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Physician is final arbiter on accuracy of EMR coding

Also, admissions, observation and discharges can span multiple days—the code depends on the circumstances

From the July-August ACP Observer, copyright © 2007 by the American College of Physicians.

By Brian Whitman

EMRs: Helpful, not perfect

Q: I just purchased an electronic medical record system. It has a coding advisor feature that automatically selects the evaluation and management level for me. Should I always bill for this recommended code?

A: The increasing prominence of electronic medical record (EMR) systems has given many physicians new and exciting ways in which to practice and has changed medical documentation for the better in many ways.

Many EMR systems include some kind of evaluation and management (E/M) advisor that will recommend to the physician what level of code to bill. Each of the myriad of EMR products on the market function slightly differently. While this might seem to have permanently solved the age-old problem of selecting a code level, it is not a perfect solution. The most significant problem with many of these advisors is that they cannot adequately process what is the most important element for Medicare and other insurance company coding—medical necessity.

Everything that is done as part of a sick visit must be medically necessary. EMRs in some cases lead to more documentation than may be necessary or appropriate for the patient and may drive the coding recommendation up too high. If your EMR system is recommending that you code a 99215 on a patient with an upper respiratory infection and no other illnesses, it is a sign of problems. The physician is ultimately responsible for code selection.

Q: Should I use the feature at all?

A: Yes. E/M advising features are of great benefit to ensure that you are documenting the level of service that is appropriate. It is almost like having the ability to audit every record for coding accuracy. However, the physician should still be making the final decision on what code to bill.

Q: I am going to be participating in Medicare's Physician Quality Reporting Initiative (PQRI) to get the 1.5% bonus. How is the bonus calculated?

A: Physicians who participate in the PQRI and report three measures on 80% of eligible patients will be eligible for a bonus of 1.5% of Medicare-allowed charges for the six-month period of the initial program. Complete details were published in the May and June issues of ACP Observer. The 1.5% includes items paid under the traditional Medicare physician fee schedule. This would exclude payments for pharmaceuticals, labs and durable medical equipment. Patients who are covered by Medicare Advantage programs are excluded from the calculation as well.

Q: I admitted a patient to observation at 11 p.m. on Monday and discharged him 36 hours later, at 11 a.m. on Wednesday. What codes should I use for these services?

A: For the service on Monday, you would use one of the initial observation services codes (99218-99220). For the discharge service on Wednesday, you would use the observation care discharge code (99217). If you saw the patient on Tuesday, there are some issues. There is no CPT code for a subsequent observation service, only an admission and a discharge. The only code that can be used in this service would be the unlisted E/M code (99499).

Q: I admitted a patient to observation on Thursday, and on Friday the patient's condition necessitated that he be admitted to the hospital. What codes should I use in this scenario?

A: In this situation, you would use the initial observation care codes (99218-99220) for the work on Thursday, and the initial hospital care codes (99221-99223) for the work on Friday. This may sound unusual because observation and the hospital may not be separate physical areas, but this is how physicians should report these services. You would not report an observation care discharge in this case.

Q: Can I use the time spent on telephone calls between visits to increase the level of my E/M coding?

A: Medicare considers all work on telephone calls to be bundled into the previous or the next E/M service, so you may consider the work done over the phone when selecting the level of history or medical decision-making that drives the level of code. Although physicians may code based on time if 50% of their time is spent on counseling or coordination of care, that time must be face-to-face with the patient in the outpatient setting. So, even if you spent an hour on the phone with a patient prior to a visit coordinating care, you would not be able to bill a high level E/M code at the next visit without the clinical documentation to support it.

Q: I have my National Provider Identifier (NPI). Do I have to start using it now?

A: HHS required the use of the NPI for entities covered by the Health Insurance Portability and Accountability Act starting on May 23. However, approximately a month before this deadline, it released a contingency plan that may delay complete implementation for some physicians. This contingency plan recognizes that some small payers and clearinghouses were not prepared for NPI implementation by the deadline and allows the continued usage of legacy identification numbers until NPI implementation can occur, but for no more than one year.

For physicians, very little has changed. The contingency plan requires a "good faith effort" to use the NPI after May 23. This means that physicians should have already received an NPI and should be attempting to use it in as many places as possible. You should hear from payers and clearinghouses if they are participating in a contingency plan. Medicare has announced plans to participate in a contingency plan for an uncertain period of time as of this writing. You may wish to use both your existing identification numbers and NPI until the end of the contingency plan period is announced.

Brian Whitman is Senior Analyst for Regulatory and Insurer Affairs in ACP's Washington office.

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