Why Do I Have to Learn E/M Documentation Guidelines?

:dropcap_open:T:dropcap_close:his particular Blue Cross Blue Shield carrier has been known to cause heartburn for doctors of chiropractic for quite some time. When I received the phone call from a doctor in that state who had been referred by a friend of a friend, I wasn’t surprised by what he told me. This Blue Cross Blue Shield carrier audited 20 of his files. Not surprisingly, in all 20 cases they determined that, based on his documentation, his initial visit Evaluation and Management code needed to be down coded one level. They were asking for quite a bit of money back. The deadline for appeal was a few short days away. He had not taken the letter as seriously as he should have and was now up against the wall. After looking at a few samples of the documentation for these patients, I felt that the doctor had some chance to defend himself against the reimbursement request. The bigger concern for both of us was—if the doctor did not appeal the decision—this carrier is known for extrapolating. Extrapolation means that they take the percentage of errors found in the 20 files and apply it to the total number of patients paid over a period of years. Since they found errors in 100% of the cases, he ran the risk of this carrier asking for a refund on every Evaluation and Management code they ever paid to this doctor.  We had to do something.  Surely, his documentation was not that bad. 
:dropcap_open:Unfortunately, the electronic documentation software used in the practice did not serve the doctor very well.:quoteleft_close:
We agreed to review all 20 files that the carrier reviewed. Unfortunately, the electronic documentation software used in the practice did not serve the doctor very well. His intake form that the patient filled out was insufficient to meet even the most basic obligations. This was exacerbated by the fact that the doctor was completely unaware of the requirements of selecting the correct evaluation and management code. There was very little in the way of good news about this audit. 
Because this doctor was also quite “old school”, he did your run-of-the-mill, basic chiropractic examination, which had a number of holes in it when compared to documentation guidelines. In the musculoskeletal specialty examination requirements, four of the most basic requirements include: 
  • Inspection, percussion and/or palpation with notation of any misalignment, inspection, percussion and/or palpation with notation of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions
  • Assessment of range of motion with notation of any pain (e.g., straight leg raising), crepitation or contracture
  • Assessment of stability with notation of any dislocation (luxation), subluxation or laxity 
  • Assessment of muscle strength and tone (e.g., flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements
Even though there are many other systems included with this examination, such as basic findings in the areas of skin, neurological, cardiovascular, constitutional, and lymphatic, the most basic of musculoskeletal findings can be included in even your most run-of-the-mill chiropractic exam. The problem in his case was that the documentation software didn’t provide for him the most fundamental of templates to include these important requirements. He documented with words like “fixations”, “taut and tender fibers”, and “postural analysis”. When I questioned this doctor about the notes, it was clear he DID the work. It was not documented properly, or he did not use words that auditors from BC/BS recognized, so he got NO credit for the work he did. 
To see the actual checklist Medicare auditors fill in when going through a practice, go to http://tinyurl.com/7xk6o9a, and click on the audit tool for EM services used by Medicare.
:quoteright_open:A few easy tweaks of his documentation software, standard operating procedures, and terminology set this doctor on the right track.:quoteright_close:
A few easy tweaks of his documentation software, standard operating procedures, and terminology set this doctor on the right track. Let’s hope you don’t find yourself with an audit letter from BCBS; but if you do, you’ll be much more confident knowing a few important things:
  • Know the EM documentation guidelines. Make sure that your electronic notes software or your paperwork aligns with these guidelines point by point to give you peace of mind. 
  • Periodically pull the last five new patient files and do a self-audit to confirm if the EM code you selected will pass muster in an audit. 
  • If the carriers you deal with publish chiropractic guidelines, make sure you’ve read them, along with any medical review policy, and include them in your compliance policy. This way, you’re proactively following the rules, and can feel confident that your efforts are in line with expectations.
Believe it or not, this audit was a good thing for this doctor. Our appeal was accepted and he didn’t have to pay back any monies, since he could demonstrate his willingness to improve his documentation and recordkeeping. He’s now well on the way to sleeping better at night, knowing that he is proactively compliant. Better documentation, better compliance and a good night’s sleep! 
Kathy Mills Chang is a Certified Medical Compliance Specialist (MCS-P) and since 1983 has been providing chiropractors with hands-on training, advice and tools to improve the financial performance of their practices. In 2007, KMC University was created to streamline, develop and offer a broader range of chiropractic solutions in the areas of coding, insurance, patient financial procedures, Medicare and compliance. Kathy can be reached at 888-659-8777 or [email protected].

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