How to avoid coding pitfalls for ambulatory services billing

Ambulatory services documentation offers compliance challenges as complex as inpatient services documentation that providers need to be aware of to avoid potential compliance risks while documenting for billing. Ellis Knight, M.D., Senior Vice President/Chief Medical Officer, of the Coker Group, focused on ambulatory coding in an HCCA webinar titled “Clinical Documentation for Compliant Coding—It’s No Longer Just an Inpatient Issue.”

Clinical documentation improvement

Knight noted that coders “speak” a different language than clinicians and therefore clinical documentation improvement (CDI) has been mainly a translational process. Specifically in relation to medical diagnoses, translating what a clinician may write down in the clinical note versus how the coder interprets the clinical note for billing purposes. Historically the focus has been on inpatient documentation, especially documentation to justify diagnostic related group (DRG) assignment and capture of major complications and co-morbidities (MCCs) and complications and co-morbidities (CCs). As a result, the “problem” is that reimbursement occurs with parties arriving at the same diagnosis with different billing codes.

Ambulatory documentation

As such, ambulatory documentation is equally as complex as the inpatient documentation arena, involving thousands of codes. A major complicating factor is that time-frame and volume of patient encounters makes ambulatory CDI a much different work process than inpatient CDI. Knight noted that among the many compliance risks associated with ambulatory CDI, documentation must support: (1) medical necessity of services rendered (CPT codes); (2) specific services and level of care provided to the patient (CPT and HCPCS codes); (3) diagnoses (ICD-10); (4) severity of illness and clinical complexity (HCCs); and (5) quality of care rendered (HEDIS).

For medical necessity, the clinical documentation must justify the ordering of tests, performance of procedures, referrals to specialists or consultants, prescribing of medications and other activities which payers must cover. It must document services and level of services performed, as errors leave practitioners at risk for overbilling the carrier which could result in treble damages under the False Claims Act. Moreover, Knight stressed that it is not enough to just document. HCCs must be documented on an annual basis and addressed, i.e., monitored, evaluated, assessed or treated, in order to be captured. In regards to quality of care, the clinical documentation must include provision of certain quality of care measures, e.g., immunizations, tobacco use, smoking cessation counseling, BMI measurement, obesity counseling, preventive care (colonoscopy, mammography).