Tell me something I don’t know: confusion in reporting Psychiatry services

CMS recently released a MedLearn Matters article about coding for psychotherapy and evaluation and management (E/M) services on the same day. This article reported that the comprehensive error rate testing contractor (CERT) had found a high error rate when E/M services and psychotherapy are reported together. Tell me something I don’t know.

 In 2012 physicians, nurse practitioners, physician assistants and clinical nurse specialists working in psychiatry reported medication management with code 90862. That code was deleted in 2013. Medical practitioners working in psychiatry who performed medication management were instructed to report the service with E/M codes. If psychotherapy was provided there were new add-on codes for psychotherapy reported with medical evaluation services. The CPT book instructed clinicians not to use the time spent for the E/M service to determine the level of service for psychotherapy. While psychotherapy codes are time-based codes, E/M services may be reported either based on time (unless provided on the same day as psychotherapy) or based on the three key components of history, exam, and medical decision-making. It was all very confusing to medical clinicians working at psychiatry.

 The MedLearn Matters article tries to clarify this. “The main error that CERT has identified with the revised psychiatry and psychotherapy codes is not clearly documenting the amount of time spent only on psychotherapy services. The correct E&M code selection must be based on the elements of the history and exam and medical decision making required by the complexity/intensity of the patient’s condition. The psychotherapy code is chosen on the basis of the time spent providing psychotherapy.” That is, select the E/M service based on the history, exam, and medical decision-making documented and add a note “After the E/M service, I spent XX minutes in psychotherapy with the patient.” Describe the psychotherapy.   The article further stated that it needed to be clear that the time spent in psychotherapy did not include the time of the E/M service.“Because time is indicated in the code descriptor for the psychotherapy CPT codes, it is important for providers to clearly document in the patient’s medical record the time spent providing the psychotherapy service rather than entering one time period including the E&M service.”

Clinicians tell me that this is a false delineation, and that there is no easy way to mark when the E/M service stopped and the psychotherapy started. But, these are the coding rules that we have in 2014. What is a medical clinician working in psychiatry to do?

Providing medication management or medical evaluation only: if this is the only service provided a clinician may use time or the three key components to select the code. If psychotherapy is not done on the same day, and the visit is dominated by counseling, a clinician may use time to select the code. The CPT describes counseling as dominating the visit when over 50% of the time of the total visit time is composed of discussion of the diagnosis, prognosis, risks and benefits, importance of compliance, and patient or family education. In that case, document the total time and that more than 50% of the time was spent in counseling. “I spent 20 minutes with the patient over half of the discussing the side effects of medication and the other issues above.”

Only psychotherapy is provided: if only psychotherapy is provided and there is no medical E/M, use the psychotherapy standalone codes based on time. These codes are hurt 90832, 90834, and 90837. Document time in the record and describe the psychotherapy that was performed.

When both an E/M services (such as medication management) and psychotherapy are provided on the same calendar date: in this case report both an E/M service and an add on psychotherapy code. Select the level of service based on the history, exam and medical decision making. Then, document the time spent in psychotherapy not including in it the time it took to provide the E/M service.. I suggest documenting the patient’s subjective report, the mental status exam and the assessment in the plan. Then note “after the E/M service was performed I also provided XX minutes of psychotherapy.” Describe the nature of the psychotherapy. Do not document the total time of the visit because that includes both the E/M service and the psychotherapy.

Although most clinicians don’t want to read the CPT book, the section about psychiatry codes includes important editorial comments and instructions for use of the codes. Because there was such a major change in 2013, and Medicare has identified a high error rate for these services it is important for someone in the office to review this section of the book. It will only take 15 or 20 minutes to read through the editorial comments in the psychiatry section and the reward will be an increased understanding and higher coding accuracy.


SGR update bill delays ICD-10 implementation

On Monday, March 31, 2014 the Senate passed House bill H.R. 4302.  This bill gives physicians yet another temporary reprieve from a fee decrease and also delayed ICD-10 implementation.  The 120 page bill addresses it in one sentence “The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD-10 code sets as the standard for code sets….”  HR 4302 has other policies, that I’ll write about in the coming days.

Everything I know about ICD-9, I learned from ICD 10

I may have already mentioned to you, in the strictest confidence, that I have been a lazy diagnosis coder in the past. The reason for that was simple: most physician services were paid based on the CPT code not the diagnosis code. Payers used the diagnosis code to deny the claim for medical necessity reasons. Years ago I was working with a general surgeon who would list all of the patient’s underlying medical problems on the charge slip. I told him “Doctor, you know we don’t get paid anymore if we put one diagnosis or four diagnoses on the claim form.”  But he said to me, “Betsy I want the insurance company to know just how sick this patient is.”  Of course, the bubble over my head was “the insurance company doesn’t care.” But, that was then and this is now. Diagnosis codes aren’t just for claims payment anymore but will have an effect on reconciliation for risk-based contracts including the Medicare shared savings program.

This brings me to ICD 10. I think only the AMA was less happy than I when CMS didn’t postpone ICD-10 another time.  But, when they didn’t, I was forced to learn ICD-10 coding. And that is when I really learned ICD-9. We consultants will tell you the many ways that ICD-10 is more complex and difficult than ICD-9. I certainly won’t deny that going from 14,000 diagnosis codes to 70,000 diagnosis codes will be a challenge. However, although ICD-10 does have unique features, there are many things that are similar between the two coding sets.

Yes, it is an entirely new system, not one built on ICD-9 and yes every code is changing.  And it’s true, a complete ICD-10 code can be 3, 4, 5, 6, or even 7 characters long.  But, many things remain the same. The ICD-10 instructions for selecting a code for physician/outpatient services are similar to those instructions in ICD-9.  Select a diagnosis code that is chiefly responsible for the service.  If there is a known diagnosis or condition, select it.  If the diagnosis is not confirmed, do not use “possible” or “rule out,” use the symptom.  Assign codes to the highest degree of specificity.  Do not code conditions that no longer exist. Code all documented conditions, which coexist at the time of the visit that require or affect patient care or treatment.  If a patient with a history of neoplasm is seen and is no longer being treated for the condition and has no signs of the disease, use “personal history of neoplasm” codes.

In addition, the book will look familiar to coders.  It starts with an alphabetic index, includes a neoplasm table and a table of drugs and chemicals.   There is a tabular list from which to select the code, after being directed to it from the index.  There are external cause codes (these are the codes the popular press loves, “pecked by a turkey”) and factors influencing health status and contact with health services that includes examination and personal history of cancer or long term use of anticoagulants.   The ICD-10 book has general instructions that give sequencing rules for many chapters.  Of course, on the physician side, we don’t always pay as close attention to sequencing as we should and as they do on the facility side. (What can I say, I already admitted I was a lazy diagnosis coder in my past.)  Physician coders should pay attention to code sequencing. Some codes may not be submitted in the first position. When you see the notation “in diseases classified elsewhere” in ICD-9 or ICD-10 it means this should not be submitted as the principle diagnosis.  Code first the condition that is classified elsewhere.  Similarly, some manifestation codes instruct the coder to “code first” the underlying condition or etiology.

Am I making it sound too similar to ICD-9?  Well, there are differences.  Besides the sheer number of codes, there are changes.  Complications of a procedure are no longer relegated to a small section of codes in the 995-999 series but are located at the end of each chapter.  Complications of a digestive surgery are in the digestive chapter, complications of eye surgery are in the eye surgery chapter.  There is a seventh character extender for some chapters, and it means something different depending on the chapter in which it is found.  In the maternity care chapter, it can refer to trimester or fetus.  In the nervous system chapter, the Glasgow coma scale.  I know you’ve heard about the seventh character extender for injuries.  And, as for coding fractures and the many seventh character extenders for those, I think most of us will concede that Orthopedics will have a difficult time.  Long term after effects from injuries are indicated by a seventh character extender.  There is a new concept of underdosing in ICD-10.  And what does “Excludes” mean? There are two meanings in ICD-10.  And, let’s not forget the placeholder code X.

What about mapping programs?  Some groups are hopeful that the crosswalk built into their systems will be sufficient, that there won’t be a need for expensive training days away from the office.  I’ve looked at some of these and here’s what I think.  The automatic crosswalks will very often yield an unspecified ICD-10 code.  Sometimes, this is because the ICD-9 code was not specific, and so the program could only map to an unspecified ICD-10 code.  Or it is because the code options in ICD-10 are much more specific than in ICD-9, such as right, left, bilateral (such as for many eye and ear complaints or musculoskeletal complaints) or foot, calf, knee, thigh, hip (rather than limb.)  In that case, an automatic mapping will always yield a code without specificity.  If these are going into the problem list, then when the patient is seen the clinician needs to review these and select a more specific diagnosis code.  I’ll write more about these mappings in the near future.

I don’t know if the conversion to ICD-10 will be more like Y2K or the end of the world as we know it.  I do know that experienced coders can learn ICD-10.  If you can code in ICD-9, you can code in ICD-10.


Have I got a Policy for you! Copy and pasting in an EHR.

The purpose of the medical record is to help the doctor and other doctors and healthcare professionals treat a patient.   Medicare and other third party payers can only be expected to pay for work performed at an E/M service on that date of service.  A payer doesn’t pay for work done at a previous visit, and copied into today’s note. With copying and pasting notes in EHRs, the rule is that you should not document it if you did not ask it, review it, examine it or consider it. If you copied from a previous note, read your new note and see if it contains any details that do not meet one of those criteria. If so, delete that element.

Let’s divide the History of the Present Illness (HPI) into two sections: a clinical summary and a section called, “since last seen.”

Clinical summary within the HPI: At times, it is useful for a physician/NPP to copy a clinical summary of the patient’s condition from a previous note.   When doing this, label it as copied and date the note from which it was copied.

Clinical summary from 1-4-14 “XXXXX”

Since last seen:  In this section, add the HPI elements or status of the patient’s condition since the last visit.

ROS:  Document the ROS as asked and reported by the patient today.  I don’t recommend copying from a previous note, even though the Documentation Guidelines allow it.  It doesn’t make sense to me and leads to inaccuracies. If the patient fills out a paper or electronic questionnaire, be sure to initial and date it.

Past medical, family and social history:  This can be imported from a previous note as long as it is reviewed with the patient.  Either update the history or note that no changes were required.  Only import the sections of the note that are needed for today’s visit.  I suggest refraining from importing family history routinely.  For 99214 only one of past medical, family, or social history is needed. For 99215, two of past medical, family and social history are needed.  If family history isn’t relevant to the visit, don’t add it to the record.  It contributes to the appearance of an overly cloned note.

Exam:  Exam is always new and should describe only exam elements documented at this visit.  Some clinicians find it useful to import a previous exam as a reminder of abnormal elements for this patient and state it is more accurate than “normal exam” because it relates to the patient being seen.  I personally do not recommend copying the exam from a previous note.  But if it is copied, it must be edited and reflect only exam elements performed at this date.

Data:  Many clinicians find it useful to carry forward in a progress note results of diagnostic tests.  It is easier than looking through the computer for tests results that may require multiple clicks and many minutes to find.  This is useful, clinically. Only new data either ordered or reviewed during the visit would be credited to determine the level of service.  Historical data re-reviewed could be credited, such as, “Comparing the EKG today with the EKG from 2012…”

Assessment and plan: A physician is paid for the conditions being managed at this visit, not for conditions managed by another physician or for conditions not addressed or reviewed at this visit.  The assessment should clearly note which problems were addressed today.

If the patient has problems not addressed at this visit, but listed in the A/P, label these as such. Insert a statement before the list, “other medical problems not addressed at this visit.”  Clinicians find it helpful to import this data into the note.  But, then, don’t use it to select a level of E/M service if the conditions were not addressed at this visit.

I suppose in a blog it is redundant to say this is my opinion?  This is my opinion, supported by reviewing OIG reports, the Documentation Guidelines, discussions with physicians, lawyers, coders and experience reading thousands of notes a year.  Obviously, obtain professional advice before adopting any policy.  CMS has not released a policy about this topic as of this date.

Risky business, or tempest in a teapot?

Some days, it appears we compliance and coding folks are like the boy who cried wolf.  We see shadows around every corner.  We emulate Captain Kirk, shouting, “Red Alert! Shields up!”  (Done mixing my metaphors now, I promise.)  The mainstream press doesn’t help with headlines of fraud accusations and sensational stories of government regulations.  In the past three days, the New York Times had headline stories about a hospital chain encouraging physicians to admit patients who did not qualify for admission and an OIG report about investigating physicians who bill Medicare a lot of money each year.  A lot of money.

 How does a practice assess its real risk?

 Think: big.  The OIG report identified 2% of physicians responsible for more than 25% of Medicare Part B revenue.  It identified 303 physicians in the country who each received more than $3 million in Part B Medicare payments in one year.  These were 55% Internists, 12% Radiation Oncologists and 11% Ophthalmologists.  I don’t think the Internists generated $3 million from moving their 99213s to 99214s, do you?  Although the report doesn’t say what services were provided, I’m going to guess diagnostics or DME played a part.  When I read about health care professionals or business types who have paid large fines or gone to jail, there is often this large component involved.  The lab that bought insurance numbers and billed for thousands of lab tests on patients who were never seen.   Sheer size is a risk factor.   I don’t mean a group of 100 has higher risk than a group of ten.  I mean, if one physician generates revenue that is 100 fold higher than might be expected, that’s a risk.

 Think: different. As in, “is my billing pattern different from the norm?”  That is hard to know. The government and payers have all the data: they are playing with a full deck of cards and all we have is the ace of spades and two of hearts.  Check your E/M profile against the norm. (email me and look at your use of modifiers. (  Look at MGMA RVU data to see if your total RVUs are significantly higher than the norm. Compare data internally.  Avoid reporting all one level of service in any category,  “all my admissions are threes, all my follow ups are twos, and all my consults are fours.”  High volume combined with unusual profile is a risk factor.

 Think: it’s too good to be true.   That diagnostic tool the sales rep tells you will make you a fortune: take a good look at coverage rules and medical necessity. 

 Think:  when you hire, can she whistle?  When I present to a group, I often ask, “Do any of the doctors here have your spouse working in the practice?   Yes?  Don’t get a divorce.”  But, whistleblower suits can be a threat to anyone.  The hospital in the NYTimes article I mentioned is being brought my multiple whistleblowers. When you are interviewing a new staff member, be alert for an attitude that the person knew more than their previous supervisor and protected the doctor from “wearing stripes” and now plans to bring their watch dog skills to you.  It’s not that I don’t want you to find and correct your own errors. That process of auditing, in which you voluntarily review your coding, correct errors, issue refunds for overpayments and educate yourself and practice is critical and should be done by every practice.  But, I want the person doing it to be on your side, helping you detect errors, research the rules, refund overpayments and correct problems.     I’m not saying co-conspirator!  I’m saying the person who works with you in the complex area of coding and compliance should be on your team.

 The only way to reduce your coding risk to zero is to stop seeing patients.  But, physicians are used to managing risk in their medical decisions.  Managing coding risk means learning about the codes and rules for the services you provide, hiring dedicated, smart staff and paying for coding education and conducting regular audits, internally or externally.  

Cloning: I read the news today, oh boy.

Certain medical stories are irresistible to the popular press: ICD-10 external cause codes that are ridiculous (W61.43XD, pecked by a turkey, subsequent encounter) or medical practices using their electronic health records in a way that increases their revenue.  A recent headline was eye-catching, as headlines are meant to be, “Report finds more flaws in digitizing patient files.”  The New York Times reported on January 8, 2014 that the Office of Inspector General (OIG) found Medicare and its contractors weren’t doing enough to prevent fraud caused by using an electronic health record.  It makes for good copy, doesn’t it?  (OIE-01-11-00571, CMS and its Contractors have Adopted Few program Integrity Practices to Address Vulnerabilities in EHRs, January 2014).   It followed a December report about safeguards in hospital EHRs.  (OIE-01-11-00570, Not all Recommended Fraud Safeguards Have Been Implemented in Hospital EHR Technology). Taken together, physician practices and hospitals are given fair warning about government concerns. 

 The December report about safeguards is a report that IT staff, practice managers and medical directors should review.  It relates to audit functions within the EHR (don’t go to sleep on me here.)  It also had a bombshell about E/M services.  The report found a lack of safeguards and issued recommendations about tracking alterations or changes to documentation. It recommended that EHRs track method of input, including copy/paste, direct entry, or import for any update. It states that EHR systems should have user authorization and access controls that positively identify by NPI the author of entries and restrict unauthorized access by user ID and passwords.  There were other recommendations related to data transfer standards. 

 This same report recommended that EHR technology not prompt a user to add documentation for E/M coding, but be able to alert a user to “inconsistencies between documentation and coding.”  There are two parts to this.  First, the program shouldn’t prompt the user to encourage higher codes. “Just add family history, and the visit is a 99204.”  The second suggests, however, that the program could warn a clinician who is coding a service at a higher level than documented.

 The January report (CMS and its Contractors Have Adopted Few Program Integrity Practices to Address Vulnerabilities in EHRs) directly discusses using copy and paste and over-documentation.  Quoting from the OIG report:

 Copy-Pasting. Copy-pasting, also known as cloning, enables users to select information from one source and replicate it in another location.  When doctors, nurses, or other clinicians copy-paste information but fail to update it or ensure accuracy, inaccurate information may enter the patient’s medical record and inappropriate charges may be billed to patients and third-party health care payers. Furthermore, inappropriate copy-pasting could facilitate attempts to inflate claims and duplicate or create fraudulent claims.

Over-documentation. Over-documentation is the practice of inserting false or irrelevant documentation to create the appearance of support for billing higher level services. Some EHR technologies auto-populate fields when using templates built into the system. Other systems generate extensive documentation on the basis of a single click of a checkbox, which if not appropriately edited by the provider may be inaccurate. Such features can produce information suggesting the practitioner performed more comprehensive services than were actually rendered.

The Documentation Guidelines that we use to audit E/M services were written in 1995 and 1997, long before most groups were using an electronic health record.  But, they are still in place today and are the guidance that we have about what parts of a previous visit can be reviewed, updated and used in a current visit and count towards today’s documentation.  Here is what they say,

A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:

  • describing any new ROS and/or PFSH information or noting there has been no change in the information; and
  • noting the date and location of the earlier ROS and/or PFSH.

Auditors and payers will allow the ROS and past medical, family and social history from a previous visit to be included as part of the current visit as long as the physician notes any new changes or that there were no changes.  It doesn’t say that the clinician doesn’t have to redo the work, only that the work doesn’t all have to be re-documented.  In a handwritten or a dictated note, that was huge time saver.   The HPI, exam, assessment and plan are not allowed to be copied, reviewed and a notation, “No changes required” made according to the Documentation Guidelines.

In a paper record, it makes perfect sense.  But what about in an electronic world?  Most programs allow a clinician to carry forward all or part of a note, and edit it.  Most auditors don’t credit the HPI that is copied from a previous note, because according to the Documentation Guidelines, The HPI is a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present. It includes the following elements: • location,
• quality,
• severity,
• duration,
• timing,
• context,
• modifying factors, and
• associated signs and symptoms.  We interpret that to mean a description of the patient’s current symptoms, not past medical history.  Since the Guidelines specifically state that the ROS and PFSH may be carried forward but not the HPI, auditors expect the HPI to change from visit to visit.  And often, reading an HPI that was copied is confusing about the time frame and inaccurate.

But clinicians see things a little differently.  The start of the history section is often a succinct summary of the patient’s condition, which is helpful to carry forward from visit to visit. “HPI: Pleasant 58-year-old with a past medical history of coronary artery disease, previous acute coronary syndrome. He had bypass surgery. His last cardiac catheterization was June 2011. At that time bypass grafts were patent. The third obtuse marginal demonstrated 80 percent stenosis in the proximal third. The RCA demonstrated 100 percent proximal stenosis. The mid RCA was supplied by collaterals.  There was diffuse coronary disease. Ejection fraction was 55 percent. There was no intervention at that point in time. In November he developed recurrent chest pain. He ruled out for myocardial infarction and was discharged on metoprolol as well as imdur and he is no longer on Benicar.” The physician certainly doesn’t want to re-type that, and yet does want it at the start of the visit, as a reminder for future visits and for other care providers.  This seems reasonable to me, but then the physician needs to add “Since last seen, he reports….” And describe the patient’s symptoms, if any, or the status of the patient’s condition since the last visit.

What about the exam and assessment and plan?  The Guidelines don’t allow for copying those sections.  Providers tell me that opening up the previous note and copying the exam into today’s visit reminds them of abnormal findings.  The provider then edits the exam.  Use extreme caution with this until we receive CMS guidance.  It runs the risk of falling into the category of both cloning and over-documentation.  I read too many notes in which I am surprised the level of exam that was documented for a follow up or minor problem. (A comprehensive, eight-organ system exam for a cast change on an 8 year old, for example.)  As for the assessment and plan, if the physician is following the patient for the same problems, and addresses each of them at the visit, then the list won’t change. And it’s possible that the status of these won’t change or the treatment plan.  The clinician needs to be sure to only include in the list those problems addressed that day and scrupulously update the status of them.  Again, the Guidelines themselves written in a pre-EHR era do not allow for using and updating a previous assessment and plan. 

When I meet with physicians, they often complain that they can’t trust the information in EHR notes from another provider.  The first duty in documenting a service is to the integrity and accuracy of the medical record.  But, keep in mind that the payer isn’t paying you twice for the same work.  Some notes are copied wholesale from a previous visit with minimal changes.  It makes it difficult to validate the medical necessity for the service and to know what happened at the subsequent visit. 

There is more than a little irony in the situation.  First, CMS all but insists that physicians use an EHR.  But then CMS seems to say, “Don’t use this tool in a way that is too convenient or that saves you any time.”  Until we receive CMS guidance, and working within the constraints of the EHR, document in a manner will help you and other clinicians to treat the patient.