QUESTION & ANSWER CPT CODES & INSURANCE COMPANIES By Jeffrey Kaufman MD, FACS California Medicare Carrier Advisory Committee, WSAUA Health Policy Chair, AACU Past-President PRINTABLE VERSION

QUESTION:
What are the specific guidelines regarding CPT codes for E & M services? How do insurance companies down code and the legality of this?

ANSWER:
The basic definitions of any CPT code are worked out among members of a multidisciplinary AMA committee which considers new technology and treatments, evaluates merit and assigns a code. Those established for E&M visits date back to the very beginning of the process many years ago and the elements involved which define any particular code can be found in the AMA's CPT publication which every physician's office should possess. Of course this is updated annually but the current CPT criteria for E&M codes were most recently agreed upon several years ago. I won't bore you with the controversies behind the most recent definitions but they had to do with whether specific bullet points were included in the physician note, how many elements needed to be present to meet billing criteria, how much time elements were used to define a specific level of service, whether the codes could be modified for specialists, how much complexity was required in decision making to meet various code levels, etc. Suffice it to say that all these discussions and others were finally agreed to in a compromise situation and the current definitions are set in writing.

The other part of the equation is more fluid and complicated. While the definitions are clearly stated, there is room for disagreement among reviewers about whether a particular encounter meets criteria. The definitions of simple, moderate and complex histories or decision making processes may lie in the eye of the beholder. Additionally, a visit may be very complex and deserve to be billed at a high level but if the documentation is lacking, there is no justification and a reviewer will down code. Similarly, some who have learned to "play the game" use templates or computers to add verbiage to a simple visit that puffs it up in order to meet criteria for a higher level code. Almost all contracts (including Medicare rules) require that care provided be necessary, appropriate and reasonable. Therefore, if a patient presents with a very simple problem requiring little time and thought but the doctor's note indicates all sorts of extraneous and unrelated information, the reviewer may claim the charges were not indicated, were unreasonable and he will down code the claim and pay less than billed. Obviously, this area is subject to interpretation (and therefore abuse) since the payers have a vested interest in viewing all treatment as more simple than the doctor's opinion (no big surprise that they undervalue the doctor's care since it gives them justification to deny payment). Finally, the legal basis for down coding lies in the contract between insurance company and doctor. Most contracts will specify the basis on which payment is made (i.e. AMA CPT codes using some type of conversion factor to determine dollars paid). The contract will also specify who has the authority to review claims and delineate appeal processes for disagreements. In my experience, the contracts are very much one sided with the payer retaining most of the power to review and down code and the appeals process fraught with challenges to the physician and very time consuming. Basically, a dishonest payer can deny payment or down code with little to lose since, even if he loses an appeal, he only has to pay what was billed in the first place. In other words, he has little to lose by trying to pull a fast one. The only option open to the physician in that case is to drop the contract.

I would urge Dr. Gershbein to document, document and document his work. Perform only that care which is reasonable and necessary. Bill for everything you do but document everything you do. Utilize a summary of those elements that determine which E&M code is appropriate for any given visit (print up an index card to carry in your pocket for quick reference). Make sure your notes reflect the complexity of the medical problem and your decision making. Be sure your history is complete and physical exam and other points support the code level you are billing at. If you are computerized, there are many software programs that prompt you to fill in certain information to fulfill the criteria for a given code and then suggest the most appropriate billing level. If you are not computerized, you can create paper templates that do the same based on your reading of the CPT code book. If you find a given payer routinely down codes or unfairly bundles payments, submit your documentation up front and then appeal everything so you are paid properly for your work. Finally, if the payer continues to abuse you, contact the CMA to report them to the state Dept. of Managed Health Care if the contract involves managed care. Last, take advantage of the many billing courses available from the AUA, CMA or AMA. The next one will be part of the practice management course at the annual AUA meeting next month in Anaheim. I don't think it's too late to register.

I hope this information helps.

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