Upcoding evaluation and management (E&M) charges as a way to boost revenue is risky business, especially under the watchful eye of the Office of Inspector General over the past several years. This practice of trying to eek out more money one patient at a time has never been a good idea and certainly isn’t a best practice for emergency department billing.
In a recent Physicians Practice blog post, G. John Verhovshek, MA, CPC, managing editor for AAPC’s publications, says, “upcoding — whether intentional, or not — is a serious compliance risk that may lead to payer audits, reimbursement take backs, and charges of abusive or fraudulent billing.”
There is a way to increase revenue properly through E&M coding, though. Practices can improve their bottom line by minimizing downcoding through monitoring, training, and improved documentation.
In a recent blog post, we talked about the importance of not arbitrarily downcoding E&M levels for the sake of adhering to Medicare’s bell curve E&M averages. Accurate coding should always be the goal and serves as the best defense against an audit.
However, coders may sense that the physician’s clinical work along with the medical decision-making would support a higher level of service than was coded if the history or exam were better documented. This would be an appropriate situation for downcoding; coders should never apply a higher level of E&M than the documentation supports. But it would also an excellent opportunity for clinical documentation improvement.
How can downcoded charts help with clinical documentation improvement? Follow these steps.
- Document each instance when a coder chose a lower E&M level because some part of the documentation was missing or incomplete for a higher level. Record which areas of the history or examination were deficient, the level of E&M chosen, and the level of E&M the coder believes could have been chosen with proper documentation.
- If possible, have your staff or medical billing company enter this information into optional fields of your practice management system or some alternative database so that you can run reports in aggregate at a later time. Be certain to capture the provider, the service location, the service date, the payer, and possibly even the coder.
- On a regular basis (weekly, monthly, or quarterly), run a report to see how many charts were downcoded and for what reasons. Use the various data fields you captured to see which providers are regularly under-documenting and in which areas. Also, calculate potential lost income using the payer information. Reports by coder can be used to audit for incorrect downcoding or to confirm documentation deficiencies.
- Using your reports to guide you, work with providers on proper documentation guidelines in the areas where they are the weakest. Your “potential lost revenue” data can offer additional incentive for providers to improve. Also, based on your findings, continue to train coders to identify proper E&M documentation in the medical record.
For more information on E&M documentation guidelines, review the Medicare Learning Network’s Evaluation and Management Services Guide. For more suggestions about how to use downcoded charts to improve clinical documentation, contact CIPROMS today.
— All rights reserved. For use or reprint in your blog, website, or publication, please contact us at firstname.lastname@example.org.