Newsletters & Industry Updates

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Charting Tips:

When you don’t follow a practice guideline when treating a patient, write reasons why in your medical records.
It is not sufficient to write “patient doing better”. In what ways is he/she doing better? Be as specific as possible in your charting.

Remember that the length of your noting in a chart is not as critical as your content of that note. Copy and pasting notes will harm you with any insurance audits and potentially in malpractice actions.

Decoding E/M Services: Auditing Traps and Word Tricks

Choosing words are very important in the medical field. The right words can mean the difference between accurate evaluation and management (E/M) coding or being accused of submitting false claims.
The words left behind in the medical record form the basis on which an auditor decides if the doctor provided appropriate care, or submitted an accurate claim, or committed the crime of submitting false claims. The auditor must examine the medical record documentation to recreate the intensity of the service.
Words convey meaning. What happens when the writer’s meaning is at odds with the reader’s interpretation? At best it results in confusion, at worst, potential allegations of wrongful code selection.

Trap #1 (Non-Contributory):
Most payer auditors disallow a history element or review of systems that is described as “non-contributory.” The rationale is that there is not sufficient information provided to adequately understand which questions the patient was asked regarding his/her history and/or review of systems. Physicians commonly tell us that they “meant” that the patient’s response was negative; therefore, they did not direct the evaluation in a specific direction.
Trick #1:
If the patient responded in the negative, document “family history is negative for (whatever you asked about,)” or that, “the review of systems is negatively related to (state the systems asked about.)”

Trap #2 (Referring Physician):
Using referring physician when intending to communicate that a specific physician has requested a consultation service. “Referring” implies (to some) that the care of the patient is being relinquished to another physician.
Trick #2
Say that Dr. X requested a consultation to evaluate whatever the condition for which you are being consulted.

Trap #3 (Missing Words):
Thinking that severity is “obvious” and neglecting to use adjectives to describe a severe exacerbation, progression, or side effect of treatment related to a chronic illness being treated. These descriptors support medical necessity for higher levels of services than the same chronic illness that is stable or mildly progressing, a mild exacerbation or a mild side effect of treatment.
Trick #3
State the obvious. Use language that leaves no doubt about the severity of a condition for which service is being provided. Words such as “severe,” “crisis,” “at high risk,” “deteriorating” etc., convey information clearly and are not likely to be misinterpreted.

Trap #4 (Clinical Information):
Relying on clinical values and findings to communicate the severity of illness and complexity of care. Medical record auditors rely on adjectives for this information and are mostly not permitted to interpret clinical values.
Use words that describe what the clinical data communicates to you. For each established diagnosis, specify if the patient’s condition is stable, improved, worsening, etc.

Trap#5 (Chief Complaint):
Chief complaint: f/u. This common abbreviation for follow-up does not describe to the auditor what condition(s) is being followed up on.
State follow-up for, and insert the condition(s), including both those that are receiving active care and any comorbidities that affect the physician’s thought processes in providing that care.

Perhaps the biggest trap of all is thinking that only words drive the code. While it’s important to completely record the work done, doing it for the “sake of a code,” may not stand up to audit scrutiny.

Use the right word to accurately describe the patient’s visit (avoiding those known to cause confusion). When the words you choose are precise and include sufficient detail to paint a word picture of the visit, the auditor can reconstruct the episode of care to validate code selection(s).

Unspecified Code Use

Payers look for claims to contain highly specific codes to support any medical necessity of a procedure or service performed in healthcare. Getting paid for “unspecified” diagnoses may be as difficult as getting paid for “unlisted” procedure CPT codes; and overuse of unspecified ICD-10 codes may subject the provider to audits.

The ICD-10 code set contains enough specificity and granularity that using an unspecified code should be your last resort. Think of unspecified ICD-10 codes just as you would unlisted procedure codes in CPT. You should use an unlisted code ONLY if a specific code for the procedure does not exist.

Unspecified code exists for a few reasons, some good and some not. A coder may resort to using unspecified codes when:

  1. Documentation is insufficient.
  2. Documentation isn’t accessible at the time of reporting.
  3. Billing sheet has overabundance of unspecified codes.
  4. The biller failing to update themselves on codes and relying on what is committed to memory.

New Codes and Billing Instructions Effective July 1

The July 2016 update to the Outpatient Prospective Payment System (OPPS) includes key changes to, and billing instructions for, various payment policies, as indicated in the 2016 OPPS final rule.

  1. The Centers for Medicare & Medicaid Services (CMS) revised Intensity Modulated Radiation Therapy (IMRT) planning billing instructions, per the 2016 OPPS final rule, effective July 1, 2016.
  2. CMS is also setting changes to the surgery section on “eye lift” surgery: Medicare does not allow separate payment for a blepharoplasty procedure, nor does CMS permit operating on the left and right eyes on different days when the standard of care is bilateral eyelid surgery.
  3. The update revises status indicators for Pathology CPT codes.
  4. Payments for drugs and biologicals based on the average sales price (ASP) are updated quarterly. Updated payment rates effective July 1 and drug price restatements are available in the July 2016 update of the OPPS Addendum A and B. Providers should resubmit claims affected by adjustments to previous quarter’s payment files.

These and other updates are available at AAPC’s website.

CMS to Reject More Unspecified Diagnosis Codes

The CMS outlines additional unspecified diagnosis codes that are excluded from both ICD-9 and ICD-10 reporting beginning January 2, 2017.

CMS missive states the codes, “will not be accepted in the Alleged Cause of Injury, Incident or Illness (Field 15) or in any ICD Diagnosis Code field starting with Field 18. Updates to previously submitted records using these excluded codes, will also be rejected.”

These additions and upcoming changes to the ICD-10 code set underline the needs for clinical documentation improvement and ICD-10 training, experts say, as code and rule freezes are lifted by the healthcare payment agency. ICD-10-CM will include 1900 new codes and several more changes and deletions. Attention to documentation will be paramount.

Medical Billing: 4 Key Areas to Risk Adjustment Documentation

Health care has quickly transformed from a fee-for-service payment model where providers are paid based on volume of services to various value-based payment methodologies. These new payment systems are focused on promoting quality of care and creating better outcomes. One of them is risk adjustment.
The goal of risk adjustment is to reward efficiency and high quality care for sicker patients. These patients require much more clinical and financial resources to treat. Health plans are paid more to cover the costs of providing care to these sick members. The severity of illness of a plan’s members is measured by the diagnosis codes that are submitted on claims received from their healthcare providers.

Providers are accustomed to documenting and coding from an E/M and CPT perspective. Changing the focus to diagnosis coding, which is the focus of risk adjustment requires some changes to what you are used to.

It is best to focus on these few key areas on best practices for risk adjustment:

  1. Make sure problem lists are kept up to date. The problem list should show the status of each condition. It should not be a long list of every condition experienced by the patient. Be sure the highest level of specificity known to the provider is captured in the diagnosis codes. These codes do not accurately show the true severity of illness of sicker patients.
  2. All problems need to be in the assessment. Problems assessed during the visit should be noted in the assessment portion and coded correctly.
  3. All diagnoses should be documented. Note all the diagnosis codes for the visit, don’t limit them. All diagnosis that were part of the provider’s medical decision making process should be documented.
  4. All chronic conditions documented at least once annually. The patient’s chronic conditions should be assessed during the encounter visit at least annually, and submitted on a claim. This includes status codes such as amputations, transplant status, etc.


Although 2016 may be the final year of the PQRS program, as Medicare implements a new payment system under the Medicare Access and CHIP Reauthorization Act of 2015, it is a critical one.  Providers and group practices that do not satisfy PQRS requirements in 2016 face up to a 6% reduction in Medicare payments in 2018.  Providers can avoid the PQRS penalty by reporting quality data as individuals, or collectively as a group practice by using the PQRS group practice reporting option (GPRO).

Practices that wish to participate in GPRO for the 2016 reporting year must register by June 30, 2016 via the Physician Value-PQRS registration system, but can modify or cancel their GPRO registration any time prior to this deadline.


Charting Tip

When not following any widely accepted practice guideline when treating your patient, write the reasons why you are not following the accepted recommendation in your medical record.

It is not sufficient to state “patient doing better”.  In what ways is the patient doing better?  Does the patient walk 5 blocks instead of 3?  Does the patient have less pain after taking the prescriptions for 3 hours?  Be more specific!

Confusion Regarding Co-Pays & Courtesy

Many managers realize that there are “compliance” issues with professional courtesy and waiver of co-pays, leading to confusion on how to handle them.

Professional courtesy needs to be distinguished from waivers of co-pay.  Professional courtesy is the waiver or discounting of the Practice’s entire fee for patients who are physicians or dependents of physicians, or discounting of the fee for these individuals, such as 50% discount.  Waiver of co-pays or insurance only may be a form of professional courtesy for physicians and their families, but is often extended much more broadly to practice staff, patients with financial hardship, or even all Medicare patients.  Some practices even market or advertise their willingness to accept insurance only for Medicare patients, even after years of warnings from the government most practices recognize that this latter practice is illegal.

There can be an overlap between professional courtesy and waivers of co-pay, such as when insurance only is made available to physician-patients and their families as a form of professional courtesy.  However, the two policies have very different legal standing.  Professional courtesy – when it consists of waiver of co-pays to physicians and family, as a professional courtesy.

It is legal to provide professional courtesy to community physicians and their families, with two exceptions.   It is illegal is when (a) it is targeted to those physicians or other persons who are in a position to refer business to the practice, or (b) when it takes the form of “insurance only”.

It is illegal to target professional courtesy to potential referrers because this may constitute a fraud and abuse “kickback” for referral of Medicare patients.  The waiver of the practice’s usual fee can be viewed by as “non-cash remuneration” for potential future referrals.

Does this mean that professional courtesy may only be provided to physicians who are not in a position to refer Medicare patients to your practice?   No.  Professional courtesy can be provided to physicians and their families, including good referrers.  What the practice cannot do is limit the availability of the free services to only the actual or potential referrers.

Professional courtesy can be expensive, particularly when the waived fee is for a surgical procedure.  Therefore, some surgical practices want to limit their courtesy to no-surgical services only.  That is fine.  There is nothing suspect about such an arrangement because referrers and non-referrers alike are eligible for the courtesy benefit.

The waiver of co-pay/insurance only is similar to waiving the entire fee in a professional courtesy situation, in that both arrangements involve reduced cost to the patient. However the  waiver of co-pays has a much more tenuous legal standing.

According to the government, waivers of co-pay for Medicare patients violates a federal statute which prohibits the offer of “remuneration” to a Medicare or Medicaid beneficiary that the health care provider “knows or should know is likely to influence” the patient to seek his or her care from the provider who is offering the co-pay waiver.  Arguably, waving the entire fee, as in professional courtesy, is also likely to “influence” the beneficiary (who doesn’t like free medical care?).  But the government only cites this statute with respect to waiver of co-pays.  It does not seem to think that waiver of the entire fee as a professional courtesy is illegal, unless targeted to actual or potential referral sources, as noted above.  The waiver of the full fee does not increase the cost of services to the Medicare program which is likely why it is not addressed. “Insurance only” courtesy has also been deemed as insurance fraud by some states.  The theory is that the practice represents a fee to the insurance company that is not the fee that it actually intends to collect.  Another way to look at this is the insurance reimbursement arrangement brings with it responsibilities for co-payments (and deductibles) that are a prerequisite for the insurance company’s payment.  By waiving the co-payment without notice, the practice implies that it complied or will comply with the patient responsibility for payment.

There is one wee-recognized but very limited exception to the prohibition on co-pay waivers.  This is a waiver based on demonstrated financial hardship.  It is fine to waive the fee, even for Medicare, so long as they are pursuant to reasonable, consistently applied hardship criteria, and are not provided as a routine matter.

In today’s environment of heightened awareness of the need for compliance in both “form” and “operation”, it is important to review co-pay and courtesy policies to remove any risk of potential impropriety.

Frequently Asked HIPAA Questions

Does the HIPAA Privacy Rule limit an individual’s ability to gather and share family medical history information?

NO. The HIPAA Privacy Rule may limit how a covered entity (for example, a health plan or most heath care providers) uses or discloses individually identifiable health information, but does not prevent individuals, themselves, from gathering medical information about their family members or others, including their health care providers.  Thus, individuals are free to provide their doctors with a complete family medical history to communicate with their doctors about conditions that run in the family.

Does the HIPAA Privacy Rule limit what a doctor can do with a family medical history?

YES. If the doctor is a “covered entity” under the HIPAA Privacy Rule.  A doctor, who conducts certain financial and administrative transactions electronically, such as electronically billing Medicare or other payers for health care services, is considered a covered health care provider.  The HIPAA Privacy Rule limits how a covered health care provider may use or disclose protected health information.  The HIPAA Privacy Rule allows a covered health care provider to use or disclose protected health information (other than psychotherapy notes), including family history information, for treatment, payment, and health care operation purposes without obtaining the individual’s written authorization or other agreement.  The HIPAA Privacy Rule also generally allows covered entities to disclose protected health information without obtaining the individual’s written authorization or other agreement for certain purposes to benefit the public, for example, circumstances that involve public health research or health oversight activities.

When a covered health care provider, in the course of treating and individual, collectors or otherwise obtains an individual’s family medical history, this becomes part of the individual’s medical record and is treated as “protected health information” about the individual.  Thus, the individual (and not the family members included in the medical history) may exercise the rights under the HIPAA Privacy Rule to this information in the same fashion as any other information in the medical record, including the right of access, amendment, and the ability to authorize disclosure to others.