Last week CMS issued Transmittal 11842. The Transmittal outlines changes to the instructions for Evaluation and Management (E/M) services within the Medicare Claims Processing Manual. These changes are consistent with those outlined within the Medicare Physician Fee Schedule Final Rule.
However, there is an alarming instruction with respect to contractors auditing time-based E/M services. The instruction states, “Our reviewers will use the medical record documentation to objectively determine the medical necessity of the visit and the accuracy of the documentation of the time spent (whether documented via a start/stop time or documentation of total time) if time is relied upon to support the E/M visit”. (emphasis added)
This statement raises many questions for providers. How will the reviewers use the medical record to determine whether the time documented was accurate? Can providers now expect to have to prove what time they entered and exited the patient room through an independent source? What about the other time they spend on the date of service which is reportable? Are we back to targeting providers who bill for the equivalent of more than 8 hours per day? How will this instruction be applied to split/shared encounters when time is used as the substantive portion?
While we wait to see how contractors will implement this instruction, organizations need to revisit how and when they are reporting E/M services based on time. Detailed policies and procedures are going to be necessary, as well as auditing and monitoring in order to reduce compliance and overpayment risk.
The Transmittal also incorporates prior communications from CMS which indicate when coding and billing for time-based services, the full time must be completed. CMS does not recognize the AMA’s “midpoint” rule. Providers are encouraged to ensure they have established effective safe-guards to prevent over-billing of time-based services to Medicare.
We are here to help. The HBE team is available to assist you with all of your clinical documentation, coding and compliance needs. We routinely provide compliance partner services to large health systems as well as physician practices. Our services include:
- Clinical documentation improvement reviews
- Coding accuracy reviews
- Policy and procedure development
- Customized education and training for clinical and administrative staff
For more information, visit our website at: https://www.hbeadvisors.com/
The Transmittal is here: https://www.cms.gov/files/document/r11842cp.pdf