When you’re providing audit feedback or education for providers, have you been receiving pushback or comments from providers regarding qualification time statements? When we think about the qualification statement that is required, well…best practices, for our time-based E&M services, those qualification statements are really needed in order to qualify the amount of time that our providers spend with the patient. Is there a documentation guideline (or requirement) that says every note that is billed based on time requires a qualification statement? The answer to that is no. But there is a rule and a requirement that every note must have medical appropriateness and be backed by medical necessity. If you’ve heard me talk on time-based E&M services (for example, What Time Doesn’t Allow: 2021 E&M Documentation Guidelines), you know that I use some really interesting examples, such as a patient with strep throat that goes into the office and our provider documents that they spent 45 minutes with this patient. We as coders and auditors think “oh my goodness! 45 minutes with strep throat?! Why-oh-why?!” But it’s those types of examples that gear us to realize if we read the note and think it seems like a crazy amount of time that was spent with this patient, we do need to validate why that patient, during that encounter, did require that amount of time. It’s not that we don’t trust our physicians or believe our physicians. It is medical appropriateness and medical necessity to support that amount of time. Simply giving their word about the amount of time spent, unfortunately, may not be enough in a carrier audit.
Now, I want to further this conversation. When talking about qualification statements, let’s also address carve out statements. This has been an area that received a little bit of a knee-jerk reaction, not just from providers, but also from coders and auditors. The reason this has caused a little bit of a knee-jerk is the perception that we, meaning even myself, as a coder, auditor, educator, trainer, are encouraging coders and auditors to be a little more stringent than needed with some of these carve out statements. My humble belief is no, we are not. Because again in the forefront, we audit for best practices and for compliance. There are two different hats as an auditor we wear, one is compliance and the other one can be defendability. But it depends upon the type of project we’re working on. My partner and friend within our organization, Sean Weiss, does a lot of work with litigation appeals where we are working hand in hand with a provider and their attorney when they received those letters from an insurance carrier and they’re demanding a lot of money to be returned. When we look at those notes through that lens, we are looking at that note from a defendability approach. How can we best defend? What legs do we stand on in this note? But when we are auditing, when we are looking at a note for best practices of compliance, we want to put on the legs of compliance to say the best practices, the best approach for documentation, is to have a carve out statement that says when this patient was seen, this diagnostic was performed, this additional testing or this procedure was performed, and that time has already been carved out of my total time.
When we work in our NAMAS training platforms and we do our workshops or our CEMA BootCamp, there are examples that we use to teach this. One such example we used in a webinar training the other day; a patient in which the auditor actually shadows the physician. As the auditor is shadowing the physician, the patient had an EKG and a chest x-ray performed. When the physician documented their qualification statement, the physician does discount that amount of time out of their total time when they document. However, in their qualification statement, there is no statement indicating that their total time disallowed for those different diagnostic services. So, when an auditor who did not shadow that service, whether it’s the carrier auditor or another coder/auditor within the internal system, reads that note, no one is the wiser that the total time disallowed for those diagnostic services. It’s always best to have a statement identifying “hey, my total time is my time, my time is the provider of the encounter today”. Now there are some providers who actually word it that way, and I will tell you that is better than no carve out. But I would still encourage you and our providers to say “this represents time not inclusive of”.
I hope this is helpful to you. Again, maybe you should have a policy. (You knew I couldn’t go without saying “maybe you should have a policy”!) If I can ever be of help to you or your organization, pop me an e-mail or give me a call.
Take a look at our video that discusses qualification statements on the NAMAS YouTube Channel. Be sure to subscribe to our blog and our YouTube channel so you never miss a tip!