Attention to documentation, decision-making requirements key to avoiding audits

Key Points

San Diego - Accurately coding for evaluation and management (E&M) services billed to Medicare requires mastering subtleties that aren't always spelled out in coding instructions, said Allan S. Wirtzer, M.D., medical director, Mid Valley Dermatology and Cosmetic Surgery Center, Sherman Oaks, Calif., at the 2012 annual meeting of the American Academy of Dermatology.

E&M services account for the majority of services rendered by dermatologists for Medicare patients, Dr. Wirtzer says. However, if one codes too aggressively without appropriate supporting documentation, "You could potentially be targeted for audits," he says.

Conversely, "If you undercode for fear of audits, you could penalize yourself in terms of reimbursement," he explains. "Your comfort level with coding has a profound effect on your ability to run your practice effectively."

By the same token, he says that in light of the push toward electronic health record (EHR) adoption, the Centers for Medicare and Medicaid Services (CMS) is taking a closer look at templates used for medical documentation. "It's easy to use a macro or template," Dr. Wirtzer says, "but if it is not in some way specific to the patient, it could be judged unacceptable."

In other words, CMS frowns upon what it calls production-line documentation systems, Dr. Wirtzer says. "Make sure your templates can be modified to take into account the situation at hand and how the patient is presenting to you. Sometimes in a record, I will see templates that contradict each other when you look at them carefully," he explains.

Abnormal, or not?

To further complicate matters, Dr. Wirtzer says that according to CMS, "There really is no preferred way of documentation. Any system is acceptable," as long is it satisfies a handful of conditions that CMS has specified.

However, "You can't have a notation in the chart of something being abnormal without elaborating" on the abnormality, he says. For example, CMS will reject a notation that a patient's lips are abnormal unless the EHR also indicates in what way they're abnormal.

"Furthermore, you can't be too general with what you say is normal or abnormal," Dr. Wirtzer says. "CMS has specifically said that they don't particularly like the idea of documenting an entire organ system as being 'negative.'"

Dr. Wirtzer says some dermatologists may jot down a phrase such as "total body exam (sometimes abbreviated TBE) negative." However, he explains, "According to CMS, that's unacceptable."

Instead, CMS prefers that physicians spell out which portions of an organ system - or, in the case of dermatology, which areas of the skin - deviate from the norm, and how.