* Can we ask a physician for more documentation?
* How can we settle compliance turf battles?
* HIPAA: How to test information security

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Compliance Hot Topics: Billing and Coding, EMTALA, Stark, HIPAA

Question of the Week

Welcome to Compliance Monitor Q&A!

Our mission is to answer your difficult compliance questions-and your simple ones, too. To submit a question, send it to Compliance Monitor Q & A editor Laura Motta at lmotta@hcpro.com. We hope you enjoy this service and we welcome your feedback.

This week's questions

• Can we ask a physician for more documentation?
• How can we settle compliance turf battles?

• HIPAA: How to test information security

• Would you be interested in learning how other organizations structure their compliance, privacy, and risk management functions, set procedures, train new employees, and handle reporting and budgets?

Q: If we're looking to assign a higher level evaluation and management code, is it acceptable to return a chart to a physician for additional elements? In some cases, physicians fail to document a complete review of systems (ROS) or a complete exam. Does it even matter whether the visit warrants the higher level?

A: I would not suggest that coders prompt physicians to change medical records after the fact. For starters, when you assign the evaluation and management (E/M) level of service, you must consider the following variables:

• History
• Examination
• Time
• Nature of presenting problem
• Complexity of medical decision-making
• Coordination of care
• Counseling

But when a physician fails to document a complete review of systems (ROS) or a comprehensive exam, you must assume that the physician did not perform them. What's more, if you challenge a physician's assignment of an E/M, your request may be misconstrued. Some physicians may see this as a non-medical staff member questioning their medical decision, even when most other physicians may code a higher level for the same diagnosis.

TIP: You may want to perform an internal chart audit to determine whether your physicians are correctly coding their E/M visits. I would also suggest an educational outreach program for your physicians, and then follow that up with medical record audits to measure its effect.

Ask your compliance department to help create forms to assist physicians in documenting each exam, and a ROS form that each patient or physician may completes at the time of service. The auditing caveat here is that physicians must note on the ROS form that they reviewed it, and then they must sign and date it. Keep these forms as a permanent part of the patient record. E/M education should be an integral, ongoing effort for all involved.

This question was answered by Barbara Aubry, RN, CCM, CPC, DABQAURP, a clinical business analyst with Info-X-Inc.

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Get internal investigations advice from experts

Join HCPro for the 90-minute live audioconference, "Internal Investigations: Know the Risks, Reap the Benefits" and gain tools and strategies to conduct efficient, effective, and beneficial internal investigations and self-audits.

This program will be presented on Thursday, July 24th, 2003, from 1:00-2:30pm (Eastern). To register or learn more, click here, or call our Customer Service Team at 800/650-6787. Be sure to mention Source Code EZ1285A.

Go to "HIPAA: How to test information security" for the rest of this article. The cost is $10. Subscribers to the online version of Health Care Auditing Strategies have free access to this article. Subscribers to the print edition can find it in their June issues.

A $30 steal!

You can read this article-and much more-in the June issue of Health Care Auditing Strategies. Your cost: Four stories for only $30! You'll learn tips for preparing your sample selection, and why now is a good time to start auditing your rehab claims. Choose between a PDF or HTML version for just $30. Online subscribers have free access to this issue. Print newsletter subscribers can find it in their mailboxes.

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Hotly debated and long awaited

The final EMTALA rule is due out within weeks. It's going to have significant implications for hospitals. In short, EMTALA governs the way hospitals have to manage patients coming into the emergency department, and how and when those patients can be transferred. Join us for a live 90-minute audioconference, "EMTALA Final Rule: New Strategies for Compliance" on July 14 beginning at 1 p.m. Eastern. Our speakers will dedicate half the program time to answering your questions.

For information or to register, CLICK HERE, or call our customer service department at 800-650-6787. Be sure to mention Source Code EZ1401B.

A: To read the answer to this question, click here.

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To submit your answer, go to the Question of the Week at Complianceinfo.com.

Here are the answers to the last survey:

Are you concerned that the new outliers rule will have a negative impact on your organization's reimbursement?

• Yes: 41%
• No: 38%
• I'm not sure what impact the rule will have on our reimbursement: 21%

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Send your comments and questions about Compliance Monitor Q&A to:

Laura Motta
Editorial Assistant
lmotta@hcpro.com