Health Information Management

News: CERT report of Part B billing/coding errors a good training tool for CDI specialists

CDI Strategies, December 10, 2009

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A recently-released Comprehensive Error Rate Testing (CERT) report detailing coding/billing errors made by Part B (physician) providers is also an excellent CDI training tool, saysGlenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, an independent consultant located in Madison, WI.
The report includes a wide variety of specialties (anesthesiology, cardiology, emergency medicine, critical care, urology, neurosurgery, and many more) from providers located in Wisconsin, Illinois, Michigan, and Minnesota. The errors are taken from claims submitted between April 1, 2008 and March 31, 2009.
While the CERT report pertains to professional services, CDI specialists working to clarify documentation in the medical record for inpatient hospital claims should also take note of the findings detailed in the report.
Many of the errors include downcoded E/M levels in which the physician reported a diagnosis without documented evidence of how he or she arrived at the determination of that diagnosis, proof that it’s not enough to have documentation of a diagnosis without context. For example, page 21, item 27 of the report states the following:
Service Incorrectly Coded
Billed CPT 99214. Refer to 1995 and 1997 E/M guidelines, CPT 2008 and PUB 100-04, Chapter 12 § 30.6.7. CPT 99214 requires 2/3 of the following key components: Detailed history, detailed exam and medical decision making of moderated complexity. Documentation submitted supports down code to 99213 with an expanded problem focused history, expanded problem focused exam and medical decision making of moderate complexity. History/exam shows no documentation reviewing/assessing details of diagnosis codes submitted on this claim.
“This says that the elements of the history of present illness—location, quality, duration, severity, associated signs and symptoms, and modifying factors—in other words, what the doctor was thinking, based on the nature of the chief complaint—may have had little to do with the diagnosis he wrote or the presenting problem,” Krauss says. “If the physician didn’t evaluate the organ systems or body area, it makes it difficult for CDI specialists to ask the doctor what the patient’s diagnosis is.”
Krauss acknowledges that some physicians sign query forms without devoting much time to reviewing them, which makes it imperative that CDI specialists include evidence from the medical record when posing a question.
“We don’t want to put words in [the physician’s] mouth and ask for something that the physician wasn’t really thinking of,” he says.
The bottom line for CDI specialists: Be cognizant of what the patient came in with, seek to determine the physician’s thinking through his or her review of systems, review the nature of the tests ordered by the physician, and then ask questions about possible diagnoses. And seek to obtain documentation in support of diagnoses, not just the diagnoses themselves.
Read the CERT report here:

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