March 15, 2024 | By Sonal Patel, BA, CPMA, CPC, CMC | CEO & Principal Strategist at SP Collaborative, LLC
Introduction
Did you know that under-documenting poses an audit hazard for any specialty provider? This is not spoken about too loudly by payors since their primary focus is identifying overpayments, rather than underpayments. Nevertheless, I believe a proactive approach to documentation and coding compliance through education would better serve the nation’s healthcare practitioners and the patients they treat.
This week’s documentation and compliance tip focuses on documenting orthopedic specialties in the medical record based on overarching medical decision-making (MDM) from the 2021 Evaluation and Management (E/M) Guidelines for Office and Other Outpatient Settings. Meaningful revisions are also found in 2023 and 2024. This tip is specific to the data analyzed column in the MDM Table. My experience has found that numerous records are in fact under-documented, and therefore, underpayments could be made. In other words, orthopedic practices are at risk of not being reimbursed appropriately upon first claims submission.
Hazards include Under-Documenting
I am currently auditing orthopedic practices that continue to under-document the data analyzed portion of the encounter visit. Time and again, physicians state, “images from 2021 reviewed showing left anterior ankle osteophytes…and joint effusion…and small loose body…and talar lesion…”. Or they state, “1 review of prior scoliosis survey and 2021 MRI of lumbar spine performed at [ACME Facility] showing multilevel foraminal narrowing”. What’s the problem here, right? In my opinion, this is detailed, nuanced, and well-written information. However, as an auditor, I see a couple of hazards or areas of deficiency that could be rectified based on the structure of obtaining a straightforward, low, moderate, or high level of MDM in the data analyzed column.
Break-Thru Examples
Let’s break it down. Pun intended! Looking at the first example:
1- “Images from 2021 reviewed showing left anterior ankle osteophytes…and joint effusion…and small loose body…and talar lesion…”
- I could not score this encounter initially since the documentation on how many images were reviewed was unclear. However, after the physician walked me through her day, she provided ample details on the ‘what’ and the ‘where’ pieces missing in the documentation.
- What images were being reviewed? Answer: One (1) outside MRI image of left ankle she looked at and assessed to see if her treatment plan was indicated.
- Where was the image from? Answer: ACME ASC, an external facility.
- With minor tweaks to the note, to include the underlined words, “External 2021 MRI image was independently interpreted by me…” the physician could receive a moderate level of MDM for the data analyzed column to support a 99214.
- Without the physician’s improvements, the encounter would only support a 99212, or a minimal level of data analyzed for one (1) image reviewed for a straightforward MDM.
Looking at the second example:
2- “1 review of prior scoliosis survey and 2021 MRI of lumbar spine performed at [ACME Facility] showing multilevel foraminal narrowing”.
- I initially scored this as a 99213 for a limited level of data analyzed since two (2) reviews of prior tests are supported in the note. However, during post-audit education, it became clear that this physician also looked at the image and assessed the 2021 MRI image on his own to develop his treatment plan and next steps for his patient.
- With minor tweaks to the note, to include the underlined words, “…I independently interpreted the 2021 MRI image…” the physician could receive a moderate level of MDM for the data analyzed column to support a 99214.
- Without the physician’s improvements, the encounter would only support a 99213, or a limited level of data analyzed for two (2) prior tests reviewed for a low MDM.
Star Students
Each time I have had the opportunity to audit for larger orthopedic practices, I have taken time to acknowledge providers that have met audit standards. I use their notes reviewed and documentation housed in the EMR as teachable moments for the other practitioners at the organization. I always have a gold star ‘student’ or two. (wink, wink) They are the quick studies for the massive overhaul of E/M coding guidelines that were just implemented three years ago. In my post-audit education, I utilize these star students’ examples of complete documentation to show where small tweaks can be made to the remaining providers’ deficient documentation. I show them how these simple, yet swift and effective improvements can be made within the organization to garner appropriate payment the first time.
Conclusion
In my opinion, the goal of auditing medical records is not to be punitive. Rather, I believe in finding ways to showcase where the clinical documentation supports the codes selected. Orthopedic practices are known to review and independently analyze images to help support their plans of care for their patients. If those images assessed are coming from an external facility, it is important for these specialists to utilize a few key words in documentation to help them appropriately achieve a moderate level of MDM for the data they analyze.
If just one other column from the MDM Table, either the number and complexity of problems addressed or risk to patient management meets a moderate level of MDM, the entire encounter can be appropriately coded and billed as a moderate level of MDM, as was the case with the examples above. I believe there is a significant difference between the national non-facility rate of reimbursement for 99214 at $126.07 versus 99213 at $89.39 and 99212 at $55.67. Therefore, I encourage orthopedic specialty practices to look closely at how they are documenting for the data analyzed column, so they do not risk being underpaid.
The new E/M guidelines are structured to help practitioners receive credit for the critical thinking skills they use in caring for their patient populations. I believe it is important to shine the spotlight on where documentation improvements can be made to help eradicate these unnecessary hazards of under-documentation that negatively impact the revenue cycles of many orthopedic practices.
