One of the most concerning aspects of out-patient wound care billing over the last several years has been the use of E&M codes, (Evaluation and Management codes which are billed when a physician and team meet certain criteria) and when they can be used.
Recently, Norton Healthcare in Louisville, Kentucky had paid the federal government over $780,000 to settle allegations of overbilling Medicare. This payment was about double the amount which the government felt Norton overbilled. These findings were focused on out-patient E&M codes, including wound care. Though Norton is not admitting to any wrong-doing, the payment reflects just how serious this issue can be.
The proper use of E&M codes in outpatient centers is compounded by the need to develop your own utilization scale, constant changes in the CMS regulations, and the complexity often associated with your average wound patient due to co-morbidities. Add to this modifiers, debridements, an OIG focus, and you have a perfect storm of coding issues!
The OIG has identified E&M’s in it’s 2011 work plan; On the focus list for 2011, the OIG has indicated that its investigators will “review the extent of potentially inappropriate payments for E/M services and the consistency of E/M medical review determinations.” The OIG will also focus on whether payments for E/M services performed during the global periods of other procedures were appropriate. If you are not ready, this could be scary!
At WCA, we were fortunate to have a billing and coding guru help us develop an exceptional system called C.L.E.M.S. (Clinical Level of Evaluation and Management System) which we installed directly into our EMR (Electronic Medical Record) program several years ago. This year, we have over-hauled our entire system with input from our clinical, compliance, billing, coding and legal teams. The end product is E.M.M.A, (Evaluation and Management Matrix Assessment) and she is a beauty! The system allows for independent levels between the professional and the technical (or hospital) teams, a simple check tool, and constant updates as needed. This system is integrated right into our Electronic Documentation allowing for it to be quick, accurate, and most importantly; used.
If your center is not currently using some kind of scoring system, please contact us immediately so we can help. I can guarantee you that our cost will be less than $780,000!