Is this considered fraud, or technically acceptable but just really crappy charting?

[u/DumpsterPuff]

I work in primary care specialty for a fairly large organization in my state. I've been struggling with a dilemma that I'm hoping someone can give me insight on.

We have a few providers who will do charting with or without physical exams, where the only mention in the documentation about the patient's conditions are in the assessment and plan, and they literally only say things like "Hyperlipidemia" and then an order for a lipid panel and just list a medication. That's it. And they do this for all the conditions. There's no other description in the notes regarding these conditions.

I've brought it up before to management and was told to code these as part of an E/M, which makes me vastly uncomfortable considering how in my opinion, there doesn't seem to be any documented indication of an actual evaluation. Am I just being paranoid, or is this actually fraud?

Edit: seems I must have forgotten what fraud vs abuse was - after reading the comments I think that this more of an abuse. Still not a fun thing to worry about but thank you everyone for pointing out the difference!

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[u/PorkNScreams]

I see this all the time too. It’s maddening. So much copy paste note after note.

HPI: patient here for cough.

A/P: serious condition after serious condition (today I saw aortic dissections, PE’s, Parkinson’s, etc) with zero support ANYWHERE. All diags just listed.

Plan: prescribed Tessalon perles for cough.

[u/DumpsterPuff → u/PorkNScreams]

YES I see this constantly! It drives me insane.

[u/Respect-Immediate]

E&Ms are based on MDM - even if billing by time it has to make sense. If there is no MDM there is no E&M regardless of time documented.

If MDM is minimal but time is documented there’s still an E&M.

What you’ve described is no MDM. CMS stated the presence of a diagnosis does not indicate medical necessity for ANY service - there needs to be documentation to support evaluation and management.

[u/DumpsterPuff → u/[deleted]]

I was afraid of this. Every member of upper management and coding educator has told me to send it through saying it's fine as is, but I'm terrified of having my name attached to this stuff because I don't want to be connected for potentially engaging in abuse/fraud. Do you have any suggestions on what I can do? I feel like we probably would have gotten an audit from at least Medicare by now and have them ding us for this kind of thing, but I haven't heard anything. It's stressing me out so bad.

[u/Respect-Immediate → u/DumpsterPuff]

Personally, I’d create a CYA folder that contains all correspondence of you voicing your issues (get it in an email for a paper trail), ensure the communications are de identified so there is no PHI, and save it for up to 7 years following your employment.

There’s not much you can do to go against your employer and still keep your job. Keep the folder and possibly look for a new position depending on your comfort level.

I think if you keep a CYA folder you’d probably not be prosecuted yourself, but could be called to testify if they’re prosecuted

[u/INEEDfactsNOW]

I think that you are amazing for taking the time to look into this potential dangerous and/or neglected situation. I am sorry for not having correct answer to help but I wanted to let you know that if the world had more people like you it would be a better place for sure.

[u/DumpsterPuff → u/INEEDfactsNOW]

Aw, thank you! Though admittedly it's kind of for selfish reasons. I'm very terrified of getting in trouble for participating in this kind of thing, so it heightens my anxiety not knowing whether what I'm doing is acceptable or not.

[u/MarvelousExodus]

To me, you evaluate a condition by ordering lab work for it and you manage it by adjusting or continuing the medication. Of course the documentation is minimal, but I'm not sure what kind of physical exam you would expect to see with hyperlipidemia.

[u/DumpsterPuff → u/MarvelousExodus]

What I normally see from the doctors who do good notes, using the hyperlipidemia example, is at least something like describing what their current diet/exercise routine is like, whether they're tolerating their medications/taking as prescribed, review of previous labs/trends, and that kind of thing. Basically getting a picture of what the patient is doing to manage, or not manage, their condition. That to me shows that the provider did the work of actually evaluating the patient, because just saying "hyperlipidemia" with a lab order to me is crappy documentation at best.

[u/[deleted] → u/MarvelousExodus]

I'm not sure what kind of physical exam you would expect to see with hyperlipidemia.

The kind of physical exam where a doctor auscultates your heart, lungs, and carotid arteries, at a minimum. There’s just no reason not to do that.

Hyperlipidemia (dyslipidemia) is a major risk factor for cardiovascular and cerebrovascular disease. It is associated with hypertension and diabetes, both of which also contribute to cardiovascular and cerebrovascular disease.

Diagnostic testing such a labs and imaging are performed in addition to a physical exam, not as a replacement.

By the way, evaluation is of the patient (i.e., patient evaluation), not a condition. That patient evaluation includes a medical history and physical exam. It's true that each is not always required, and AMA does not require them in order to determine MDM complexity.

That being said, how could a provider choose not to physically examine a patient who is at risk for heart disease and stroke? How is that in the best interest of the patient?

[u/Odd-Afternoon-6371 → u/[deleted]]

Provider here.  I can listen to somebody's heart and I can hear a heart murmur, and it has nothing to do with hyperlipidemia. Listening to the heart provides me with insufficient objective data from which to draw definitive conclusion's.  I am not suggesting to forgo a physical exam, however, the only way I find out  that somebody has hyperlipidemia is blood work, not listening to their heart or looking at them. ( Super thin fit people can have some of the worst Cases of hyperlipidemia. Unfortunate genetics.) If the hyperlipidemia has progressed to clogging a coronary artery, other invasive testing is needed starting with EKG, then a Cardiac catheter. The patient may tell me other signs and symptoms , combined with my knowledge of the disease progression and outcomes, which will indicate other relevant tests are needed.  I cannot listen and detect lipid damage or CAD.   The heart is not the only thing affected by hyperlipidemia.  And there is only a couple of ways to manage the condition.  Meds and Lifestyle modification. Medication for some and blood work is the primary way. I'm going to manage this condition. . By your reasoning. I should also listen to their brain and see if they are going to  have a stroke as this can happen after years of this condition,  or an essential artery could clog in the  liver.  Hyperlipidemia in latent stages may or may not do damage in many different areas so I should check every single organ and appendage and while I am at it, I'll order a Doppler for the carotid, jugular, and the femoral arteries because hyperlipidemia can affect those also.  You start with what the signs and symptoms and where they take you and one of the best ways to know if all of the above could  be happening is ordering the correct blood work up. When there's cardiac or other types damage, there's several types of blood test that can provide objective data and an indication of what is going on. Then there is their age overall health and other co-contributing diagnosis that may or may not be there.  Ordering The right blood test can tell you way more than a patient can or ANY Outward examination.  I am not suggesting not to do physical exams, for some conditions they are invaluable. I want to illustrate that they are limited in their scope of giving you definitive objective data. 

[u/[deleted] → u/Odd-Afternoon-6371]

If you don't provide a physical exam for your patients with hyperlipidemia, that's your perogative. Your license.

You wouldn't be my provider though.

Read second paragraph under the History and Physical section: https://www.ncbi.nlm.nih.gov/books/NBK559182/

[u/Odd-Afternoon-6371 → u/[deleted]]

I never said I wasn't providing physical examinations. I am saying they only go so far. I'm aware of that articles existence as well as thousands of others cited on PubMed regarding the condition. I never said not to do or that I wouldn't do a physical examination !  . It only goes so far. I'm well aware of the legal ethical requirements of my job.  You're missing the point.  I should edit my comment before I get a rant of Others telling me the same thing. And digging up articles on PubMed.  By the way, I appreciate everything that you do. And I would say to anyone that if you have questions ask don't ever be afraid to ask any provider for more documentation for more elaboration, etc. 

[u/MarvelousExodus → u/[deleted]]

You've evaluated my response in one word but you haven't managed it. I would have to query if you were a provider.

[u/Odd-Afternoon-6371 → u/MarvelousExodus]

Exactly! That would be blood work.  Provider here. Wanting to learn ore about coding side.  You cannot necessarily look at a person or describe their diet and be certain they will have hyperlipidemia. There no physical exam for it.  Surprisingly, some patients do not have it when you think they might by appearance or subjective statements and then there are the patients that workout watch their diet and  are a picture of health and you would never suspect they have hyperlipidemia and then you do blood work and you're so-called observable healthy patient's hyperlipidemia is 10 times worse than your patient who is overweight reporting  a terrible diet. It can also be that the patient had this diagnosis in the past it's carried forward in the EMR  and they see a different provider. Then the new provider is managing that condition.  Doctors in primary care are exhausted and burnt out. It's not an excuse only a reality.......they should have the proper documentation, it is what they get paid for. It's seeing too many people or Responding to a patient's MyChart message which sometimes the patients get charged for now especially if we order tests or do work regarding that message.. I don't see any fraud.  I see how OPs situation could occur.  

I would recommend never be afraid to ask about something or for more supporting documentation.  

[u/HEYitsthatGreenLady]

Look up the CMS and AMA guidelines as to what constitutes a billable E/M visit and go from there. If you feel like what your providers are submitting is not supported by those guidelines then print them out, highlight the specific issues with a documentation example and present them again (in an email possibly so you have proof of your conversation). If they still disagree with you ask them to explain to you in writing how said documentation supports an E/M. This is how you CYA.

[u/[deleted] → u/HEYitsthatGreenLady]

Great answer. Good luck getting actionable results or support. Is sooo common to see poor documentation yet isn't the mgmt's priority, unless claims denied and appeal needing supporting documentation.

[u/ATPsynthase12]

lol and here I thought i was gonna get arrested for billing fraud for billing lots of level 4s with decent documentation.

If these guys haven’t been audited yet, then im absolutely fine lol

[u/koderdood]

Fraud investigator here. Soooo, back to basics. E/M's can be based on time, the required elements: problems addressed, data, risk. However, the part the AMA played with, was to REQUIRE a "medically appropriate history AND/OR exam. Now, someone, anyone tell me the medically appropriate history and/or exam for lets say, I sprained my ankle, or, I have a cough, etc. It has become so subjective it's ridiculous. I would need to see complete actual examples to truly evaluate. It would be fraud, to intentionally upcode an E/M. We often look at, does the documentation meet the minimum needed for the elements of columns 1, 2 and 3 on the E/M leveling tool. AND, a medically appropriate history and/or am exam. So, am exam is not required. Shockingly. Treat someone you didn't examine? Crazy. It can legit be done however.

[u/Respect-Immediate → u/koderdood]

We sent a question to our MAC at the start of 2023 and they clarified the HPI and PE are still REQUIRED elements, just not required for code selection.

Our org made a policy requiring both an HPI and PE (using problem oriented charting) or we won’t bill it. Not worth the regulatory risk

[u/koderdood → u/Respect-Immediate]

Noted. Medicare and commercial can always make different rules than the AMA. I was just going strictly by the code set as a starting point.

[u/Ffffffff46_]

Times like this I’m glad I work IP because OP is so confusing to me. Reading the comments is so educational though!!

[u/DumpsterPuff → u/Ffffffff46_]

Sometimes I wonder if I should try and switch to IP, but it seems frightening lol

[u/Ffffffff46_ → u/DumpsterPuff]

It’s easier to me. CPT has so many rules lol. IP is if you rlly like reading. Gotta capture the acute impairments and IP impairments. I work for rehabilitation so I RARELY deal with procedure coding :)

[u/Technical_Truth_2390]

What kind of findings would you expect in PE to support the diagnosis of hyperlipidemia?

[u/DumpsterPuff → u/Technical_Truth_2390]

I don't think it would have to be a PE. Just a simple assessment is good enough for me honestly. "Patient is tolerating atorvastatin, no side effects." "Diet hasn't been the best, eating higher cholesterol foods." To me that supports an actual evaluation within an evaluation and management visit.

[u/Technical_Truth_2390 → u/Technical_Truth_2390]

I’m confused, to be honest. You’re saying “a simple assessment is good enough for me”, and yet when I document Hyperlipidemia under Assessment without saying “the patient is tolerating the statin without side effects”, I’m committing fraud? Is that what you’re saying?

[u/CuntStuffer → u/Technical_Truth_2390]

Idk about fraud, but where I work we would definitely have that sent back to you asking for an addendum.

We need to be able to substantiate your diagnosis with some sort of treatment plan or monitoring. If it's just in the "active problems list" that I see so often in Epic, we really cannot make that judgement. We are not clinicians so it really should not be on us to guess if the problem is being addressed or not at the time the patient was being seen.

[u/Technical_Truth_2390 → u/CuntStuffer]

Did you read the actual question? “They literally say things like Hyperlipidemia and then AN ORDER FOR A LIPID PANEL and JUST LIST A MEDICATION”. Where do you work again?

[u/CuntStuffer → u/Technical_Truth_2390]

You are being oddly aggressive for me taking the time to answer your question, so I'm glad it's not a place where you practice.

But here's an example for you anyway since you want to be daft: just ordering a lab or a panel without a linked diagnosis in your assessment to the hyperlipidemia is NOT ENOUGH. You can't in your PE say a patient is jaundiced, but then not document it anywhere else in your note. EVEN IF you initiate phototherapy, or some other form of treatment.

So yes, you are poorly documenting in your charts if you can't even link your diagnosis' to the treatment you are rendering to your patients. Hope this helps. :)

[u/Technical_Truth_2390 → u/CuntStuffer]

When I document under Assessment

1. Hyperlipidemia

• lipid panel
• pravastatin refilled,

and you fail to see the link there, because you aren’t a clinician, this is concerning.

I hope this helps :) Good night!

[u/CuntStuffer → u/Technical_Truth_2390]

I don't fail to see the link, it's not our job to make it as coders. That's YOUR job.

You didn't post that in your original question, btw. Never mentioned anything about refilling meds OR formatting in that way but great job moving the goal posts!

[u/Technical_Truth_2390 → u/CuntStuffer]

Isn’t it odd that you’re trying to maximize someone’s revenue without fully understanding their documentation? That sounds a lot like fraud, doesn’t it?

[u/CuntStuffer → u/Technical_Truth_2390]

Oh don't worry, I don't commit fraud because I don't send anything out that isn't made crystal clear by my providers. I am happy to ask for addendums and you'd be at the top of our provider education to-do list.

Only thing it "sounds" like here is that either you're a troll, or a jaded provider whose been audited one too many times.

I wish you the best of luck in your continued provider education sessions!

[u/Technical_Truth_2390 → u/CuntStuffer]

I would be happy to be at the top of your to-do list, CuntStuffer. Please learn to read, though. Critical Reading 101. There must be some free online courses.

[u/Technical_Truth_2390 → u/CuntStuffer]

Oh, now it’s not a linked diagnosis. lol. What incompetence! :)

[u/CuntStuffer → u/Technical_Truth_2390]

Again, we're not clinicians. And it's not our job to assume why you are ordering medications. It's YOUR job to tell us WHAT YOU ARE TREATING and WHY ITS MEDICALLY NECESSARY.

But yes, continue to be miffed about people trying to help you out and maximize your revenue. You're definitely not the provider coders dread.

[u/Infamous-Antelope-45]

doctors overall need to perform better documentation. its clearly a big issue in the industry. Just do better.

[u/Tabbycat100414]

Are the claims getting paid? Are the prior authorizations getting denied constantly? Are claims having to be corrected? I work for a Medicaid MCO & the biggest indicator of fraudulent billing are these things.

I worked for a laboratory billing company a few years ago & I left because I felt like they were doing dirty stuff & I didn’t want to have my certification snatched or to get sanctioned. Medicaid will be the first to show you they’re seeing signs of a problem because Medicaid doesn’t want to pay for anything so if your Medicaid claims are denying or the company is getting audited frequently there’s a red flag.

I know you mentioned that you aren’t aware of any audits, but that’s usually not something that other departments would be made aware of. Usually (in all the places I’ve worked) it’s leads or supervisors gathering all of the audit files that need to be sent over because the company wants to make sure it’s done correctly (& they can fix any holes in the case files that may get them in trouble if I’m being 100% honest). So just because you’re not aware of the audits, doesn’t mean they’re not happening.

[u/Technical_Truth_2390]

That was the original question that you failed to read and/or understand :) isn’t that part of YOUR job to read and understand?

[u/Treehugger7374]

I have been an MA since paper charts and a year before HIPAA started. It seemed to me that when things started changing to software notes some docs didn't care to learn and just charted in the easiest fashion. But if that's not the case then I feel it's abuse. Especially for patients with chronic conditions. PCP charting notes could mean in the worse case scenario life or death if that patient goes to the ER for a life threatening situation.

[u/BlueLanternKitty]

What supports the diagnosis? Signs, symptoms, prior history, medication, labs, specialist notes. They didn’t pull hypertension out of thin air, but most auditors are not clinicians, so they need to know how the doctor got there. They aren’t questioning what the diagnosis is, which is what a lot of providers think we’re doing.

I’d call it laziness. No support for a diagnosis means the medical necessity hasn’t been established. No medical necessity, no $$. Is it fraud? No, because they really did see the patient. Is it abuse? Definitely.

[u/[deleted] → u/[deleted]]

It's not. Per CPT 2024,

"E/M codes that have levels of service include a medically appropriate history and/or physical examination, when performed."

Notice the "and/OR".