E/M coding delay doesn't let you off the hook
E/M coding delay doesn't let you off the hook
Few things can equal the relief of a postponed college exam. You've put off studying until the last minute and you're dreading your scheduled cram session when, lo and behold, the teacher gives you a two-day reprieve. In fact, you're so relieved that you put off studying for a few more minutes while you celebrate your good fortune.
Speaking of celebrations, HCFA's recently announced delay of enforcement of its Evaluation and Management (E/M) coding requirements have led many physicians to breathe a sigh of relief. However, I would argue that just as it pays to begin studying for that postponed test right away, so it is imperative to use this downtime during HCFA's indefinite delay of enforcing the new E/M guidelines to focus on your methods of documenting encounter data more accurately.
Bonuses depend on documentation data
Some of you may argue that physicians with mainly capitated business don't need to document encounter data. My response to that is, "not necessarily." Although it's true that one of the provisions of the new documentation guidelines was that independent practice associations and physicians caring for patients on a risk basis were given a safe harbor from some of the penalties imposed by the requirements, let me point out a sad but true fact: A physician's reimbursement does depend on correct documentation of encounter data.
Here's why: The ability to earn a bonus from a managed care organization you contract with often is affected - directly or indirectly - by data obtained solely through documentation.
Most HMOs or IPAs base these bonuses (or, in some cases, a certain percentage of a participating physician's baseline reimbursement) on parameters that equate with efficient care delivery. One of these parameters is hospital lengths of stay.
The typical retort by a physician who does not receive a bonus because of longer-than-average lengths of stay is, "My patients are sicker." While this may be true, the only way to determine the validity of the statement is to look at the encounter data for a physician's patient population.
If the encounter data do indeed reflect sicker patients because the physician has documented more procedures and diagnoses, then the physician has evidence to support this argument.
But the reverse can be true as well, because numbers don't lie. If a physician has failed to document patient encounters because "it shouldn't matter under a capitated system," then he or she will have no evidence documented that his patients are sicker. Without such evidence, not only will there be no argument that the lengths of stay are appropriate, there also will be no argument that the physician deserves a bonus for efficiency.
How will the reviewer know?
The same logic applies when looking at numbers of patient referrals to specialists. Number of procedures, diagnostic tests performed per patient, and admits per 1,000 can support an argument that your patient population is indeed sicker. Sicker patients have higher numbers in all these areas, but a reviewer (whether the reviewer is an HMO utilization manager or the physician's own IPA) will not be able to tell if the patient population is sicker if the encounter data are not appropriately documented.
In fact, some physicians naturally attract sicker patients. For example, some internists or family physicians specialize in the care of AIDS and HIV-positive patients, even though they are categorized as generalists. If their encounter data do not reflect their sicker patient population, then when they are compared to their generalist peers, they will look like outliers and even be penalized. However, they may be very efficient caregivers for a very ill population. Without assiduous attention paid to encounter documentation, no one will ever know unless a costly chart review is undertaken.
The take-home message? Let us all breathe a collective sigh of relief that the 1997 E/M documentation requirements are going to be put off indefinitely. But we can take even more advantage of our good fortune by turning our attention to improving our documentation procedures. When the test finally comes, we'll be ready with ammunition.
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