Public Policy

Submission Support

Electronic health records (EHR) are assisting physicians and other providers with legibility issues, and can help take the guesswork out of the note’s content. If a physician is still writing notes by hand, a transcription could be sent along with the documentation to prevent unnecessary denials. It is not advisable to do this for all requests, but only for requests involving providers who have particularly problematic handwriting.

Timeliness of Response

Once the documentation request is received, the physician has a small window of opportunity to review the request, collect the information, and issue a response. A lack of physician response always results in a service denial or a refund request. Once denied, the physician must go through the proper channels of appeal (with a different insurer reviewing department). Requests for refunds are more difficult to overturn. It is difficult to “open” a case that has been “closed.” Denials resulting from a failure to respond to a pre-payment request are a bit easier to resolve because the resulting denial is typically the payor’s initial determination of the claim. The physician usually is allowed an appeal of the payor’s initial determination. However, it is not a cost-effective process to handle prepayment requests in this manner. Always attempt to respond to the initial request within the designated time frame. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

  1. Pohlig, C. Documentation and Coding Evaluation and Management Services. In: Coding for Chest Medicine 2009. Northbrook, Ill.: American College of Chest Physicians, 2008;79-109.
  2. Centers for Medicare and Medicaid Services: CR 5971 Clarification-Signature Requirements. Medicare Learning Network Web site. Available at: www.cms.hhs.gov/MLNMattersArticles/downloads/SE0829.pdf. Accessed Sept. 1, 2009.
  3. Pohlig C. Evaluation and Management Services: An Overview. In: Coding for Chest Medicine 2009. Northbrook, Ill.: American College of Chest Physicians, 2008; 65-78.

Coding Tip of the Month

When a payor requests documentation, be sure to include all pertinent information in support of the claim. The request typically will include a generic list of items that should be submitted with the documentation request. Consider the following items when submitting documentation for services listed below:

Initial Hospital Care

  • Codes: 99221-99223
  • Requests to justify the level of service: Physician notes, resident notes, mid-level provider notes; dictations, when performed; admitting orders; labs or diagnostic test reports performed on admission.
  • Requests to identify the correct admitting provider: Include all information above and the registration sheet (to show the admitting group/physician).

Subsequent Hospital Care

  • Codes: 99231-99233
  • Requests to justify the level of service: Physician notes, resident notes, mid-level provider notes; physician orders; labs or diagnostic test reports performed on the requested date.
  • Requests to justify concurrent care: Physician notes, resident notes, mid-level provider notes; physician orders; labs or diagnostic test reports performed on the requested date; specialists’ notes from the requested date (to demonstrate non-overlapping care).

Inpatient Consultations

  • Codes: 99251-99255
  • Submit: Physician and resident notes; physician orders; labs or diagnostic test reports performed on the requested date; documented consultation requests from the requesting provider (these might be in the order section of the chart or in the assessment and plan of the requesting physician’s note from a previous day).

Discharge Day Management

  • Codes: 99238-99239
  • Submit: Physician notes, resident notes, and mid-level provider notes; physician orders; labs or diagnostic test reports performed on the requested date; discharge instructions; discharge summary.

E/M service reported on the same day as a procedure

  • Codes: E/M codes with Modifier 25 (e.g., 9922x-25)
  • Submit: Physician notes, resident notes, mid-level provider notes; physician orders; labs or diagnostic test reports performed on the requested date; procedure report (to demonstrate the separateness of the E/M service).—CP
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