ReimbursmentOver a billion claims are filed to Medicare each year.  Undoubtedly, Medicare may make a few payment mistakes along the way.  In order to minimize payments made in error or for the incorrect amount, the Office of the Inspector General (OIG) provides compliance guidance in this area.  Providers are required to submit only correct claims – the first time – and the provider’s documentation must support the service(s) rendered.1

CERT contractors (The Center for Medicare and Medicaid Service’s Comprehensive Error Rate Testing entities) report that they are seeing an increase in Evaluation and Management claim denials due to improper coding and insufficient notes.  In the April 2018 issue of the Medicare Quarterly Provider Compliance Newsletter, CMS says, “the 2017 improper payment rate for E&M services was 12.1%, accounting for 10.6% of the overall Medicare FF (Fee for Service) improper payment rate.”2

While this article focuses on proper documentation as related to reimbursement, there is also increased risk, in the form of malpractice liability, if a provider does not accurately record the service that was rendered.  This is reflected in the AAPC’s (American Academy of Procedural Coders) Coder’s Creed, “If it is not documented, it didn’t happen.”3 CMS echos this in their Evaluation and Management Services bulletin.4

Improper payments can also trigger audits and/or yield increased administrative work when refunds have to be issued for a wrong payment amount received.

Valerie Sisson, CPC, RCC is the Lead Coder for Comprehensive Medical Solutions, Inc. (CompMed). Sisson and CompMed’s certified coding staff review and code thousands of provider’s services every year.  Sisson is instrumental in helping CompMed clients with documenting proper clinical records as well as ensuring the clients receive appropriate reimbursement.  The first priority is for the provider to document correctly and adequately in the patient’s medical record the actual service or services that he/she provided to the patient.  While billing is the next concern, what is documented in the medical record/dictation is what should be coded and billed out.  Accurate dictation/documentation should be given top priority so that charges billed ultimately render the appropriate reimbursement.  Sometimes “add on” CPT codes can be billed, however, not all add-on codes translate into reimbursement.  The most important concern is to properly document all service activity.  Are you leaving money on the table because you are not documenting properly? Is your office issuing a high volume of refunds?

The following items are ones that Sisson sees as recurring documentation or dictation mistakes, and some of these mistakes may lead to over, or under, payment.

NOTE:  The information contained herein corresponds to current coding guidelines at the time this article was written.

Visit Related Services4

  1. Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results
  2. Assessment, clinical impression, or diagnosis
  3. Medical plan of care
  4. Patient Type should be correctly documented so that the appropriate New Patient or Existing Patient CPT can be assigned.  CMS defines a New Patient as an individual who did not receive any professional services from the physician/non-physician practitioner (NPP) or another physician of the same specialty who belongs to the same group practice within the previous 3 years.4
  5. The service setting must be documented accurately, such as Hospital Inpatient, Outpatient, or ER, Office, Skilled Nursing Facility, etc.  There are payment differentials between Facility and Non-Facility settings.
  6. Ensure that Split/Shared Services are documented appropriately.
  7. Ensure that you are complying with Incident To billing rules.


  1. CT Angiography of the Chest – Most standards of care nowadays provide for MIP/3-D reconstruction exams.  Once you have changed to the protocol that includes 3-D reconstructions, you should make sure that your dictation incorporates the discussion of the MIP/3-D reconstruction.  There is no additional reimbursement for this add-on code, however, it is appropriate to include this in your dictation.
  2. Abdominal Ultrasound – Anything less than a complete abdominal ultrasound study is considered a limited abdominal study.  Even if all elements except for one is missing, it is still considered a limited study.  Not billing a true limited study as a limited study can potentially have serious consequences.  In order to bill for a complete abdominal ultrasound, these body areas must be mentioned:  liver, gallbladder, common duct, pancreas, spleen, and kidneys.  If a structure is not fully able to be visualized, for example the pancreas, it is necessary to mention that fact and that would render adequate dictation.  The most common mistake is not to mention the aorta and inferior vena cava.  Not mentioning these areas changes the exam and billing from a complete to a limited study.  It is improper to dictate and bill for a “complete” study when the exam was actually limited in nature.
  3. MRCP – Some protocols include MIP/3-D reconstruction, some don’t.  As mentioned previously, if 3-D reconstruction is performed, it should be dictated and thus billed for.  Additionally, if 3-D reconstructions are performed at a separate workstation as opposed to the MR scanner itself, your dictation should mention that as well.
  4. Contrast and route of administration – Just mentioning that contrast was administered is not adequate.  The route of administration should also be included in your dictation.  For example, intravenous or IV, etc should be dictated.  If contrast and route of administration are not mentioned, then the coder should assign a lower level non-contrast study CPT, which means loss of revenue to you.
  5. Renal/Retroperitoneal Ultrasound – We usually think of this kind of study as having to do with the kidneys and perinephric spaces.  However, for billing purposes, a complete study also requires that you perform and then discuss evaluation of the bladder.  This is especially pertinent if the clinical history has to do with urinary tract pathology.
  6. Mammography CAD charges and CT 3d Rendering – If a CAD is performed on a mammogram, you must state this in your dictation, however, it is not separately reimbursable.  If 3d rendering was performed in addition to a CT, then the dictation must state that 3d rendering was performed.  Not only is this important to provide complete documentation in the patient’s medical record as to what procedure was performed, there may be an additional CPT code that you are allowed to bill.  CAD is included in current mammography CPTs; the CT 3d rendering is separately billable except when the exam is a CTA.
  7. OB Ultrasound less than 14 weeks – The gestational sac and embryos/fetus(es) should be discussed, but it is proper to also notate the amniotic fluid volume and placenta if able to be demonstrated,  the uterus and adnexa should also be mentioned.  Again, if any of these structures cannot be visualized, the absence should be discussed as well.
  8. OB Ultrasound greater than 14 weeks – The fetus(es), amniotic sac, fetal anatomic survey, placenta and location, amniotic fluid assessment and biometry/fetal measurements, and adnexa should be performed and discussed.  An incomplete performance of the fetal anatomic survey/measurements should also be discussed.
  9. Transabdominal and transvaginal Pelvic or OB studies: The reason the transvaginal examination was performed should be documented.  Document if the pelvic structures cannot be visualized.  It is proper to separate the two techniques into two separately dictated paragraphs.
  10. Ultrasound vascular access – You should document the access sites, the patency of the vessel, visualization of the needle entry and access into the organ or vessel.  This procedure also requires that the image is permanently saved or stored.
  11. Conscious sedation – The administration, route of administration, and the trained individual(s) present to assist in the monitoring of the patient should be documented.  You should document when the sedation agent was administered (begin time) as well as when the procedure was concluded (end time).  Many codes do not allow a separate CPT to be billed out for reimbursement purposes, however, it is appropriate to state this in your dictation for appropriate documentation of what was performed.

It goes without saying, terms like “suspected,” “probable,” “rule out,” etc. should not be used.


    1. Ensure you document the correct type of anesthesia rendered:  General, Regional, Moderate (conscious) Sedation, Minimal Sedation, Local or Topical Anesthesia.
    2. Document which provider(s) performed the service: Physician or other qualified provider, like a Certified Registered Nurse Anesthetist (CRNA) so that Personally Performed, Medically Directed, Medically Supervised can be billed correctly.
    3. Apply the correct anesthesia modifier:  Personally Performed is when the physician (MD or DO) personally performed the service alone. An AA modifier is applied. The OIG has listed this as an audit item in their 2016 Work Plan, because AA renders higher reimbursement than modifiers applied for CRNAs.5 Medically Directed is when a physician (MD or DO) medically directs a qualifying individual in 2, 3, or 4 concurrent cases.  Medical Supervision is when the physician is involved in more than 4 concurrent cases.
    4. When applicable, use an appropriate anesthesia pricing modifier:
      • QS – Monitored Anesthesia Care
      • G8 – MAC for deep complex, complicated or markedly invasive surgical procedure
      • G9 – MAC for patient who has history of severe cardiopulmonary condition
      • GC – This service has been performed in part by a resident under direction of a teaching physician
      • 23 Unusual anesthesia
    5. According to Palmetto GBA, when using any of the modifiers in 4 above, do not bill Physical Status Modifiers P1 – P6 when billing Medicare.6
    6. The Pre Anesthesia Evaluation must be performed within 48 hours prior to the surgery.
    7. Document the actual start and stop time of the encounter – do not round time up and do not round time down.

Details are very important.  Details can mean the difference between being paid correctly or incorrectly or lack of appropriate documentation can lead to potential legal consequences.  CompMed routinely discusses dictation and coding matters with its clients.  When is the last time you heard from your coder?  If it’s been a while, call CompMed today for a confidential and complimentary review of your documentation, coding and billing.  Contact Angela Patterson at (423)903-6796


  1. Federal Register Vol 65 No 194, OIG Compliance Program for Individual and Small Group Physician Practices,
  2. Medicare Provider Quarterly Compliance Newsletter, April 2018,
  3. AAPC,
  4. Department of Health and Human Services, Medicare Learning Network, Evaluation and Management Services, August 2017,
  5. Office of the Inspector General, 2016 Work Plan,
  6. Palmetto GBA$File/Webinar_Documenting_Anesthesia_Services_Handout.pdf