On November 1, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2019. OFFICE OUTPATIENT VISIT CODEIf the EHR gives credit for this information, physicians need to recognize that the E/M level may be inflated, and they should override the code manually, she says.Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019 If the physician isn’t actively managing these conditions, they shouldn’t be counted toward the visit’s E/M level. She provides the example of a physician who includes rule-out diagnoses for continuity-of-care purposes. Does the EHR require physicians to bill a certain code? The code that the system calculates may not be accurate, and physicians always need the ability to override it when necessary, says Jimenez. Everything they do should be based on their own clinical judgment.”ģ. “Physicians shouldn’t be forced to do something just because the EHR is telling them to do it. Do diagnosis-specific templates require physicians to perform certain tasks every time they see a patient? All work must be clinically relevant, says Jimenez. It shouldn’t happen automatically, she adds.Ģ. Best practice is for physicians to manually select what they want to bring forward. This practice is extremely risky because physicians don’t often remember to review the information or they may simply forget to deselect it, says Jimenez. Does the EHR auto-populate information and require physicians to deselect what’s not pertinent to the visit? For example, an EHR might auto-populate a complete review of systems and require physicians to deselect the systems they don’t review with the patient. Jimenez says to consider these three questions:ġ. Physicians should also know whether their EHR might be putting them at risk for upcoding. Have I reported the most specific ICD-10-CM diagnosis code to justify patient severity? What specifically elevates the level of effort that’s required to treat this patient? Have I documented this information in the record? 3. Is this patient sicker than most of the patients I see? 2. To avoid payer scrutiny, Jimenez advises physicians always to ask themselves these three questions before assigning a level 4 E/M code:ġ. Over time, it may appear to payers that a physician is upcoding as compared to peers. “The computer just picks up on keywords and boxes, but it’s not smart enough to realize that a visit might be over-documented,” she adds.įor example, pulling information forward, such as a comprehensive family history or a complete review of systems, can inadvertently drive a level 4 E/M code when the nature of the presenting problem (e.g., otitis media) in no way supports this level of service, explains Jimenez. That’s because the EHR pulls information forward that might not be clinically relevant or even pre-populates information that falsely inflates the actual work the physician performs. When using an EHR, though, it’s easy for physicians to default to a level 4 E/M code that might not be justified, says Jimenez. Payers may deny level 4 E/M codes for patients who respond well to treatment and are generally well-managed, she adds. When physicians report a level 4 evaluation and management (E/M) code, they’re telling payers they should be paid more because their patient requires medical management for an exacerbation of an existing chronic condition, a complication, or a new problem, says Raemarie Jimenez, CPC, vice president of membership and certification solutions at AAPC in Salt Lake City, Utah. The difference between a level 3 and level 4 office visit might not seem like much, but to payers, these visit types each tell a completely different story about the work that’s required to treat a patient.
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