The main purpose of the medical record is to produce an accurate, legal, and legible document that serves as a comprehensive account of healthcare services provided to a patient. Documents/reports supported in this chapter will meet the criteria as described in Chapter 7 (section 7.2 - Purpose). The CDA book provides clear and easy to use guidance to implement the standard, with numerous examples covering many of the nuances of the standard. Readers can learn not only how to implement healthcare IT using the CDA standard, but to 'speak' in the language of the standard, and to understand. DocuMed improves the quality and affordability of health care by providing quality electronic medical record and outcomes analysis software products and services. Clinical documentation is used throughout healthcare to describe care provided to a patient, communicate essential information between healthcare providers and maintain medical records. The CDA Book describes the HL7 Clinical Document Architecture Release 2.0 standard, a standard format for clinical documentation. It is thus intended for.

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HMSA periodically conducts post-payment reviews of evaluation and management (E/M) coding to determine whether services were coded at the appropriate level of care and, when applicable, whether criteria for the use of modifiers were met.

Coding reviews are conducted by the Medical Management department as part of its utilization management activities. These reviews provide an opportunity for HMSA to share information about coding and documentation guidelines with practitioners. The process is described in further detail below.

In the event of potential fraud and abuse of E/M coding, a fraud and abuse investigation may be conducted by HMSA's Benefits Integrity Department, in which case the process described below would not apply. For more information, please see Fraud and Abuse Investigations.

The Process

Coding reviews focus on practitioners with billing patterns that differ from their peers. For each practitioner reviewed, a sample of records will be requested for review by a certified professional coder (CPC).

If the CPC reviewing the records believes that a particular claim was incorrectly coded, records are reviewed by a second CPC. If the second CPC concurs with the first CPC, the code billed will be deemed inappropriate. If the second CPC does not concur, the case will be forwarded to a third CPC for the final determination. All findings of incorrect coding are reviewed with a medical director.

Medical directors will asses the level of medical decision making when the chief complaint or established reason for the visit does not warrant the level of care billed. Documentation that is not relevant or necessary to the patient's clinical condition for which they are seen will not increase the level of the visit.

For these cases, the final code will be based on medical necessity and the complexity of the medical decision making.

In accordance with CMS guidelines, 'Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided to maintain an accurate medical record.'

For each practitioner reviewed, HMSA will provide a list of the claims reviewed with review findings and service dates.

If the findings indicate that the practitioner did not meet the minimum compliance rate set for reviewed E/M services, the following will apply:

• For practitioners being reviewed for the first time: HMSA will forward its findings to the practitioner with educational information on E/M coding and opportunities for improvement.
• For members covered by a government plan (e.g., Federal Plan 87, FEP, 65C Plus, QUEST), or a self-insured plan, HMSA will request a refund following the first review if one or more reviewed claims are determined to be overpaid.
• For practitioners undergoing subsequent reviews: HMSA will forward its findings to the practitioner with a request for a refund of HMSA's payment for claims that were overpaid. Payment is due within 30 days of the date of the determination letter. If a refund check is not received from the practitioner within 30 days, the requested payment amount will be deducted from future payments.

Benefit overpayments may also be deducted from future payments based on projected findings of the review. For more information, see Benefit Overpayment.

If the findings indicate that the practitioner undercoded for selected E/M services, corrected claims may be submitted for additional payment.

Copies of CPC or medical director review worksheets will be made available upon request. Instructions on how to request the review worksheets will be included in the determination letter from HMSA.

If a practitioner disagrees with HMSA's findings, they may appeal the decision. The appeal must be submitted in writing to the address indicated in the determination letter from HMSA and must identify the specific case(s) the practitioner disagrees with. A rationale must be included for each case, stating why the practitioner believes the finding(s) are incorrect.

Documentation

Legibility is the key to good medical record documentation. If two CPCs find that portions of the records submitted are illegible, the illegible information will not be considered when evaluating the key components of the visit. This may result in reducing the code to a lower level of service. If information needed to review the record is insufficient due to illegibility, the claim will be considered overpaid for the total amount of the service.

Review Criteria

The following criteria will be used when conducting post-payment reviews of E/M coding:

• The applicable E/M service guidelines, descriptive terms, and identifying codes published by the American Medical Association (AMA) in the Current Procedural Terminology (CPT) manual for the year services were performed.
• The Centers for Medicare and Medicaid Services (CMS) 1995 or 1997 Documentation Guidelines for E/M Services.

In the event an issue is not clearly defined in either resource, HMSA will rely on published guidance from Medicare.

Review Tools

HMSA's CPCs use a documentation checklist and review worksheet when evaluating coding for appropriate level of care. Links to these tools are provided below.

• Coding Worksheet - Established Patient Visit - 95 - The review worksheet used for coding of established patient office visits based on CMS's 1995 guidelines.
• Documentation Checklist - A checklist of key documentation guidelines based on the most current version of the American Medical Association's CPT book.

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Providers are encouraged to use the documentation checklist and worksheet for self-audits and staff training.

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MM: July 2011