My doctors use an EMR with specific templates for established patient return visits. We recheck the history information on every visit and they only click the physical exam points that they performed that day. However, the review of systems; past, family, and social history; and physical exam look very similar for each patient and each visit. The history of present illness is always different, as is the plan of treatment. An outside consultant that we hired to do some audits denied the E&M visits, stating they were “cloned.” Is she correct? Can Medicare deny an entire claim or not count parts of the documentation—resulting in downcoding the service—because parts of it look similar?
You are not alone with this problem. We have run into this issue in reviewing audits performed by other consultants and compliance officers. The fact that “The HPI is always different, as is the plan of treatment” solidifies the fact that the encounter is not cloned. However, if the ROS, PFSH, and PE are identical, then you may have to prove that that information was recaptured, not copied.
We strongly recommend that you record a unique HPI and develop a new template to “update” the ROS and PFSH, as recommended by the documentation guidelines. For the PE, we would strongly encourage you to only document those exam points that are clinically medically necessary for that visit. This will reduce the likelihood a reviewer would determine that your records have been cloned.
Our practice is providing UroLift as an option to treat BPH. Most of the claims are being paid, but we often have problems getting payment for all the implants that are being used. We are using code 52441 for the first implant and 52442 for each additional implant. Often with private payers, we are only being paid for one additional implant. Medicare will typically pay for six total implants. What should I be doing?
We will split this answer into billing for the physician services and billing for the facility fees. For physician services and for those patients provided the UroLift implant in the office, the codes you have listed above are correct for the reporting of the UroLift and you have correctly noted that you are to report additional implants under code 52442.
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Although many payers have edits that will cap the total number of implants, most payers we have seen will allow up to six total implants without requiring additional documentation or changes in coding. You will need to check with each payer to determine what limits have been put in place for the number of implants and for coverage of the procedure.
The most common problem we have noted, if the service is covered by the payer, is actually a mistake in prior authorization (PA). Make sure that when you obtain prior authorization, you include the number of additional implants that will be used and reported under code 52442. As an example, if you are projecting that you are going to place four total implants, obtain a PA for 52441 x1 and 52442 x3; if you then place more implants, you have then exceeded the PA and will likely receive a denial. In short, make sure that you have a PA that covers the number of implants that you use. Medicare does not require a PA.
Billing for the facility will require that you have the correct reporting of the physician services but may require separate codes. Medicare has developed special interim codes—C9739 for one to three implants and C9740 for four or more implants—for the ambulatory surgery center and hospital. Hospitals are also required to submit the actual number of implants under code L8699. Payment will not change but will be tracked for potential coding adjustments at a later date.
For private payers, you will need to check with each payer for special reporting requirements. As a reminder, payers will match facility and physician coding, prior authorization for the number of implants, and proper reporting of physician services for all implants is required for proper payment to the facility.