NGS Medicare Releases New Audit Tool

June 30th, 2017 - Liz Wilson, RHIT, CCS, CDIP, CPC, CRC, CEMC
Categories:   Evaluation & Management (E/M)   Audits/Auditing   Documentation Guidelines  
0 Votes - Sign in to vote or comment.

Evaluation and Management (E/M) codes are defined by the AMA Current Procedural Terminology (CPT®) codebook and while they are the most commonly utilized CPT codes, their code descriptions have not changed in years. However, while CPT® defines the three key components as History, Examination and Medical Decision Making for services billed based on documentation (and not time), CPT® does not explain how to meet the different levels within each of these three key components.  Medicare recognizes the 1995 and 1997 Evaluation and Management Documentation Guidelines (DGs) as an official source on how to level the appropriate E/M code based on the provider's documentation. However, seasoned auditors will tell you that 1997 offers explicit guidance on how many and which elements of documentation are needed to meet the any of the four levels of an examination (Problem Focused, Expanded Problem-Focused, Detailed and Comprehensive), whereas the 1995 DGs were vague in explaining the requirements of a Detailed Exam. Exactly how much detail is needed to distinguish between a provider's EPF exam and a Detailed Exam? Most auditors rarely agree between these two exam levels when using 1995 DG since the assessment of a "detailed" examination is a subjective conclusion and typically based on the medical auditor's cumulative experience in reviewing documented exams from multiple medical specialties.

National Government Services Medicare is the Part A and Part B MAC for Jurisdiction 6 (Illinois, Minnesota and Wisconsin) and Jurisdiction K (Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island and Vermont) and they've just released an updated E/M Audit Tool to clearly define how to score an EPF exam versus a Detailed Exam using 1995 DGs.

Previously, NGS Medicare had subjectively defined these as follows:

EPF Exam = 2-7 Body Areas or Organ Systems Detailed Exam = 2-7 Body Areas or Organ Systems

NGS Medicare has newly defined these as follows:

EPF Exam = 2-5 Body Areas or Organ Systems Detailed Exam = 6-7 Body Areas or Organ Systems

This eliminates the NGS Medicare subjective auditing factor that had created gray areas for auditors: the previous NGS tool led to inconsistent audit results among medical auditors, and lacked clear definition and parameters needed in order to better educate healthcare providers on proper exam documentation and how it contributes to the overall E/M level billed. By establishing a point method in counting up the body areas and organ systems, all medical auditors should be able to agree on the level of exam met with the 1995 DGs so long as the auditors are well-versed in the clinical language that describes a visual observation, physical palpation or testing of a body area or organ system. The 1997 DGs offer key clinical language in the descriptions of the bullet points that can better assist an inexperienced medical auditor in understanding which documented words correlate to an examination of a particular body part or organ system.

NGS Medicare previously mandated the use of this revised tool for all Evaluation and Management services dated July 1, 2017 and thereafter, but have rescinded this policy and made the news announcement on their website on June 14, 2017 to declare that this new system is only suggested and no longer mandatory. Providers may continue to rely on the older audit tool to level their examination

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

​​Polysomnography Services Under OIG Scrutiny
September 2nd, 2021 - Raquel Shumway
The OIG conducted a study dated June 2019 wherein they indicated that there were approximately $269 million in overpayments for polysomnography services for the period of 2014 through 2015. According to the OIG “These errors occurred because the CMS oversight of polysomnography services was insufficient to ensure that providers complied with Medicare requirements and to prevent payment of claims that didn’t meet those requirements.” So what are those requirements?
Medicare Advantage - The Fastest Growing Government-Funded Program Undergoing Multiple Fraud Investigations
August 16th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Medicare Advantage is the fastest growing form of government-funded healthcare and the rate of fraud within this segment has come under increased scrutiny. Funding is determined by the health status of each beneficiary; therefore, accurate coding based on detailed documentation makes the medical record vital to the process because some ...
Billing Dental Implants under Medical Coverage
August 12th, 2021 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
Implants can be costly to the patient and the provider, and it is crucial to understand how to bill a patient’s medical insurance to ensure there is adequate coverage for the best treatment. Implants are commonly billed in a dental office under a patient’s medical benefits.    Implants could be considered ...
New Codes for COVID Booster Vaccine & Monoclonal Antibody Products
August 10th, 2021 - Wyn Staheli, Director of Research
New codes have been announced for the COVID-19 booster vaccine, Novavax vaccine, and monoclonal antibody treatment.
Medicare's ABN Booklet Revised
July 29th, 2021 - Wyn Staheli, Director of Research
The “Medicare Advance Written Notices of Non-coverage” booklet, published by CMS’s Medicare Learning Network, was updated. This article discusses the changes to this booklet regarding the use of the ABN.
Chronic Pain Coding Today & in the Future
July 19th, 2021 - Wyn Staheli, Director of Research
Properly documenting and coding chronic pain can be challenging. As is commonly the case with many conditions, over the years, there has been a shift in the identification of different types of pain, including chronic pain. Understanding where we are now and where we are going will help your organization prepare for the future by changing documentation patterns now.
How Does Global and Professional Direct Contracting (GPDC) Affect Risk Adjustment?
July 15th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
CMS recently announced the 53 Direct Contracting Entities (DCEs) that will be participating in the April 1, 2021 through December 31, 2021 Global and Professional Direct Contracting (GPDC) Model. Among those participating is Clover Health Partners, who runs an in-home primary care program that has the potential to help Medicare ...



Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2021 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association