Would your charts survive scrutiny?

October 15, 2011

With the Office of Inspector General's heightened awareness of coding and documentation errors, physicians should be aware of some specific areas to check and double-check in their daily routine of documentation.

Johnson reviewed some of the areas that are currently under scrutiny, including place-of-service issues, evaluation and management (E&M) codes, utilization, and diagnostic services.

• Place-of-service issues. Always make sure that place-of-service reporting on outgoing claims is accurate. Some billing systems default to "office" for diagnostic tests and exams, which means someone needs to pay attention and override that setting when the service is provided outside your office-perhaps in the emergency room or a nursing home.

"It's kind of a blessing and a curse that we have both E&M and ophthalmologic (eye exam) codes to work with," she said. "The blessing is that eye codes are easier to work with, they pay a little better, and they are ophthalmology-friendly. The curse is the confusion caused in determining which code set to used.

"The majority of all ophthalmic exams can be identified by using the eye exam codes," she explained, but not all.

When choosing an E&M code, remember all of the elements: history, exam, and medical decision making. If the staff is doing this coding, oversee their work and don't let them take shortcuts, Johnson advised.

Many non-Medicare payers still accept consultation codes and adhere to the same rules that Medicare provided in the past. You need a request for the consultation, usually required in writing, and a written report back to the requesting physician. Be careful to distinguish between a consultation and a transfer of care.

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