EDITOR’S NOTE: This is the second in a three-part series about the author’s encounter with a physician and his staff regarding the clinical documentation of a patient who had suffered a hairline fracture of the left ankle. In this installment, Dr. Jones is challenging the office coder.

“Listen, it was the patient’s first visit for the fracture, so isn’t that acute? Yes, that’s acute,” she blurted out in an obdurate manner. “And the notes did not make a connection to the osteoporosis, either. Then the patient had a typical run of no-charge visits for the same fracture all the way until the last visit, when we re-X-rayed it and saw it was finally healed. So isn’t aftercare after all the care has been rendered during those fracture care visits?”

Needless to say, at this point I reached for my bottle of Excedrin (ICD-9-CM code 307.81, tension headache; ICD-10-CM code G44.209, tension type headache, unspecified, not intractible)!

Whatever one might think about this real-life case scenario, it is typical – perhaps not typical in every respect, but frankly, I haven’t performed a preparatory ICD-10 documentation assessment in the last year that did not yield similar results. Dr. Jones’ practice was just making it easy by, ahem, centralizing all of the possible opportunities for improvement into one neatly compressed binder of audit results.

Here’s a breakdown of the issues surfacing during this single audit case of an elderly woman with a fracture, osteoporosis, revealed in-office X-rays and clinically followed in the routine “fracture care” method used by most orthopedic offices:

Signatures and Authentication; Integrated MR Entries by Unidentified Staff

Recent increases in federal and state activity in the realm of provider documentation audits is a direct result of governmental fraud, waste and abuse (FWA) prevention initiatives, manifesting in MAC/Part B carrier reviews and audits by the OIG, the RAC entities, the CERT contractors and other scrutinizing bodies such as ZPICs. Medicaid integrity programs such as MIC and PERM also account for this increased war on healthcare FWA, bringing to the forefront the need to closely adhere to basic MR documentation best practices. This includes legibility, patient and date identifiers, correctly identified non-provider staff annotations and clear provider contributions to the notes and overall provider authentication.

Prescient to this activity, in June 2010 the final revised Change Request 6698 (Transmittal 327) was issued by CMS, setting the foundation for expected provider signatures in or on MR documentation, including eMR. These standards are for CMS and CMS-related administrative and auditing bodies (CERT, for example); if individual state medical code parameters are more stringent, then those parameters need to be followed as well.

As with case No. 1 for Dr. Jones, if or when staff annotations in the MR permeate and cloud the evaluation and management (E/M) visit notes, it becomes difficult for outside reviewers to discern who actually saw the patient and to what degree each provider and/or staff member was responsible for that particular E/M visit.

MACs and Part B carriers such as Trailblazer Medicare (the jurisdictional MAC for Dr. Jones) have specific criteria that must be followed in the rendering of an E/M service, particularly one whose documentation is riddled with staff annotations. Not all staff can make entries in all portions of the E/M note, with those portions being segregated into the a) history, b) physical examination and c) medical decision-making sections. Each staff member should legibly sign his or her office note contributions. Above all, providers must sign their MR documentation. The provider’s signature also authenticates all entries made for that E/M service. With the advent of eMR, this step has gotten easier in terms of compliance, but numerous practices still are crafting office notes by hand or via a mixture of handwritten, dictated and/or eMR notes. The provider’s work for each patient during the E/M visit must be clear, and the provider’s authentication of the work, as well as supervision of staff contributions, must be evident in accordance with CR 6698 and CMS jurisdictional regulations.

Diagnostic X-ray Reports – A Necessity?

Both CMS and numerous jurisdictional Medicare entities (such as Trailblazer) have made it quite clear that there must be a separate or discrete radiology interpretation and report maintained in the MR in support of billed radiology services. This mandate first is underscored by the definition of the CPT codes when reported as global services and not solely as the technical component (-TC modifier) or the professional component (-26 modifiers, and for some payers, the -PC modifier). CPT states that “a written report signed by the interpreting physician should be considered an integral part of a radiologic procedure or interpretation.”

The Medicare Claims Processing Manual, based in part on the Code of Federal Regulations, addresses the issue for radiology services connected to emergency department visits, and then rather obliquely refers the reader to the Part B radiology billing requirements for all criteria involving such services reported by physicians (chapter 12, sections 10 and 70, as well as chapter 13, section 20.1). Therein, as well as within the individual billing guides published by numerous jurisdictional entities such as Trailblazer, are quite straightforward guidelines addressing the need to prepare and maintain diagnostic radiology reports. They make reference to the fact that a one-line “interpretation” buried in the visit note is tantamount only to a “review” of the diagnostic X-ray, not a full interpretation and report.

Those brief reviews are considered included in the reimbursement for the E/M service, and cannot be billed separately. In those cases, the global CPT code for the X-ray cannot be reported (73600 radiologic examination, ankle, two views, for example). Supported solely by a brief annotation buried in the note, the provider is limited to charging for the technical component only, or 73600-TC.

Finally, a more direct reference to the necessity for X-ray report preparation appears in the best practices data established by the American College of Radiology (ACR). The ACR’s singular recommendation for radiology reports, called the “Practice Guideline for Communication of Diagnostic Imaging Findings,” comprises the industry-accepted standard that in many instances has been adopted directly and published by jurisdictional Medicare entities such as Trailblazer.

The bottom line on this issue? If you bill it, you must be able to support it. Prepare and maintain reports of diagnostic X-ray services when performing these separately billable services in your practice. These reports can be separate or “standalone” reports in terms of composition, or they can be a part of the E/M note – as long as the X-ray results comprise a discrete aspect of the note, address the medical necessity issues for the X-ray study (who, what, where, when, why), and can be furnished to outside providers and federal/state reviewers upon request (and if they’re separate reports, sign those too!).

About the Author

Michael G. Calahan, PA, MBA, is vice president of physician and hospital compliance for HealthCare Consulting Solutions (HCS).

Contact the Author

mikiecal@hotmail or questions@hcsglobal.net

To comment on this article please go to editor@icd10monitor.com

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