The problem: Ancillary staff, such as nurses and medical assistants, document elements of the history of present illness (HPI). E/M Documentation Guidelines state that ancillary staff can document the review of systems and past, family and social history but are silent about whether those staff members can record the HPI. That means billing providers – physicians or non-physician practitioners who are the billing providers or are rendering incident-to services – must document the HPI.

I am often asked how to explain the difference between “medical necessity” and “medical decision-making” when speaking to a clinician. The answer, as you might expect, isn’t as clear as you would like it to be and involves insurance companies, litigation, settlements and physician judgment for specific patients.

This chart presents the upper-level denial rates for the 12 specialties that billed E/M visits the most in 2010. These denial rates, based on a Part B News analysis of 2010 Medicare claims data, factored in the total service counts and denied service counts of initial visit codes 99203-99205 combined with subsequent visit codes 99213-99215.

A physician sees a patient for asthma complaints and does an office visit (medical history, physical exam and medical decision-making). As part of the MDM, the doctor also does a spirometry test (94010) and determines nebulizer treatment (94640) would improve the patient’s condition. After the nebulizer is given, the patient receives a post-spirometry assessment for the effect of treatment on lung function. Do you bill the pre- and post-spirometry code (94640) instead of 94010?

This chart shows the denial rates for five nurse physician practitioner (NPP) specialties for E/M office visits, based on 2010 Medicare claims data. For each specialty, the denial rates of level 3, level 4 and level 5 E/M office visits is depicted, based on a combination of E/M codes billed for initial patient visits and subsequent patient visits (99203-99205 and 99213-99215).

While you have only two weeks left to prepare your hospital-affiliated practice for the three-day billing rule set to cut physician payments July 1, practices are no longer charged with deciphering whether they are wholly owned or operated by a hospital and thus subject to the rule. Instead, CMS put the onus on hospitals to determine ownership and implement policies to comply with the rule, said Craig Dobyski, a CMS practitioner services expert, on a June 7 open-door forum conference call.

You may be awarded an extra $20 per Medicare beneficiary per month as part of the Comprehensive Primary Care Initiative (CPCI), a program for which CMS recently began to accept preliminary applications. Primary care practices in Arkansas, Colorado, New Jersey and Oregon, as well as in parts of New York (Capital District-Hudson Valley region), Ohio and Kentucky (Cincinnati/Dayton region) and Oklahoma (Greater Tulsa region) are eligible.

Don’t let non-compliant patients prevent you from collecting copay-free revenue from annual wellness visits (AWVs), one of the few Medicare services with a lopsided profit margin. You can bill AWVs with minimal denial or audit risk by documenting uncooperative patient behavior and doing your part under the letter of the rule, experts say.

Make attesting for stage 1 meaningful use easier by factoring in some of the proposed meaningful use stage 2 requirements into your current workflow. Regardless of what stage of the electronic health records (EHR) process you are in, “you can’t really be focused on stage 1 without considering stage 2,” says Todd Searls, director of regional extension center (REC) operations for Wide River Technology Extension Center in Lincoln, Neb.