation, it could turn out not billable.
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Question 11:
When giving data credit for independent interpretation, does that only get counted if the radiologist interp is not ready when the physician interprets the image?
Answer 11:
Only one provider can get credit for the interpretation.

Would like to open a discussion about this answer.

The ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient
encounter are not included in determining the levels of E/M services when the professional interpretation
of those tests/studies is reported separately by the physician or other qualified health care professional
reporting the E/M service
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