2. Physician Documentation & Billing
Impact on Hospital Revenue

3. Trends in Healthcare
Hospitals have been acquiring physician practices.
Hospitals have been establishing joint ventures with physicians.
Hospitals have been forming affiliations with physicians

4. Hospital – Physician Affiliations

5. The Effect on the Hospital Revenue Cycle
Physician Billings from affiliated practices now impact hospital revenue.
Physician billing errors can now create compliance issues for the parent hospital.
Rac Auditors are now focusing on E/m billings

6. WHY YOU SHOULD BE CONCERNED Reason #1
Medicare Carrier Finds 50-90% Error Rate for E/M Codes
Written by Leigh Page | February 22, 2011
Tags: claims | error rates | Medicare | Part B
A random survey of claims by the Medicare Part B carrier in five states has uncovered average error rates of percent for E/M codes, according to a report by Part B News. TrailBlazer, the carrier in Colorado, New Mexico, Oklahoma, Texas and Virginia, said the most common cause was "documentation errors." TrailBlazer also cited some obvious errors, such as the reason for encounter was to receive lab results, which doesn't count as an E/M and also some not so obvious ones, such as that the frequency of E/Ms billed per beneficiary exceeded documented needs for management of stable, chronic conditions. "I could see maybe 20 percent (error rate) or a little higher. But 90 percent I just haven't seen before," said Seth Canterbury, an education specialist for the University of Florida Jacksonville Physicians.

7. OUR EXPERIENCE IN AUDITING THE DOCUMENTATION AND BILLING RECORDS FOR OVER 200 PHYSICIANS
WE HAVE SEEN AVERAGE ERROR RATES BETWEEN 35% AND 70% WITH SOME MUCH HIGHER.
WE FOUND BOTH UNDER CHARGED AND OVER CHARGED ERRORS.
MOST ERRORS WERE CAUSED BY POOR OR INADEQUATE DOCUMENTATION BY THE PHYSICIANS.

8. DOCUMENTATION??

9. WHY YOU SHOULD BE CONCERNED Reason #2
RACs Expand into Physician Practices, Adding Pressure to Existing Audit Burden
Written by Lori Brocato | Thursday, December 20, 2012
HDI and Connolly Make First Strides
Two RACs recently mentioned upcoming reviews of physician practices and medical groups. One is taking a generic approach, while the other will hone in on specific issues sorted by provider type. Regardless of the methodology used, however, we predict that other RACs will follow suit.

10. WHAT YOU CAN DO:
Install sophisticated electronic medical documentation and billing systems in all affiliated physicians’ offices. (Can be expensive and will be effective only if physicians properly use it)
Hire medical scribes to assist each affiliated physician. (Very expensive and depends on the training of the scribes)
Teach the physicians to properly document and correctly bill for services. (A reasonably priced alternative that will be effective with most physicians)

11. TYPICAL DOCUMENTATION
FROM ELECTRONIC MEDICAL
RECORD SYSTEM

12. E & M BILLING
THE OVERWHELMING MAJORITY OF PHYSICIAN BILLING IS FOR EVALUATION AND MANAGEMENT (E & M) SERVICES.
THERE ARE CLEARLY DEFINED PROTOCOLS FOR THE PROPER DOCUMENTATION AND CORRECT BILLING OF E & M SERVICES.
THERE ARE PUBLISHED AUDIT GUIDELINES FOR ESTABLISHING THE ACCURACY OF E & M BILLING.
YET MANY PHYSICIANS ARE UNAWARE OF THESE PROTOCOLS AND GUIDELINES.

13. EVALUATION & MANAGEMENT PROCESS
E&M Encounter
Take Patient History
Document History
Perform Examination
Document Exam
Make Clinical Decision
Document Decision Making
Code & Bill

14. E & M Documentation
Clear and concise medical documentation is required to provide patients with quality care, and is critical to receive accurate and timely payment. It is also necessary to ensure that a service is consistent with the patient’s insurance coverage and to validate the following:
The medical necessity and appropriateness of the diagnostic or therapeutic services provided
The site of service
That services furnished have been accurately reported

15. E & M General Principles
The documentation of each patient encounter should be legible and include:
Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results
Assessment, clinical impression, or diagnosis
Medical plan of care
Date and legible identity of the observer

16. Defining the levels of E & M services
Key components:
Patient History
Examination
Medical decision making
Contributory components
Nature of presenting problem
Time
Counseling
Coordination of care

17. PATIENT HISTORY
History includes some or all of the following elements:
Chief Complaint (CC) is required for any level of service and validates the medical necessity of the service.
It should be a concise statement describing the symptoms, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter. It is usually stated in the patient’s own words.
History of present Illness (HPI) or Status of Chronic Conditions is required for any level of service and Must be documented by the MD.
Review of Systems (ROS)*
Past Family and/or Social History (PFSH)* *Must include Physician Notation, MD signature and date
The extent of the history documented should depend on the nature of the problem

18. HISTORY DOCUMENTATION SUMMARY
Type of History
History of Present Illness
(HPI)
Review of Systems
(ROS)
Past Family and/or Social History
(PFSH)
Problem Focused (PF)
Brief
1 – 3 elements
N/A
Expanded Problem Focused
(EPF)
Problem Pertinent
1 system
Detailed
(D)
Extended
4+ elements
2 – 9 systems
Pertinent
1 area
Comprehensive
(C)
Complete
9+ systems
3 areas

19. PHYSICAL EXAMINATION
The extent of examinations performed and documented is dependent upon clinical judgment and the nature of the presenting problem. They range from limited examinations of single body areas to general multi-system or complete single-organ system examinations.

20. PHYSICAL EXAMINATION DOCUMENTATION
The body areas:
Head, including face
Back, including spine
Chest including breasts and axillae
Abdomen
Neck
Genitalia, groin, buttocks
Each extremity
The organ systems:
Constitutional
Eyes
Ears, nose, mouth, throat
Cardiovascular
Respiratory GI GU
Musculoskeletal
Neurological
Skin
Psychiatric
Hem/lymph/imm

21. 4 LEVELS OF EXAMINATION - CPT
Problem Focused (PF): a limited examination of the affected body area or organ system.
Expanded Problem Focused (EPF): a limited examination of the affected body area or organ system and other symptomatic or related organ systems.
Detailed (D): an extended examination of the affected body area and other symptomatic or related organ systems.
Comprehensive (C): a general multi-system examination or complete examination of a single organ system.

22. MEDICAL DECISION MAKING
Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option, determined by considering the following factors:
Number of possible diagnoses and/or number of management options considered;
Amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed;
Risk of significant complications, morbidity and/or mortality as well as comorbidities associated with the patient’s presenting problems, diagnostic procedures, and/or possible management options.
To qualify for a given type of medical decision making, two of the three above elements must be met or exceeded.

23. MEDICAL DECISION MAKING SCORING FOR COMPLEXITY
Number of diagnoses and treatment options 1
Minimal 2
Limited 3
Moderate 4
Extensive B
Amount and Complexity of Data
Minimal/Low
Multiple C
Highest Risk
Low
High
Type of Decision Making
Straight
forward
Complexity
If no column contains more than one entry, choose “Low Complexity”

24. BILLING E&M SERVICES
When billing for patient visits, select the codes that best represent the services furnished during the visit.
It is the provider’s responsibility to ensure that the submitted claim accurately reflects the service provided.
Do not use the volume of documentation to determine which specific level of service to bill.
In order to receive payment from Medicare, the service must also be considered reasonable and necessary.

25. New Patient Office Visit (All 3 key components met or exceeded)
Level
History
Exam
Medical Decision
99201
Problem Focused
Chief Complaint
Brief history of present illness (1 – 3 HPI elements)
Exam of affected body area/organ system (1995 guidelines – At least 1 system with 1 element or 1 comment)
Straight-forward
99202
Expanded Problem Focused
brief Hx of present illness (1 – 3 HPI)
Problem pertinent system review (1 ROS)
Exam of affected body area/organ system
Exam of other symptomatic or related body area/organ system (At least 2 systems with at least 1 element or 1 comment)
99203
Detailed
Chief complaint
Extended HPI (4 or more elements)
Extended system review (2 – 9 ROS)
One pertinent PFSH
Extended exam of affected body area/organ system
Extended exam of other symptomatic or related body area/organ system
(At least 4 systems with at least 4 elements or 4 comments - 4 X 4 rule)
Low
99204
Complete
Extended HPI (4+ elem)
Complete ROS (10+)
Complete PFSH (all 3)
Complete single system specialty exam or
Complete multi-system exam (1995 guidelines – at least 9 systems with 1 element or 1 comment)
Moderate complexity
99205
Complex or Severe
Complete single system specialty exam or
Complete multi-system exam (1995 guidelines – same as Level 4 above)
High complexity

26. Established Patient Office Visit (2 key components met or exceeded)
Level
History
Exam
Medical Decision
99211
Problem Focused
Does not require presence of a physician
Presenting problems are minimal
99212
Expanded Problem Focused
Chief Complaint
Brief history of present illness (1 – 3 elements)
Exam of affected body area/organ system (1995 guidelines – At least 1 system with 1 element or 1 comment)
Straight-forward
99213
Detailed
Chief complaint
Brief history of present illness (1 - 3 elements)
Problem pertinent system review (1 ROS)
Exam of affected body area/organ system
Exam of other symptomatic or related body area/organ system (At least 2 systems with at least 1 element or 1 comment)
Low
99214
Complete
Extended HPI (4+ elements)
Extended ROS (2 – 9 ROS)
Pertinent PFSH (1 PFSH)
Detailed exam (At least 4 systems with at least 4 elements or 4 comments – 4X4 rule)
Moderate complexity
99215
Complex or Severe
Complete ROS (10+ ROS)
Complete PFSH (2 of 3 PFSH for complete)
Complete single system specialty exam or
Complete multi-system exam (1995 guidelines – at least 8 systems with 1 element or 1 comment)
High complexity

27. Evaluating E & M Documentation
How others will judge
The quality of your
The patient history
The Exam
The complexity of your decision making
Copy of the Marshfield Clinic
Audit Worksheet commonly used
To evaluate E & M documentation

28. THE TRAINING APPROACH
Electronic medical documentation and the use of scribes can be effective methods to reduce the problem of physician billing errors, but they are expensive to install and maintain.
Physician documentation/billing training is a less-expensive alternative that can produce significant documentation improvements, increased revenue and reduced risk of compliance errors and RAC vulnerability.

29. PHYSICIAN TRAINING
Group training for Physicians and practice support staff.
Sample audits of the billings and documentation for each Physician.
One-on-one training with each physician.
Remedial follow-up audits and training at regular intervals.

30. I. GROUP TRAINING
All physicians, billers and support staff attend a 2 – 4 hour training session covering the following:
A detailed explanation of how to correctly document an E & M encounter with relevant examples.
Instruction on standard billing protocol and proper selection of the appropriate E & M code.
Introduction to the standard audit worksheet used by outside auditors to evaluate the quality of the physician documentation and the accuracy of the billing.

31. II. AUDIT OF SAMPLE BILLINGS
A sample of 20 to 30 E & M bills are randomly selected for each physician.
Each bill is carefully audited, using standard audit protocols, to confirm the accuracy of the bill and the completeness of the documentation
Every error and inadequacy is clearly explained with indication of the correct or more appropriate choice.
A report is prepared outlining the accuracy and completeness of the billings for each physician.

32. III. ONE-ON-ONE PHYSICIAN TRAINING
A qualified trainer meets with each physician for an individual one-hour post-audit training session.
The audit report is presented and explained so the physician clearly understands every error or inadequacy and the correct way to document and bill.

33. PROVIDER E/M AUDIT RESULTS SUMMARY
SAMPLE OF ACTUAL AUDIT RESULTS
M. LECO & ASSOCIATES
ABC MEDICAL PRACTICE
PROVIDER E/M AUDIT RESULTS SUMMARY
Provider
Audit Date
Post Audit
Final Report
Under
Over
Correct
Total
Error
Revenue
Interview
Coded
Audited
Rate
Impact
DR. A
10/3/2012
10/8/2012
10/10/2012 15 2 5 22
77.3%
$787.00
DR. B
10/4/2012
10/18/2012
10/29/2012 7 3 10 20
50.0%
210.00
DR. C
10/31/2012
11/15/2012
11/19/2012 17
15.0%
258.00
DR. D
25.0%
410.00
DR. E
10/23/2012 9 6
60.0%
DR. F
11/7/2012
12/13/2012
12/14/2012 1 19
5.0%
20.00
DR. G
10/22/2012 4 14
30.0%
50.00
DR. H 13
35.0%
140.00
DR. I
12/19/2012
12/20/2012 8 12
40.0%
220.00
DR. J
145.00
DR. K
36.8%
10.00
DR. L
12/21/2012
90.00
DR. M
12/18/2012
1/5/2013
1/7/2013
200.00
DR. N
11/29/2012
1/8/2013
1/9/2013
DR. O 11
65.0%
316.00
DR. P 16
20.0%
DR. Q
1/10/2013
1/15/2013
70.0%
420.00
DR. R
11/30/2012
1/11/2013
370.00
DR. S
12/4/2012
1/17/2013
1/18/2013
120.00
TOTALS
104 31
241
376
35.9%
2,855.00
Typical report presented along with narrative to management staff

34. THE POTENTIAL BENEFITS
Most physicians under code and under bill because of compliance concerns.
Most physicians could code higher if they adequately documented.
The average physician is under coding and under billing about $5 to $10 per patient encounter.
Physicians can typically handle 20 – 40 encounters per day (approximately 500 per month or 6000 per year)
That could mean $30,000 to $60,000 of under billing per year per physician.
100 physicians = $3 million to $6 million per year!

35. RESULTS OF TRAINING
Most physicians significantly improve the quality of their documentation and the accuracy of their billing.
Most physicians greatly reduce the risk of billing non-compliance because their improved documentation now supports their billing choice.
Many physicians increase their average amounts billed because the improved documentation adequately supports higher billing levels.

37. ACCURATE E/M BILLING