Cloning the Medical Record; Dilated Eye Exam; New Patient Requirements

Cloning in the medical record

Q: I've read a lot about cloning in the medical record, and the HHS Office of Inspector General (OIG) Work Plan includes comments about increased frequency of medical records with identical documentation. How worried do I need to be about my EHR? How much "sameness" is OK?

A: Medicare carriers and contractors have said that documentation is considered cloned when each entry in the beneficiary's medical record is worded exactly like or similar to the previous entries. Cloning also occurs when medical documentation is exactly the same from beneficiary to beneficiary.

Each part of the chart these days has elements that can be generated solely by the EHR, or with elements added by the physician. The chief complaints can be the "labels" or names of the template. If you use these, make sure they match the history of present illness (HPI) content that follows.

The HPI can be made up of a series of queries covering the elements of location, duration, timing, quality, etc. If you use these, make sure they make sense. No one wants to see "duration: 2." Two what? Days? Hours?

The review of systems (ROS) is a routine offender. For instance, inadequate charting might involve: If a physician includes a disclaimer such as "complete 14-point review of systems negative except as noted in the HPI above," and he fails to include the ROS in the HPI; or it is a Level 3 visit and doesn't require a full ROS; or there is a standard ROS blurb that conflicts with something in the HPI.

The physical exam is the second element most frequently cited as a cloning or cut and paste concern. Like the ROS, this information can be significantly out of proportion to the presenting problems. The ROS and exam proportion issue ties directly to the payer position that cloned documentation does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information. Payers will tell you that cloning of documentation is considered a misrepresentation of the medical necessity requirement for coverage of services. They would rather see patient specific details than generic documentation to cover a given topic or element of an encounter.

Physicians also need to consider whether the assessment and plan area overstates the number of problems addressed. A long list of codes with no visible management does not meet medical necessity criteria. Medicare has repeatedly said that it wants to see the number, acuity, and severity/duration of problems addressed through the history, physical, and medical decision making, rather than just seeing it in the A/P section of the chart.

The increased frequency of medical records with identical documentation across services appears as a concern in the OIG Work Plan for physicians for the third year in a row. Stress to your providers that this is not idle chatter: There is concern at the federal level that current EHR misuse results in significant overpayments, and it likely is.

Comprehensive ophthalmological codes

Q:  Does the 92014 ophthalmology code require a dilated exam component?

A: The descriptions of the comprehensive ophthalmological codes in CPT say that 92014 often includes as indicated: biomicroscopy, examination with cycloplegia or mydriasis, and tonometry. It does not say that you must dilate for this aspect of the exam. This said, most ophthalmologists seem to recognize the dilated exam as an indicator of the 92014.

Perhaps of greater concern is the next sentence in the CPT guidance on these codes that says the comprehensive exam always includes the initiation of diagnostic and treatment programs. This may cause more problems for the 92014 or even 92004 codes as these are often used for glaucoma screening or follow up when either no specific treatment or initiation of treatment is provided. I recommend checking with your specialty society for best practices in this regard.

New patient visit requirements

Q: It is my understanding that we have to code an established patient visit if an exam is not done on a new patient. Is this correct?

A: If you code the visit by time you don't need the exam to meet the new patient visit requirements; if you code by the components of history, exam, and medical decision making you do need the exam. Essentially, without the exam, and coding by components, you could still code an established visit.

Most often, when there is no exam there is some amount of counseling going on and the time rules apply. For instance, you must state something like, "Greater than 50 percent of the encounter spent counseling on 'X.'"

Requirements for 99283 and 99284

Q: The CPT manual lists the decision making as moderate for emergency medicine codes 99283 and 99284. Therefore, we assume that if we meet the history and exam requirements for a 99284 that is really all we need. Is there a problem with this approach?

A: There is actually quite a bit more to it than that. In an ER, it is not unusual for the history and exam to be routinely at the comprehensive level, effectively removing those elements as indicators of a given level.

The 99293 and 99284 codes do both have moderate decision making, but if you look deeper in the CPT manual at the nature of the presenting problem associated with each code, you'll find a real difference in the two codes. For a 99283 the CPT manual says, "Usually the presenting problems are of moderate severity." Moderate severity is defined as a problem where the risk of morbidity without treatment is moderate; there is moderate risk of mortality without treatment; there is uncertain prognosis; or there is increased probability of prolonged functional impairment.

For a 99284 the CPT manual says, "Usually the presenting problem(s) are of high severity and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function." High severity is a problem where the risk of morbidity without treatment is high to extreme; there is a moderate to high risk of mortality without treatment; or there is a high probability of severe, prolonged functional impairment.

The 99283 code repeatedly says moderate severity. The 99284 code says urgent evaluation and high severity. Although the label of the decision making is the same, there is a clear distinction between the two codes.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years.

This article originally appeared in the May 2014 issue of Physicians Practice.