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Hello everyone, this is Michael MIscoe with MIscoe Health Law with this week’s installment of ChiroSecure’s Growth Without Risk podcast series. And today we’re going to talk about evaluation management services.
The focus turned away from content related to the history and examination.
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Now all that’s required is that you have to do an appropriate history and exam, whatever that is depending on the encounter, which may interestingly enough include no history and exam. For example, if you’re doing a report of findings or something like that, you already have a current history examination.
Now you’re here. Thank you. To go over the results with a patient so you would not document a history and exam because you don’t really need to. It’s not appropriate for that encounter. Nonetheless the instead of history examination, medical decision making accounting for the level of service, now it’s just about medical decision making or time, and we’re going to talk about both of those scenarios, but first we have to talk about, is it appropriate to bill and evaluation management in the first place?
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Now, there’s a presumption not supported by the rules, interestingly enough, that you can bill you have an automatic right, if you will, to bill an Evaluation Management Service on the patient’s initial visit. Especially where you’re going to institute therapy of some sort at that encounter, or do a diagnostic test, or any other procedure or service.
Certainly, where the Evaluation Management Service is the only. service you provide, certainly you can bill it. And in that scenario where there’s no other procedure or service by the same provider on the same date, you don’t need the 25 modifier and you should not report it. The 25 modifier is only used when the evaluation management service is billed in addition to any other thing.
An E& M and an X ray, because you did an X ray, now the E& M needs a 25 modifier. And the issue is the 25 modifier justified? What we have to look at in that scenario is what does a 25 modifier mean? It means significant separately identifiable, evaluation management service performed on the same day as any other procedure or service by the same provider.
So an X ray would be any other procedure or service. Having established that what makes the E& M significant and separately identifiable? Interestingly enough, in Modifier 25, that term is defined as meaning you have documentation to support the E& M. But there’s also guidance that says it has to be more than the usual amount of E& M associated with whatever the other service is.
And that’s where it gets a little tricky because the The therapy services, for example, or the decision to perform an x ray, is it going to require a certain amount of evaluation management service? Question being, are you doing more than that? And that always ends up being a subjective analysis.
That being said, you’re fairly safe billing the initial evaluation management service for a new patient or the initial evaluation management service for an established patient where the established patient is starting a new course of care for a new problem or maybe after having been absent for several months the patient’s condition there was a recurrence, usually with a mechanism.
And in that case, you’re establishing a new course of care and therefore you can usually bill an evaluation management service. Now, where docs get in trouble is where they. Do what I would call pro forma re evaluations every 12 visits, every 30 days, and they do it because 12 visits or 30 days have passed not.
To evaluate changes in the patient’s condition necessarily or to demonstrate that there’s a revised diagnosis or a revised plan of care. From that perspective, be very cautious. I would not recommend that you bill your routine reavals. Now, during the course of care. If something significant were to happen, a patient fell out of a tree they developed a new problem basically something that causes all your diagnoses to come into question, your plan of care to come into question, then you’re going to have to do an additional history exam work, of course, that won’t really influence the score of the E& M, but The decision making that it prompts, meaning you’re going to have to re establish your diagnosis, re establish a new plan of care change your discharge date, maybe you’re doing different therapies something, but that decision making would generally And I say air quotes generally payers differ widely on this, but would support reporting the E& M with modifier 25.
Now, if you’re doing patient fell out of a tree, you do your history exam, your diagnoses don’t change, your treatment plan doesn’t change, and ho hum, you continue, for another three times a week for four weeks, don’t fill an E& M. Okay? You’re gonna have medical necessity problems anyway, but, that is not the basis by which you bill an evaluation management service.
Again, something has to change and the decision making associated with that change is going to become the predicate for the 25 modifier and billing the E& M separately. Now, you need to watch your E& M billing profile because providers get audited routinely when they bill E& M services too often.
Or too predictably when a payer sees an E& M every 30 days or once a month every 12 visits, whatever it is that is a pattern that’s going to get you audited. And usually the reavals are where you’re going to get clipped. And if they do a statistical projection. Depending on what the look back statute is in your state, how far they can go back it can be a fairly sizable number.
I’ve seen providers foolishly billing E& M separately on every date and that is quickly going to get identified and targeted for postpayment review. But if you keep your E& M billing to new problems, recurrences after a significant absence from care where you’re laying out a new plan of care, with objective measurable goals and all that fun stuff then I think you can safely bill the E& M with modifier 25, but it’s important that you understand what the 25 modifier means.
It will get that E& M paid separately, but it has to be justified by the documentation. Now, having So we’ve talked about that. Let’s talk about how we pick the level of E& M. And I’ll start with a very general statement. If you’re using medical decision making to score your E& M as a chiropractor doing physical medicine work, the level of medical decision making is almost always going to come out to a 3.
Whether it’s a new patient or established patient, it doesn’t matter. The decision making criteria are exactly the same for level three, regardless of whether it’s a 203 for a new patient or a 213 for an established patient. Where you’re going to make your points, as it were, there are three components to medical decision making.
Diagnosis management, the amount or complexity of data reviewed, and risk. Okay? Now, under the diagnosis management component, when you have Multiple one or more acute injury conditions, or potentially multi I’ll get into multi or at least, or a chronic condition the diagnosis management element is going to be low.
Now, when you have multiple chronic conditions, which you really shouldn’t have maybe in a reaval somewhere down the road or something like that in theory, the diagnosis management component Could jump up to moderate, but don’t get excited about billing a level four because you have to hit moderate in one of the other two categories.
Data, you’re not going to do it. The most points you’re going to get there is maybe two points for the review and or order of a diagnostic test. You get a point for review, point for order. If you got two points there, that’s low. You’re not going to generally get points. To drive you up into moderate, if you were also to review and order an x ray, assuming that the review of the x ray was not for an x ray that you’re already billing the professional component for, it would have to be let’s say you reviewed an x ray, you reviewed lab results, and you reviewed an MRI.
taken somewhere else and you’re not billing the codes associated with those diagnostic tests, that would get you three points, and that would maybe get you into moderate. But it’s very unlikely that you’re going to have all of that. On the risk side, you’re doing manipulation therapy without risk factors and if there were risk factors, you probably wouldn’t be doing manipulation.
So your risk is always going to land in the low category. So for that reason, for medical decision making, just be sure you document at least two conditions other than a symptom. Okay. So you can have subluxation, cervical radiculitis, lumbar radiculitis, some kind of syndrome, sprain strain, muscle spasm, whatever.
But as long as you have two objectively identifiable conditions that you’re treating that will get you into the low category under Diagnosis Management, and then, of course, just by nature of the services that you’re doing, you’re going to be in the low category on risk, and you got a level three.
Okay? Just make sure that your diagnoses are clear, and then It’s to identify whether they’re acute or chronic. Okay. If it’s a recurrence of a previously chronic and unresolved problem, and it’s now flared up because of a mechanism, which you should document then, it’s acute again. Okay.
So that, that hopefully gives you some very basic guidance on medical decision making. Now, on time You have options for all levels of code. 99211, you’re not going to bill because that’s a no physician present code. So hopefully, you’re there when you’re doing your evaluation. And when we talk about time, your documentation has to change a bit.
So what you’ll need to. Embed in your EMR if you’re spending a significant amount of time with your patients and a level three doesn’t get you there financially, you can build level fours and fives. Understand it’ll get looked at, but you need to be very clear about how you document your time. So here are the components.
Review of history or prior records. So you’re reviewing records from prior visits or prior so you have that element and you put however many minutes you spent doing that. Performance of examination. How many minutes spent doing that? Review of diagnostic test data that’s not billed under another code, meaning, you can’t let’s say, take and do the technical and professional component of an X ray and then bill the time associated for reading the X ray because you’re already paid for that under the X ray code.
But if you’re reviewing data from outside, somebody brings their films and you’re reviewing those films, maybe even writing up your own little report on it. Hooray! That that time can count and you should have that element. Develop diagnosis, prognosis, and plan of care. Time associated with that.
Counseling of the patient. Now I know some of you like to do your report of findings on a second, a separate day. What that hap, what that ends up with in your billing profile is two E& M’s back to back. And it looks odd. I’m not saying it’s. Not justifiable, but, it’s going to draw an audit.
And once an audit happens, you never know where it’s going to go. What I would recommend is that you counsel your patient on the first day and use that time for justifying your level of E& M. Coordination of care. That is coordinating care with other physicians. If that occurs, that time counts.
Understand that time for the, under the new E& M rules, it doesn’t all have to be face to face with a patient like that. The old rules. Let’s say you pull your charts in the morning, you’re reviewing your histories, and let’s say you take five minutes for that patient to review that. Then you see the patient, you’re doing an exam, you do your development, prognosis, whatever, patient’s sitting in a waiting room, then you bring them back in, report of findings, it all that time counts.
And then finally, believe it or not, you do get time credit for time spent documenting the encounter, either however you do that in your EMR or whatever. So that time counts. So those become the bullets. That you’re going to fill in at the end of your note, review of history, prior records, so many minutes, performance of exam, so many minutes, review diagnostic test data, it’s not built under another code, so many minutes develop diagnosis, prognosis, plan of care, so many minutes, counseling, so many minutes, coordination of care, so many minutes, documenting visit.
If the minutes are zero, just put zero, and then you just total it all up. And then based upon the time, whether now new or established makes a difference, just read in the descriptions what your time components are and there’s a range and if you’re in that range, you build that code. But and time can be your friend in a big way, but you have to document it correctly.
I don’t recommend, even though it’s technically appropriate to say total E& M time without the subdivision, So many minutes. Nobody’s going to believe it. Do the breakdown and that way it becomes absolutely justifiable and don’t put like, 45 minutes reviewing past records. A, that’s not probably necessary and no one’s going to believe it anyway.
But B, rational in your time hacks and the reason for the breakdown is to demonstrate Wear this, say, 45 or 60 minutes of time that you spent working on this patient doing an E& M, how it was broken down and it becomes a lot more believable. We talked briefly about E& M profile, but just remember, your E& M profile is something that payers look at.
If you’re billing higher levels of E& M because of time and it’s justified, understand that you might get audited, but as long as your documentation is tight, I’m not really too worried about it. Look at the number of E& Ms you bill, and again, I would withhold billing for routine re exams. I don’t even recommend doing routine re exams.
If you get to 30 days and you haven’t had a reason to re exam the patient, it means your care is not working and you’ve got a bigger problem. And when you’re doing interim evaluations, documenting what has changed with the patient towards your goals I, I don’t necessarily, because there’s an efficient way to do that, we can talk about that in, in another, at another time, but I usually don’t bill reavals associated with that.
Stick to new problem New diagnosis plan of care, recurrence of an old problem, which means restatement of the diagnosis and prior plan of care, documenting how the condition changed since the patient was discharged. And remember, I think we talked about this several months ago. When you have a recurrence, make sure you start your history documentation as of The last prior encounter, five months ago, patient was dismissed.
This was their status. They did fine for three or four months. Then they tripped over the cat, get a head plant into the wall, and now they’re in my office with recurrent, excruciating neck pain. So bridge the gap, as it were. And then the only other time is maybe a discharge of valve, but on a discharge of valve you normally don’t treat the patient that day.
So you do a discharge, you’re going to go over home exercises, activity restrictions, whatever it is. But their last visit could be in E& M without a 25 modifier. And in theory, you could bring a patient back every 6 months just to see how they’re doing and play the medical model. If they have a ongoing chronic problem, maybe you need to change their home exercises because, they’ll tend to accommodate those.
You could bring a patient back and just do E& M’s in theory. And don’t treat. It would look weird to a carrier, but there’d be nothing wrong with it. So hopefully that helps you out with your E& M billing as to when to bill and what level to bill. And we will see you next time. Hi folks.
This is Mike MIscoe with MIscoe Health Law, and I just Finish recording a session on evaluation management services, when to bill them, and at what level. And during that, we touch briefly on billing for routine re evaluations. One, not a fan for reasons of it. Making your E& M profile look weird and it’ll get you audited.
Two you don’t have the juice to support the modifier 25. We spent a little bit of time talking about modifier 25. And a proforma reevaluation every 12 visits or every 30 days doesn’t get you there. Because there’s no apparent reason that you’re doing it other than 30 days have happened, or 12 visits have happened.
And the problem with that is, is that as you well know, patients conditions don’t logarithmically or they don’t change predictably in a linear fashion, such that every 30 days, you’re guaranteed to have a significant change that’s going to warrant a change to your diagnosis or treatment.
It just doesn’t happen. So the reality is you should reevaluate patients. When something significant happens better or worse, they, fall down and go boom their condition is significantly worse, you document the mechanism, and the reason that you would potentially bill that evaluation management is because you have significantly changed circumstances that warrant the additional evaluation management work.
When you do an every 30 day, I’ve read thousands, millions of them, Symptoms, basically the same. Exams, basically the same. There’s an assessment statement the patient’s improving and maybe we’re backing that up with a maybe a slight change in their VAS or something like that, indicating a palliative result, which raises medical necessity problems, but.
The diagnoses are the same, the treatment plan is three times a week for four weeks and reevaluate, and it’s the same old. No payer is going to pay for an E& M for that type of reaval and the reason we’re doing this topic is because I’m going through a truckload of audits right now where payers are pushing back exactly on that issue.
If you want to do every 30 day reavals, knock yourself out, but I don’t think it makes sense clinically. You should do reavals when the patient’s condition significantly changes that would prompt you to potentially change the diagnosis, change the therapy to continue the patient’s improvement.
Now the 30 day thing, if you look at the underpinnings of the every 30 day rule and where it comes from, basically it means if nothing’s happened in 30 days, To warrant a reaval, you need to stop because it means your care is not working. And if your care is not working, continuing. With the same treatment that hasn’t demonstrated any results for the patient doesn’t make any sense clinically.
And it’s no doubt going to be deemed medically unnecessary. Use the 30 days is like a stopping point that if you haven’t done a reavow by then, you’re Because there was no significant change, better or worse, then you have to stop and reevaluate why your care isn’t working. Maybe you order additional diagnostic tests.
Maybe the patient’s not compliant. You have to counsel them. I don’t know what the rationale is, but whatever it is, you need to demonstrate that you’ve identified it. You’ve resolved that problem such that ongoing care is expected to work. And if it still doesn’t work, then you’re done. But just be cautious about billing the routine reaval because in that scenario, there’s no justification for modifier 25 and absent the modifier 25, the E& M bundles into the therapy or other services that you’re billing on the same day.
When you’re doing reavals, consistent with when changes occur. In theory, if there’s a change to the diagnosis or plan of care, where it’s evident that you really turned your brain on and you’re really thinking about what’s going on and what you’re going to do, you could probably get away with a 25 modifier.
Be sure to watch your carrier policies very carefully. There are some payers that will not pay for any reavals. They’ll only pay for the initial encounter. Others, just adopt the 25 modifier, but their view of it is very different than yours, no doubt. Just be cautious and I hope that additional information is helpful to you and clears up any confusion from the initial portion of the presentation.
Till next time.
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