How to Conduct Self Audits for Your E/M Services

Evaluation and management codes figure at the top of the list of services that medical practices tend to miscode most often. These codes are used almost everywhere and there are very specific guidelines around these codes. And getting the right level of E/M service every time for each patient can be challenging.

For example: Auditors have for long had their eyes on E/M coding and incident-to billing – and the scenario has not changed much even now. One would expect practices to be more watchful with E/M coding; but in actuality, error rates have actually gone up, the latest report from CERT suggests.

According to the 2014 Medicare Fee-for-Service improper payment rate went up to 12.7 percent in 2015, worse than the error rates logged in year 2012 and 2013.

But you can safeguard your organization from potential audits and penalties by conducting internal audits before the payers do. Any organization/practice that’s not conducting self-audits at least once a year is living life on the edge as self-audits can help you identify coding issues before they take the form of a complete crises.

How to conduct self-audits

Example: Physician is performing a level-four established patient office E/M (99214); but he is only documenting a level-three service (99213). Here, a self-audit would help the practice locate the problem and provide education to the physician. When medically appropriate, the service needs to be documented well at the 99214 level or correctly coded at the 99213 level. In both cases, the selection of code was incorrect.

How to self-audit E/M coding

This involves reviewing and vetting a lot of documentation. The encounter notes on your claims must reflect all required elements for the E/M level. To put it in simpler terms, during the self-audit review of E/M charts, ensure the documentation for history, exam, and medical decision-making support the level of E/M you are coding. While reviewing claims, you can follow either the 1995 or 1997 E/M documentation guidelines – but you must make it a point to follow them to the letter.

Moreover, watch out for Evaluation and Management Coding: examples where you witness an E/M coding pattern that doesn’t line up with documentation. E/M coding basically involves these two issues: One, coding at a particular level for patients with certain issues and secondly reporting an E/M service every time a patient presents for a procedure.

Get more insight on ways to conduct self-audits and understand the intricacies of E/M coding and pitfalls using Evaluation and Management Coding Handbook of The Coding Institute.

Immigration and Medical Exams – What to Expect and Do

Upon knowledge that one will need a medical exam to go through immigration, it can be a bit overwhelming. In fact, the entire process for immigration is very involved. Thankfully there are many immigration medical exam locations to help.

Within immigration medical exam locations, one may not know what to expect. Here is some great information so that one can be prepared for the process and have it go as smoothly as possible.

What to Expect

First off, the applicant will need to show the passport or some type of photo identification as well as an appointment letter up front. They will go over their medical history with the doctor, and get x-rays, blood tests and of course a physical examination. The physical exam will check ears, eyes, nose and throat, heart, lungs, extremities, lymph nodes, and skin. It’s really more of a screening than a complete exam. It’s important not to ask the medical professional to check for anything else at this time, and simply schedule a later appointment for any concerns.

The results will often go to the embassy or consulate direct, but sometimes they will be handed to the applicant in a sealed envelope. In this case, the applicant needs to bring them from the immigration medical exam to their interview. It’s important that the applicant have an approved physician do their exam.

Common Questions

There are many questions that applicants have in regards to the physical or immigration medical exam, locations are usually happy to answer these but here are the most common and their answers.

What if the applicant had syphilis?

Those applicants that had syphilis must simply prove that they have been treated by giving up a written certificate stating so. If one has ever had a positive VDRL test and they weren’t treated they need to provide a written explanation of why. This should be provided at the immigration medical exam location.

What about a positive tuberculosis test?

In the event of a positive tuberculosis test, the applicant must do the same as stated above but also provide any x-rays that were taken along with treatment.

What actions are taken for pregnant women?

The United States CDC (Centers for Disease Control) allows women who are pregnant to connect with an immigration medical exam location that will use a double layer, wrap-around lead shield when conducting x-rays. Other than that, the exam will be conducted as usual as there are no other concessions than to protect the applicant and her unborn child.

Should any medications being taken be reported?

All applicants who are under treatment for any reason should be aware of the medical condition and the medications they’re taking. They should present any certificate or information related to this and a list of prescribed medications when they go to the immigration medical exam location.

What vaccinations must the applicant have?

Here is a list of the vaccinations currently required by doctors during an immigration medical exam:

Hepatitis A
Hepatitis B
Influenza type b (Hib)
Tetanus and diphtheria

If this list is incomplete the vaccinations will be arranged to be given in most cases. If the applicant has a waiver for one or more of the above-listed vaccinations, they should present it to the examining doctor.

Any other questions one may have can be addressed as well, doctors are happy to guide applicants through the immigration medical exam process and help them as much as possible in order for them to get their visa. Choosing the right location will ensure the process will go smoothly.