The CPT Fun Begins.

It was just a matter of time. BehaveNet has obtained a copy of a letter sent to Optum network providers warning that the insurance company may audit records and approve or deny reimbursement accordingly. Excerpt:

"In the event of an audit, claim submissions with records that do not support an E/M code billed will be denied. You will then have the option of either submitting a corrected claim for the services as supported by the documentation provided for the audit, or submit an appeal with additional supporting documentation.

"We may request documentation to verify the services billed are recorded in a manner consistent with industry guidelines. In line with HIPAA rules associated with Treatment, Payment and Operations, we may ask for Progress Notes to complete the audit. Progress notes should include, but are not limited to: Medication prescription monitoring (if applicable), functional status, symptoms, session start and stop times [sic] modalities and frequency of treatment furnished, clinical testing results (if applicable) and a summary of the following: diagnosis, treatment plan/goals, prognosis and progress to date. Any additional information that is necessary to support the services billed should also be provided at this time."

Those who use EMRs with templates and boilerplate can easily expand on those they already use to cover the items listed here, especially when the same text applies to numerous patients or remains the same over many encounters. For example, my EMR allowed me to prepare a boilerplate item I can add to a note with one click. I can then key in numbers to replace highlighted double question marks before tabbing to the next pair:

"Start time: ??:??; Stop time: ??:??."

However, my EMR keeps diagnoses and medication records separate from progress notes. We will see whether payers find it in their own interest to adapt to such changes. Ultimately they should access cloud based EMRs directly, if only to avoid risks associated with transmission of private information.

I predict such policy by this and other payers will lead better providers to drop out of their networks. The increased time required will add to the overall cost of health care. Premiums may or may not decrease. Availability of providers willing to provide such documentation will decrease, leading to increased morbidity. Payers will require more reviewers to read ever increasing documentation. And when a sufficient number of providers have achieved compliance payers will demand still more documentation in an effort to deny more reimbursement. 

Someday the payers will demand access to a video feed of every "procedure," or maybe I'm just paranoid.

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