Coding changes and here come the audits

By Catherine Lightfoot, CPA, CHBC, Director of Healthcare at EEPB

 

While nobody could have expected 2020 to be such an interesting year, most practices are settling in with the function of Personal Protective Equipment (PPE) and starting the forgiveness applications for their Patient Payroll Protection loans (PPP). Let me remind you of the original P acronym, Patients over Paperwork, that started in 2017 and continues to drive changes out of CMS.

Through “Patients over Paperwork,” CMS established an internal process to evaluate and streamline regulations with a goal to reduce unnecessary burden, increase efficiencies, and to improve the beneficiary experience. What this means to you from a financial perspective, is an increase in denials and a loss in collections if you do not adapt to the new rules.

Medicare and the AMA have published the 2021 E/M documentation update, and the changes are to be implemented on January 1^st, 2021. The new AMA CPT E/M changes are specific to Office or Other Outpatient Services (99201-99205 and 99211-99215) codes along with ER and Observation service. Documentation will now focus on the physician’s thought processes on how to take care of patients, instead of the current requirements to re-record elements regarding the chief complaint and history.

Additional changes will include:

• Eliminate history and physical as elements for code selection
• Many new definitions and terminology for 2021
• A new Medical Decision-Making (MDM) Table specific to 99202-99215
• Allow physicians to choose whether their documentation is based on Medical Decision Making (MDM) or Total Time
• Guidelines for reporting “Time” when more than one individual performs distinct parts of an E/M service, along with total time on a given date, including coordination of care
• The definition of time is the minimum time, not typical time, and represents total physician/qualified health care professional (QHP) time on the date of service. Medicare is attempting to recognize better the work involved in non-face-to-face services like care coordination.

Templates became useful during the transition to ICD -10 to assist providers with the new rules and requirements. Although documentation of history and physical examination will still be required to some degree, the amount of history or number of body areas or organ systems examined and documented will not be part of the scoring used to determine the overall E/M level of service. The reliance on templates will need to be adjusted to fit the new MDM requirements. In the past, more emphasis may have been placed on the amount of time spent with the patient.  Now with the new MDM option, processes will need to be reevaluated. Time is still a factor, but more importantly, medical necessity for the level of service must be identifiable within the documentation.

Some of the chart auditors I work with mention that, in many of their chart audits, the medical necessity is not obvious from the chart notes, much less the reasoning to get there. The changes to the E&M codes beginning in 2021 will require practices to evaluate current workflows, thinking, planning, and processes now. This change in E&M coding is on the magnitude of the switch to ICD-10.

Late July, HHS extended the public health emergency (PHE) declared for the COVID-19 pandemic. The original declaration made in late January was set to expire. The extension will last for another 90 days, as the law stipulates. Extending the PHE allows a number of regulatory changes that have been enacted to help providers manage outbreaks of the coronavirus to continue, including the rollback of telehealth restrictions that have eased access to virtual visits. Other changes that will now continue include the 6.2 percentage point increase to the federal share of Medicaid funding and tweaks to value-based care programs from the CMS innovation arm.

CMS has stated that regardless of the status of COVID-19, audits will resume in August. CMS halted audits in March for RACs, SMRC, TPE, and most other pre and post-payment audits. CMS cites that these audits are critical to their Integrity Programs.

Be prepared for these possible audit targets:

1. COVID-19 screenings. The OIG activity in this area has been significant in the past few months.
2. Application of COVID-19 Dx and documentation to support the use of the codes.
3. Telehealth Services – medical necessity should be the driver for the level you select, not time.
4. In-person encounters with minor procedures (modifier 25) during the same visit.
5. Surgical procedures – specifically the review of major surgery codes prior to the stay in place issued in many states and the resumption of surgeries once the stay in place was lifted.

As always, your best defense is a consistent process of evaluating and correcting. Corrective actions and voluntary refunds will go a long way to reducing any potential audit outcomes.