Trailblazer is at it Again: Auditing Emergency Room Services

I have attached this notice in it’s entirety because it makes an important point for all Medicare providers – after all, if they are hitting the DOCTORS like thing, what hope do other providers have for doing the “appropriate documentation.”  Here are the highlights – the full text is after the jump:

Probe Review Findings

Overall error rate for the probe review was 45.14 percent. In short, $45.14 of every $100 paid for ED and other services was paid in error.

Medical Review Findings

We identified errors due to multiple medical record deficiencies. Providers coded their Evaluation and Management (E/M) ED service level higher than was reasonable and necessary to adequately care for the patient’s needs or treat the presenting problem based on information provided about the patient’s medical condition(s). Medicare refers to these errors as “medical necessity” errors. We identified errors due to providers coding their services for more key component work than they documented.

What does this mean?  It doesn’t mean 45% of all ER visits billed to Medicare were not payable. It means that 45% of the total payments for ER services were wrong – and judging from the comments below, it seems that it may really mean that the incorrectly billed ER visit occurred significantly more that 45% of the time, though that statement is never made. I’m going to translate what is said a little bit – if 100% of ER bills to medicare were incorrect, the average percentage overbilled was 82%, or if the medicare allowable for an average visit was $200 based on the audit of records, then Medicare actually paid $364.56 for the average visit because of upcoding.

This brings into play a lot of issues, not the least of which is a False Claims Act prosecution; potentially both Civil and Criminal liability attaches to those claims. I will be interested to see if this gets any play in the larger media . . .

Emergency Department (ED) Services Medical Review Results

Date: (3/13/2012)
Notice ID: 14854
Through statistical analysis, TrailBlazer identified potential improper utilization of ED services (CPT codes 99281–99285) reported to Medicare. A widespread probe review was recently conducted to verify if this perceived improper utilization was actual. This review is called “widespread” because documentation is evaluated from multiple providers. TrailBlazer used the Progressive Corrective Action (PCA) process to identify a random sample of 100 claims containing ED codes reported by 10 Texas and Oklahoma providers with Dates of Service (DOS) January 1, 2011, through June 30, 2011. The selection of providers for this review was based on a scoring methodology that considered the following variables for the review period:

  • Distribution of claims volume for CPT codes 99281–99285.
  • Distribution of paid dollars for CPT codes 99281–99285.
  • Percent of claims billed with modifier 25.
  • Percent of the number of claims billed with CPT codes 99284 and 99285 compared to the number of claims billed with CPT codes 99281–99285.

The primary focus of this review was to evaluate the documentation for ED services reported to Medicare to validate the services were medically reasonable and necessary, coded correctly and requirements of Medicare coverage policies were met. In addition, all other services reported on the sampled claim were reviewed and a medical necessity determination was made.

Probe Review Findings

Overall error rate for the probe review was 45.14 percent. In short, $45.14 of every $100 paid for ED and other services was paid in error.

Medical Review Findings

We identified errors due to multiple medical record deficiencies. Providers coded their Evaluation and Management (E/M) ED service level higher than was reasonable and necessary to adequately care for the patient’s needs or treat the presenting problem based on information provided about the patient’s medical condition(s). Medicare refers to these errors as “medical necessity” errors. We identified errors due to providers coding their services for more key component work than they documented.

TrailBlazer denied payment (in part or in whole) for the E/M ED service codes in the sample of claims reviewed for one or more of the following reasons:

  • Failure to submit physician’s notes documenting component work with the medical record.
  • Key component work was not performed by the physician or mid-level provider. Hospital personnel work must not be included in the work reported to Medicare as the physician’s E/M service.
  • Services were reported with the incorrect Provider Identification Number (PIN) for the rendering provider. Services were rendered by a different physician than was reported on the claim, and the rendering physician was not a member of the billing group. These services were not reported with either a Q6 or Q5 modifier to indicate a locum tenens or reciprocal billing arrangement.
  • Documentation failed to meet the key components for the level of E/M service reported:
    • History component documentation was insufficient for the level of service reported:
      • History of Present Illness (HPI) subcomponent was brief or contained information that is not considered HPI, such as repetition of the chief complaint, past history, examination findings, etc.
      • Review of Systems (ROS) subcomponent addressed a limited number of systems and/or failed to address the presenting problem. Template-generated records captured asymptomatic or clinically unrelated systems for coding purposes and did not clearly identify physician work:
      • Statements, such as “see HPI,” “see nurses’ notes” or “all systems otherwise negative,” did not support the physician actually reviewed the system during the encounter.
      • Systems were auto-populated to “negative” or “WNL” in Electronic Health Records (EHRs). There were patterns of gender mismatch between the patient and the systems documented as negative.
    • Examination component documentation did not meet the level of E/M service reported:
      • Exam findings did not address affected, symptomatic or related body area(s) or organ system(s) and included clinically unnecessary body area or organ systems to report the highest-level visit codes for problems of low to moderate severity.
      • Exam findings were limited in detail and/or in the number of areas or systems addressed. Statements such as “WNL” or “normal” contained limited information about the system examined.
    • Medical Decision-Making (MDM) component documentation did not support the level of E/M service reported:
      • Documentation of the MDM did not reflect the complexity of work expected to establish a diagnosis and/or select a management option to support the level of service reported.
      • Perfunctory statements for MDM scoring, such as reviewing of medical records or pulse oximetry readings, were not based on the patient’s condition. The records did not support these were used in the actual care of the patient.
      • High-complexity MDM was not supported when reporting the highest-level ED service (99285).
      • Documentation was submitted without physician’s orders, which may have caused the reviewer to underscore the MDM.
  • Documentation did not support the medical necessity for the level of E/M service reported. Patterns of overcoding ED services were found with template-generated records, including EHRs and T-sheets. Clinically irrelevant systems appeared to be auto-populated, defaulted to “negative” or contained a backslash negative on the form to score a complete subcomponent. It was unclear whether the physician actually obtained the information during the encounter.
  • Pronouncement of death only (i.e., no treatment or resuscitation in the ED) should be reported with the lowest level code of the E/M family (i.e., 99281) when performed outside the inpatient setting.
  • Requirements for split/shared services were not met. To qualify as a split/shared service, the physician must perform a medically meaningful portion of the encounter. Both the physician and the mid-level provider must document his portion of the rendered service in separate signed notes. Supervision of the mid-level provider is not reimbursable under Medicare Part B.

Denial of other services on the claim reviewed along with the ED E/M service occurred because of the following findings:

  • Requirements for reporting cardiography services were not met:
    • Local Coverage Determination (LCD) documentation requirements for EKGs were not met for the interpretation of the study.
    • Documentation did not support the medical necessity of repeated EKG studies at specified intervals.
    • Rhythm lead interpretations were inappropriately unbundled from 12-lead EKG interpretations since CPT code 93010 includes a report of rhythm and interpretation. In addition, the documentation did not support medical necessity and lacked both a clinical indication (i.e., a triggering event) and evidence the results were used in the management of the patient’s care.
  • Requirements for reporting the professional component or interpretations of X-ray studies were not met:
    • Complete written reports of the X-ray services were not submitted to support an interpretation was performed.
    • Independent viewing of an image is included in the ED service itself.

TrailBlazer identified additional concerns that by themselves did not result in a denial or code change:

  • Documentation requirements for scribed services were not met. The medical record must contain the complete first and last name and the qualifications (i.e., professional degree, medical title, etc.) of the scribe. Both the physician and the scribe must sign the record.
  • Stamped signatures were found in medical records. Medicare requires a legible identifier for services provided/ordered. The method used must be either a handwritten or an electronic signature (stamped signatures are not acceptable) to sign an order or other medical record documentation for medical review purposes. Electronic signatures must be identified as such.

Below is a case study TrailBlazer believes exemplifies many of the shortcomings for which an ED service was denied in part or in whole.

Case example: Reported CPT code 99285.
Medical review action: CPT code was recoded to 99283.

This case demonstrates a record for which the reported ED service was not correctly documented. Physician work required for ED services specifies that all three key components must meet or exceed the CPT stated levels. In addition to completing key component work, the documentation must also support the medical necessity for the intensity of the E/M service level reported. For code 99285, the presenting problems are usually of high severity and pose an immediate significant threat to life or limb as defined by CPT:

  • The risk of morbidity (between this encounter and the next one) without treatment is high to extreme.
  • There is a moderate to high risk of mortality without treatment.
    Or,
  • There is a high probability of severe, prolonged functional impairment.

Patient name: Doe, Jane
Date of Service: March 15, 2011

CC: Abdominal pain

History of Present Illness (HPI):
L sided abd pain X 2 hrs. Severity: mild-mod (pain scale field left blank).

Past Medical, Family and Social History (PFSH):
Past Medical History: Asthma, hypertension, thyroid disease
Family History: Not significant

Review of Systems (ROS):
No fever. No SOB. No chest pain. See HPI for GI. All systems otherwise negative.

TrailBlazer audit notes: The history component scored as expanded problem- focused. The HPI was briefly documented with the location of the pain and duration. The severity of the pain lacked a pain scale rating to support circling mild-moderate on the form. The ROS was extended and addressed a limited number of systems. The PFSH was incomplete.

When reporting CPT code 99285, the documentation for the history component must include an extended HPI, an ROS that is directly related to the problem(s) identified in the HPI plus a review of all additional body systems and a complete PFSH.

Examination:
General: NAD
Skin: WNL
Eye: WNL
ENT: Dry mucous membranes
Neck: WNL
Heart: WNL
Lungs: WNL
Abd: Soft. Tender to palpation (body diagram picture marked for the left lower quadrant). Bowel sounds +. Slash marks through template statements of obesity, scars, distended, bruit, guarding, rebound, organomegaly, mass and positive signs.
Rectal: WNL
Genital: WNL. Template included fields for scrotum, testis and penile assessment findings for this female patient.
Back/CVA: L tenderness, mild
Extremities: WNL
Neuro: WNL

TrailBlazer audit notes: This record contained very limited information regarding the physical examination of the patient. While technically the documentation addressed a sufficient number of systems to score as comprehensive, coding at a higher level based on clinically unnecessary (or anatomically incorrect) systems examined is not acceptable.

Clinical work-up/orders:
1) CBC: normal (circled)
2) Metabolic profile: normal (circled)
3) UA: normal except WBC 5-10/bacteria light/moderate protein
4) CXR:
5) CT Abd/Pelvis with contrast: Bladder thickening present. Otherwise unremarkable.
6) IV: NS 1L bolus
7) Morphine 3 mg IV/Zofran 4 mg IV
8) Levaquin 750 mg IV

Clinical impression/diagnosis:
1) Abdominal pain
2) Acute UTI

Disposition:
Home – follow up with PCP on Monday. Rx: Levaquin 500 mg po daily. Increase fluid intake.

Why This Documentation Does Not Support a 99285 CPT Code

Reporting the highest-level ED service code (99285) requires all three key components: comprehensive history, comprehensive examination and high-complexity MDM. In addition to meeting required component work, the nature of the presenting problem should usually be of high severity and pose an immediate significant threat to life or limb as defined by CPT.

As shown in the example, the patient is complaining of mild to moderate abdominal pain. The brief HPI and ROS failed to elicit more information that would have supported a higher acuity in her clinical condition. When reporting CPT code 99285, the documentation for the history component must include an extended HPI, an ROS that is directly related to the problem(s) identified in the HPI plus a review of all additional body systems and a complete PFSH. Insufficient documentation of the history component automatically lowered the CPT code to no more than 99283. This record contained very limited information regarding the physical examination of the patient. While technically the documentation addressed a sufficient number of systems to score as comprehensive, coding at a higher level based on clinically unnecessary (or anatomically incorrect) systems examined is not acceptable. Reporting CPT code 99285 requires MDM of high complexity. In this example, the MDM scored as moderate. The number of diagnoses or management options scored as multiple. The amount or complexity of data reviewed was limited. The risk of complication and/or morbidity and mortality was moderate. The nature of the presenting problem was of moderate risk. The risk conferred by diagnostic procedures ordered was low. The risk conferred by therapeutic options was moderate.

In addition to completing key component work documentation, medical necessity for reporting the intensity of the service level must be evident in the medical record. To demonstrate medical necessity for Medicare payments of ED services, the medical record must show that the intensity of the ED service met, but did not exceed, the patient’s clinical needs and that the care provided met the prevailing standards for acceptable medical practice. Physicians using template documentation, including EHRs, should be mindful of incorporating medical necessity into their coding determinations. For coding purposes, the inclusion of clinically unnecessary systems, or information that was auto-populated in an EHR and not truly obtained by the physician, is not appropriate to report to Medicare for payment. The physician work identified in the documentation was an expanded problem-focused history, a complete examination and moderate complexity MDM. The documented key components and presenting problem met the requirements for CPT code 99283.

Guidelines Available

Understanding and adhering to Medicare guidelines regarding coverage and documentation requirements associated with ED services will ensure accurate payment.

Coverage and documentation requirements as well as links to CMS’ Web site are available on the Evaluation and Management Services Web page.

In conclusion, Medicare expects providers who bill these services to:

  • Document key component work and/or contributory factors described by CPT per CMS requirements:
    • Insufficient documentation of any component or subcomponent may result in incorrect coding of the entire service.
    • Inclusion of asymptomatic and/or clinically unrelated systems is not appropriate for coding purposes.
  • Report and document the level of ED service appropriate to treat the presenting problem(s). Medical necessity is the overarching criterion for any service billed to Medicare. The ED code reported must reflect the patient’s needs, work performed and medical necessity. It is inappropriate to request Medicare payment when the patient’s effective management does not require the code’s work.
  • Document testing procedures appropriately:
    • Documentation must support the medical necessity of any service ordered and performed.
    • LCD requirements for services, such as EKGs, must be met.
    • Reporting the interpretation of an imaging study requires a complete written report maintained as part of the medical record. Independent viewing of an image is included in the ED visit itself and not separately reported for payment.
  • Ensure the requirements for split/shared services are met. The medical record must clearly indicate what portion of the encounter was personally performed by the physician.
  • Ensure physician billing groups report the correct PIN for the person rendering the ED service or the correct modifier to report an alternative billing arrangement.
  • Ensure the requirements for scribed services are met.

This content pertains to…

Programs: Part B
Topics: Medical Review, Specialty Services
Subtopics: Admitting Physicians, CERT, Documentation Tips, Evaluation and Management, Part B Medical Review
2 Responses to Trailblazer is at it Again: Auditing Emergency Room Services
  1. [...] not going to cross post the whole thing, but I direct you to this post on my Texas Nursing Law blog.  Read it carefully and see if it sounds familiar . . . the 98% error [...]

  2. Annette Davis
    August 6, 2012 | 12:44 pm

    I recieved an emergency room bill, after paying $100 copay and my insurance coverage paying their alloted portion. I had a jagged object puncture my eye, a PA saw me, gave me some eye drops that I didn’t really need. Quick and easy vistit. The hospitals are charging outrageous amounts for the services being rendered.
    Thanks,
    Annette, RN