Review Billed Service Levels with These Tips

You cannot get inside your ENT's head to know whether his MDM requires the E/M service code that he reported – however Medicare auditors are training eyes on this area while examining E/M claims, so you need to stay alert.

Auditors are not scrutinizing the exam or history as much as they weigh toward medical decision-making. However you can be your otolaryngologist's front line of defense and ensure his notes withstand scrutiny if you follow these tips:

Tip 1: Take this strategy's help to identify a mismatch

When your staff gets together for an education meet next time, remind your ENTs that medical necessity should be the overarching factor they use to choose the E/M service level. Just because a physician does a comprehensive history and examination does not mean he should report 99215. Medical necessity should drive the components that he carries out. This is of particular importance with the implementation of EHR systems, which automatically code encounters without regard to medical necessity. It's very easy to document high levels of history and exams, particularly for established patients, which'll result in level four services when the medical necessity may dictate only level two or three services.

You can help ensure your doctors are choosing the proper codes by occasionally pulling a sample of their charts. Take a look at the patient's chief complaint and the encounter's outcome or its final diagnosis. If the main ICD-9 code doesn't support a billed upper level of service, you should really read the chart notes.

Tip 2: Look for potential MBM-boosting factors

However, complimenting factors could make 99214 and 461.x a match. The patient may have comorbidities or other chronic conditions. And medications that the patient is already taking or or adverse reactions the patient had to previous medications could up the level of MDM. Comorbidities, frequency of episodes of sinusitis, the plan of care, and the like may complicate the medical decision making also.

To add to it, evaluation of symptoms possibly related to sinusitis like fatigue, headache, fever and cough can boost the MDM. When you work up a sinusitis, if a patient has these other symptoms also, then you ensure he does not have any problems that could be more serious.

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Tip 3: Uncover extra complexity in these places

Medication can lead to a higher-level MDM another way. Take a look at the tests and medications the otolaryngologist ordered for clues to the extra complexity the doctor may not be explaining. Here are a couple of tips to make identifying increased complexity easier:

See the history of present illness and review of systems to determine what the ENT is trying to rule out.

Encourage your ENTs to state what diagnoses they hope to rule out or confirm.

Be wary: Do not put such ‘rule out' diagnoses on your claims. Doing so would not be right coding.

Tip 4: Give due credit for clear management options

Intimate your doctors that they should indicate clearly when they are taking an immediate step that they do not believe will solve the patient's problem. For instance, they may try antibiotics before a more aggressive treatment, however that the patient may need a more aggressive approach can boost the level of MDM. Documenting the extra step shows that the physician considered more management options (one element of MDM).

Tip 5: Look at patient's complexity

Sometimes a low level of MDM can support a 99214. You cannot just look at the MDM; you also have to look at the complexity of the patient.