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Medical Necessity: Documenting What the Payer Wants

Rheumatology Practice Management August 2018 Vol 6 No 4 - Billing Update
Jean Acevedo, LHRM, CPC, CHC, CENTC, AAPC Fellow
President and Senior Consultant
Acevedo Consulting
Delray Beach, FL

Recently, it seems there has been an uptick in the number of practices receiving payer denials and overpayment requests. These requests have not only been from the Centers for Medicare & Medicaid Services Medicare Administrative Contractors, but across the spectrum of commercial and managed care payers. The common denominator for most of these issues has been that the physician practice billed for services that were governed by payer policies it did not know about.

Quite often, physicians are unaware that payers outside of Medicare have expectations when it comes to medical necessity, documentation guidelines, clinical indications, and coding policies. Yet, there is an expectation on the payers’ part that physician documentation supports these requirements. If the practice is contracted within the plan, there is an explicit obligation to abide by all of the plan’s applicable reimbursement policies and procedures—both from a clinical and a coding perspective.

Compounding the situation is the sheer volume and inconsistency of payer policies, and the fact that guidelines change. What may have been covered last year (or just last month) with minimal requirements could now be subject to a 20-page payer medical policy with very specific medical necessity, use, and documentation requirements. Unfortunately, in the healthcare world, ignorance is not bliss and payers show little consideration for the “I didn’t know” defense.

Regardless of the ancillary services provided, all rheumatologists bill for high-level Evaluation & Management (E/M) Services, and often need to use Current Procedural Terminology (CPT) modifier 25. Both of these have been under payer scrutiny lately, so let’s take a look at some basics to help rheumatologists and their coding and billing staff do it right.

CPT Modifier 25

Per the CPT, this modifier is defined as a “significant, separately iden­tifiable E/M service by the same physician or other qualified healthcare professional on the same day of the procedure or other service.” This modifier is appended to the E/M code to indicate that on the day another CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided, or beyond the usual preservice care associated with the procedure that was performed. Although there are some non-Medicare payers that will not pay for a visit and a procedure at the same encounter, the majority of payers, including Medicare, will do so, assuming the service was medically necessary and appropriately documented.

To help rheumatologists determine whether an E/M service is separately payable, it may be best to consider whether the procedure performed was planned. For example, a patient who receives a series of viscosupplementation injections may be asked whether the previous injection has helped, whether the pain and functional activities of daily living have improved, and whether the knee(s) may be examined for swelling, crepitus, etc. Although the note for this encounter will now contain some documented history and examination, this would be considered part of the preservice work for the injection. Alternatively, when a rheumatologist sees a patient for knee pain and, after an appropriate evaluation, a decision is made to perform arthrocentesis, it may be medically necessary to have performed (and documented) a separate and distinct E/M service. In the latter case, both the visit and the injection procedure would be billable, assuming that each is well- documented.

Level 4 Established Patient Visit (CPT Code 99214)

Because of the complex nature of a rheumatologist’s patients, it is common for this specialty to report a fairly high percentage of established patient office visits with medical decision-making of moderate complexity. Unfortunately, there has been a myth promulgated that a patient receiving methotrexate is automatically of moderate or high complexity. Putting aside for a moment the history and examination requirements, it is just not the case that all patients receiving methotrexate are moderately complex. Although the drug may be on the list of high-risk medications as one component of medical decision-making, if the patient’s rheumatoid arthritis is controlled, the patient has no comorbid conditions, and the only diagnostics reviewed or ordered are clinical laboratory tests, then coding complexity may be straightforward or low. I understand that from a clinical perspective, this may seem contradictory to a physician. So, let me point out that there are 3 variables that one must take into account when determining complexity: (1) the number of problems being managed, (2) the amount/complexity of data, and (3) the overall risk for complications, morbidity, or mortality. Therefore, from a coding complexity perspective, a patient with 1 stable problem, clinical laboratory tests ordered or reviewed, and a management option consisting of a high-risk drug supports a level 3 (CPT code 99213) at best.

Ultrasound-Guided Injections (CPT Code 76942)

When performing an injection procedure under ultrasound guidance, the medical necessity for the imaging guidance must be documented. From a medical necessity standpoint, each code (or component of a code) must be supported by the documentation. This documentation must reflect that all components of the procedure were performed and that each one was medically necessary. In the simplest of terms, the payer wants to know why, for example, an arthrocentesis required ultrasound guidance. After all, it was not that long ago when most joint injections were performed without any imaging guidance. Is the patient morbidly obese? Does the X-ray show severe narrowing of the joint space with osteophytes? Are there other clinical aspects to support payment for the ultrasound guidance?

Steps to Success

The following are some key steps that you can implement within your practice to decrease the likelihood of payer denials and overpayment requests.

  1. Before implementing, providing, and billing for any new service, be sure to check with all payers for applicable local coverage determinations, medical policies, and documentation requirements. In addition to the listed clinical indications, look for any requirements for qualified personnel or training. If these are stated, maintain documentation to support that these requirements are met. It is not enough to report a covered International Classification of Diseases, Tenth Edition code. The medical records should also support the clinical presentation supporting the diagnostic or clinical service.
  2. Be sure that all supervision requirements are understood and will be met for the new service when applicable.
  3. Develop a process to ensure that all payer-specific requirements have been met before the claim goes out the door. Consider having an internal process to review the documentation of the first 10 claims before submission to the payer. This proactive approach of validating that the documentation supports not only that the service was performed as coded, but that the clinical policies and any medical necessity guidelines are also well-documented can prevent future successful recoupment.
  4. Educate physicians, nonphysician practitioners, and other pertinent staff on payer-specific requirements and internal processes.
  5. Review all applicable payer medical policies and local coverage determinations on an annual basis for any changes and update internal processes and education accordingly.

The saying “Just because you’ve been paid doesn’t mean you can keep the money,” is a painful lesson to learn when a practice has billed and been paid for services without a working knowledge of the payer’s conditions for payment. Understanding what is meant by medical necessity and applying that knowledge in the clinical documentation can go a long way toward helping your practice “keep the money.”

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Last modified: October 26, 2018
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