 |
QUESTION
& ANSWER |
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:
You
are asking a very basic question that refers to how CPT coding is established
and used. 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 contract 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.
Disclaimer: "Question & Answer" is published by the California Urological Association as a service to CUA members. Your comments are welcomed. The California Urological Association, Inc. (CUA) believes the information in this newsletter is as authoritative and accurate as is reasonably possible and that the sources of information used in preparation are reliable, but no assurance or warranty of completeness or accuracy is intended or given, and all warranties of any kind are disclaimed. This newsletter is not intended as legal advice nor is the CUA engaged in rendering legal or other professional services.