Importance of Proper Documentation in Cardiology Billing

A lot of cardiology claims got denied due to improper and incomplete Documentation. It’s really frustrating not to receive insurance reimbursement for the delivered services, though you completed all steps in cardiology medical billing. While focussing on billing and coding guidelines, sometimes cardiologists might not maintain proper documentation. Proper documentation is not only critical in justifying medical necessity and selection of codes but primarily it ensures accurate payments. Proper documentation tells the story of a patient visit by recording pertinent facts, findings, and observations. Insurance carriers will refer attached documents to verify coding choices, site of service, medical necessity, appropriateness, and accurate reporting of furnished services. Let’s see, how we can reduce cardiology denials with proper documentation.

Reduce Cardiology Denials with Proper Documentation

Avoiding Identical Documentation

One of the items that the insurance carriers are looking into is multiple office notes that seem to be ‘cloned’ or ‘identical.’  There are many pitfalls that you can fall into using the ‘copy-and-paste option on your electronic health record (EHR). Medicare contractors have noted an increased frequency of medical records with identical documentation across services. By copying and pasting documentation from previous notes, cardiologists may document more complexity in a visit than necessary. You might even be surprised to see your own health assessment copied and pasted on another physician’s note.

Since the volume of documentation doesn’t always determine the code, make sure the medical necessity warrants the appropriate code you have chosen for each visit.

Some of the proper documentation tips for EHR are as follows:

• Make sure that your review of systems is pertinent to the patient’s chief complaint
• Don’t forget the prime rule, ‘If it’s not documented it wasn’t done’
• Ensure that all EHR documentation authorship is accurately recorded
• Check that the automated code generated is associated with your documentation and correct based on your medical decision making
• Beware of fields that have automatically populated answers
• The EHR must still follow the same guidelines for documenting as when you documented in paper charts
• Just because the information is found somewhere in the EHR, it will not be counted towards your documentation unless you note the date of service as a reference in your documentation
• Your note has to stand alone, applicable to complete EHR documentation

Avoid Documentation Denials for E/M Coding

In addition to the components of an evaluation and management (E/M) service, there are several principles of proper documentation that must be considered:

• The medical record should be complete and legible
• If not documented, the rationale for ordering diagnostic and other ancillary services should be able to be inferred easily
• Past and present diagnoses should be accessible to the treating and/or consulting physician
• Appropriate health risk factors should be identified
• The patient’s progress, response to treatment, changes in treatment, and revision of diagnosis should be documented
• The CPT and ICD-10-CM codes reported on the claim form or billing statement should be supported by the documentation in the medical record

Insurance carriers will request medical records to compare billing (your choice of CPT and ICD-10 codes) with documentation. They will check for the site of service errors, the medical necessity, appropriateness of the diagnostic and/or therapeutic services provided, and an accurate reporting of services provided.

Using Accurate POS Codes

If your claims are being denied, it is important to make sure the information on your claims is correct. One of the billing issues identified by the government as problematic has to do with coding for the location where services have been provided. Recently, the Centers for Medicare and Medicaid Services (CMS) revised instructions for what Place of Service (POS) codes to use for your claims. These instructions, issued as a result of a report published by the Office of Inspector General (OIG) on improper coding practices by clinicians, are designed to reduce errors in POS coding. Specifically, they help cardiologists determine how to assign POS codes when interpreting diagnostic tests outside of the office setting. You can refer to the CMS webpage on the Place of Service (POS) code set for the complete list.

POS codes must be assigned based on the setting in which the beneficiary receives the face-to-face service. Because most services include a face-to-face component, this rule applies to the overwhelming majority of services. Where there is no face-to-face requirement, such as where an interpretation of a diagnostic test is performed remotely, you should use the POS code for the setting in which the beneficiary received the test (also referred to as the technical component (TC)) of the test.

This determination is generally made easily when distinguishing between a hospital and a physician’s office. However, it becomes much more complex when services are provided in the hospital because a determination will still need to be made as to whether the patient is being treated as an inpatient or an outpatient. When reporting POS, CMS instructs providers to pay more attention to the patient’s general inpatient or outpatient hospital status, rather than the precise inpatient or outpatient code. That said, if you know that a determination has been made regarding inpatient or outpatient status that is what should be reported.

We referred to information available on CMS and the American College of Cardiology websites to discuss, how to reduce cardiology denials with proper documentation. Medical Billers and Coders (MBC) is a leading medical billing company providing complete medical billing and coding services. We can assist you in cardiology billing to get accurate insurance reimbursement from private and government insurance carriers. To know more about our cardiology billing and coding services, contact us at: 888-357-3226 or drop an email at: [email protected].

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