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More Information: |
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| • The Problem | ||||
| • The HCFA E&M Guidelines | ||||
| • History | ||||
| • Physical Exam | ||||
| • Decision-Making | ||||
| • Summary | ||||
| • The Solution | ||||
| • Key Benefits | ||||
| • Clinical Setting |
ZapCode
Everything you want to know about Zapcode and more is below. Use the navigation bar
to the left to jump to a specific location of text. All sections end with a "back to top" link, which
will bring you back here.
Click here to go to the ZapCode product page. or click here to view the
ZapCode Manual.
Need more specific questions answered about ZapCode? Go to our FAQ'S section on our support page.
Take a look at the "detailed information" pages for the other ZapMed Products, ZapBill & ZapICD.
The Problem
The Health Care Financing Administration (HCFA) which sets the rules for Medicare physician services has embarked on a campaign to reduce "fraud and abuse" by physicians. HCFA feels that there is a significant amount of "up-coding" of physician charges as well as outright fraudulent billing.
The campaign to encourage medical practitioners to bill properly has two components. One is a newly updated set of guidelines for selecting the proper billing code (HCFA Evaluation and Management Guidelines). The other component is a series of audits of physician practices to measure compliance with the guidelines. Practices that cannot document compliance with the guidelines are often accused of Medicare fraud and face heavy fines. The key here is that the practices must document their compliance with the guidelines. This documentation must exist in the patient's chart. The audits will look for written evidence in the chart of each of the components that make up each CPT charge. If there is not written evidence that all of the claimed components of a claimed charge code were actually performed, the auditors assume that the service was over-billed. Up until now, the auditors have seemed to be looking for maximum impact by assuming that undocumented billing is fraudulent billing.
The problem, as anyone who have ever worked in a medical office knows, is that medical decision making is complex (even for "simple" problems) and that physicians do not always produce written documentation of everything they consider when they have a patient encounter. Negative findings are frequently omitted from written documentation. Positive findings that are unrelated to the presenting complaint are often not documented in the current visit note. They may be documented elsewhere in the medical record. The physician is aware of the findings and has taken them into account in his or her decision making for the current problem.
The problem is compounded in that the new HCFA EM guidelines are very complex and very specific in their requirements for documenting patient encounters. Many practitioners feel that the documentation guidelines represent an overly onerous burden that requires significant additional time on their part with no resulting improvement in patient care. Various medical groups have appealed to the HCFA to relax the guidelines to be less of a burden. HCFA, for its part, has been reluctant to back down from its position.
Even though the "final" version of the HCFA EM guidelines have not be approved, the HCFA audit of physician practices continues using the "proposed" guidelines. The reality is that the guidelines are in place and are being enforced.
Some practices have developed simplified guidelines or grids that attempt to shortcut
the EM Guideline process. However, these run the risk of overbilling and underbilling. A recent case brought by federal prosecutors in Chicago against an ER billing company
highlights these problems. They created lists of common ER problems and billing codes. Since these lists didn't
take into account all of the E/M Guidelines factors, this led to inaccurate billing and a federal prosecution.
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The HCFA E/M Guidelines
Just what do the HCFA E/M guidelines say must be done?
The guidelines specify standards to use in assigning the CPT evaluation and management billing codes. These codes are in the 99000 series of CPT codes and cover the majority of billing by medical practitioners to HCFA.
They provide definitions and documentation guidelines for the three key components of E/M services and for visits which consist predominately of counseling or coordination of care. The three key components--history, examination, and medical decision making--appear in the descriptors for office and other outpatient services, hospital observation services, hospital inpatient services, consultations, emergency department services, nursing facility services, domiciliary care services, and home services.
The guidelines are intended to produce consistent billing by requiring complete documentation of the clinical encounter. The E/M codes are intended to standardize the way physicians, coders, and claims processors code patient visits.
The E/M guidelines specify three main components that are used to determine the proper
billing code. These are the history, examination, and medical decision making. Additional components that may affect
the selection of the proper billing code are counseling, coordination of care, presenting problem, and time.
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History
The history component consists of chief complaint (CC); the history of present illness (HPI); a review of systems (ROS); and past, family, and social history (PFSH). The guidelines are very specific on the factors that must be documented within each of these components. For instance, the history of present illness consists of: "The HPI is a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present. It includes the following elements: location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms." For purposes of ROS, the following systems are recognized:
• Constitutional symptoms (e.g., fever, weight loss)
• Eyes, Ears, Nose, Mouth, Throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Integumentary (skin and/or breast)
• Neurological
• Psychiatric
• Endocrine
• Hematologic/Lymphatic
• Allergic/Immunologic
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Physical Examination
These types of examinations have been defined for general multi-system and the following single organ systems:
• Cardiovascular
• Ears, Nose, Mouth and Throat
• Eyes
• Genitourinary (Female)
• Genitourinary (Male)
• Hematologic/Lymphatic/Immunologic
• Musculoskeletal
• Neurological
• Psychiatric
• Respiratory
• Skin
There are different requirements for the physical examination depending on whether
the physician is performing a general multi-system exam or a single organ system exam. The latter would be common
for specialists. Each level and type of exam has specifications for examinations that must be documented and this
information is taken into account in arriving at the proper billing code.
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Medical Decision Making
The third major component of determining the proper billing code is the degree of complexity of the medical decision making that the practitioner must perform. "The levels of E/M services recognize four types of medical decision making (straight-forward, low complexity, moderate complexity and high complexity). Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:
• the number of possible diagnoses and/or the number of management options that must
be considered;
• the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained,
reviewed and analyzed; and
• the risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with
the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options."
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Summary
The actual rules for selecting the proper code take all of these factors into account
and are complex and specific. The document that describes the E/M guidelines is over 50 pages with many tables
specifying the procedure to arrive at the proper code. American College of Physicians President William Reynolds,
MD, estimates that doctors could expect an additional 140 200 minutes a day correctly documenting 20 patient
visits. It is difficult for practitioners to determine the proper billing code quickly and easily.
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The Solution
By now you must understand that the process to determine the proper billing code is
so complicated that you may be exclaiming: "I need a computer to do this!" Exactly. However, the problem
with most computers is that they aren't that handy. They tend to be large and anchored in place by wires. The Palm
computer is different. It is "handy". It can be held in your palm and is easily carried in a pocket.
ZapCode is computer software that runs on the Palm computer (and also on the larger Windows variety for use when
they are handy). ZapCode quickly and easily collects all of the information necessary to make a decision on the
proper billing code. It is programmed with algorithms that incorporate all of the rules in the HCFA E/M guidelines.
It quickly and accurately determines the proper billing code. It can also help with documentation by printing out
the factors that went into deciding on the proper code.
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Key Benefits
• Fast, easy, portable billing code calculation
• Runs on Palm and Windows computers
• Creates a record of services for audit
• Ensures accurate selection of the proper CPT code according to the HCFA Evaluation and Management guidelines.
• Helps prevent Up-coding and Down-coding
• Up-coding (billing a code higher than allowed by the guidelines) is a problem because of the risk of penalties
during an audit.
• Down-coding (billing a code lower than that allowed by the guidelines) is a problem because the practitioner
is not receiving proper reimbursement for services rendered.
ZapCode allows the practitioner to quickly accurately determine the proper code for
the services they have performed. It takes less than a minute to check off the services and the ZapCode then calculates
the proper billing code. We have designed the ZapCode to be simple to use. For maximum portability and ease of
use, it runs on the 3Com Palm Pilot handheld computer. It also runs on the Windows platform. It can save and print
a record of the factors that went into determining the billing code. This can be part of the documentation for
the medical record to show compliance with HCFA E/M guidelines in the event of an audit. ZapCode can also be used
to perform chart reviews and self audits to give practitioners feedback on proper billing procedures.
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In the Clinical Setting
ZapCode has been designed to integrate easily into the workflow of the clinical setting.
This makes it a tool to improve productivity. It uses the organizing and scheduling capabilities of the Palm computer
to provide workflow management. Each clinician's schedule is maintained using any compatible scheduling program.
This includes most of those available for the Windows and Macintosh operating systems. At the start of the day,
each clinician's Palm computer is "synched" with the master schedule. This is a simple process of placing
the Palm computer into a cradle and pressing a button. It takes less than a minute. It is so fast and easy to "sync"
the computers that it is easy to repeat this process during the day to keep the Palm updated with schedule changes.
As the clinician sees patients during the day, they are selected from the built-in "Date Book" Palm application,
the appropriate information is entered into ZapCode, and the proper billing code is determined. (If the patient
is not on the schedule, they can be easily entered at the time of service.) The proper billing code can then be
checked on the office superbill/route slip for patient checkout or the billing documentation page can be printed
immediately using the Palm computer's built-in infrared transmitter to an infrared capable printer. Documentation
of the billing code for each patient is saved in the Palm computer. The documentation is automatically "synched"
with the master computer and can be printed or saved in electronic format. Since the Palm is so portable, the clinician
can carry it everywhere and it is always handy. Even on rounds in the hospital! We might add that there exists
a large amount of medical software for the Palm computer. Many clinicians have found this software invaluable in
improving the quality and efficiency of their medical practice.
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References on HCFA E/M coding accuracy:
Billing for physician services: a comparison of actual billing
with CPT codes assigned by direct observation
[see comments] SO - J Fam Pract 1998 Jul;47(1):28-32 TA - J Fam Pract VI - 47 IP - 1 PG - 28-32 DP - 1998 AU -
Chao J AU - Gillanders WG AU - Flocke SA AU - Goodwin MA AU - Kikano GE AU - Stange KC AD - Department of Family
Medicine, Case Western Reserve University,
USA.
Variability in code selection using the 1995 and 1998
HCFA documentation guidelines for office services.
Health Care Financing Administration. SO - J Fam Pract 2000 Jul;49(7):642-5 TA - J Fam Pract VI - 49 IP - 7 PG
- 642-5 DP - 2000 AU - Zuber TJ AU - Rhody CE AU - Muday TA AU - Jackson EA AU - Rupke SJ AU - Francke L AU - Rathkamp
WT AD - Department of Family Medicine,
Saginaw Cooperative Hospitals and Michigan State University, 48602, USA.
For more information:
Mark H. Spohr, MD
Medical Informatics, Inc.
PO Box 6984 Tahoe City, CA 96145 USA
Phone: 1.530.583.3097
Fax: 1.530.583.3146
Email: Email Contact Form
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