Medical Coding 2018: Will Your Records Survive an Audit?

Transcription

1 Medical Coding 2018: Will Your Records Survive an Audit? Richard Soden, OD, FAAO & Michael J. McGovern, OD, FAAO November 10, 2018 COPE Course ID: PM Course: PM-03 Abstract: The United States Government and the healthcare industry recoup significant amounts of money annually from healthcare providers as a direct result of medical record audits. For many providers, the adoption of electronic record systems in recent years has only increased the complexity of being in compliance with an already complex system. This course will provide a review of the necessary knowledgebase required for the proper documentation of optometric records, including required exam elements, interpretation and report, modifiers and drawings. Recommendations on steps to take when being audited will also be discussed. As healthcare delivery transitions from a fee-for-service to a fee-for-value model, the question is no longer will I be audited but when will I be audited. This course will prepare you for potential health care audits. 1. Common Audit Principals a. The Bell Shaped Curve b. Medicare and other insurance audits c. Benchmarking d. Common triggers for an audit: i. Insufficient documentation errors ii. Medically unnecessary errors iii. Incorrect coding errors iv. Less common triggers 2. Importance of the Case History/Chief Complaint a. Drives entire exam b. Case history proper documentation and coding c. Chief complaint do s and don ts d. Medical vs. routine eye care e. New patient vs. established patient criteria vs Which Codes do I Choose? a. Review of the differences between the various sets of codes i series of codes 1. New patient: / Established patient: /

2 ii series of codes 1. New patient: Established patient: b Areas of documentation i. History ii. Physical exam iii. Medical decision making c History i. History of present illness (HPI) ii. Review of systems (ROS) iii. Past (medical), family and social history iv. Social history d Physical exam i. Twelve physical exam elements ii. Two brief assessments of mental status e Medical decision making (MDM) f coding - see Attachment A 4. Procedures requiring an Interpretation and Report a. Should include: i. What was done ii. Why it was done iii. What was found iv. What will be done about it b. Visual fields (CPT ) c. Extended ophthalmoscopy (CPT ) d. Anterior segment imaging (CPT 92286) e. External ocular photography (CPT 92285) f. Fundus photography (CPT 92250) g. Corneal topography (CPT 92025) h. Optical coherence tomography i. Anterior segment (CPT 92132) ii. Posterior segment (CPT ) i. Sensory motor evaluation (CPT 92060) j. Corneal hysteresis (CPT 92145) k. Serial tonometry (CPT 92010) 5. Sample Clinical Cases: Will they pass or fail an audit? a. Routine vs. Medical b documentation guidelines c vs d. Proper use of modifier 25 e. Surgical coding f. Place of service coding see Table 1 2

3 6. The concept of Time a. Can be utilized to increase the level of E&M coding when more than 50% of the office time was coordinating care and educating the patient b. Must be face-to-face c. Documentation crucial 7. Surgical coding a. Minor surgical procedures i. Stand alone codes 1. Modifier 25 ii. Global Surgical Fee 1. Modifiers 24 and 79 b. Major surgical procedures i. Co-management coding 8. Modifiers a. See Table 2 b. Modifier 59 i. XE: Separate Encounter ii. XS: Separate Structure (organ/structure) iii. XP: Separate Practitioner iv. XU: Separate Non-overlapping Service (service does not overlap usual components of the main service) 9. Advanced Beneficiary Notice of Noncoverage (ABN) 10. Self-auditing a. Sample size recommendations b and code worksheets c. Specialty codes i. The importance of Interpretation and Report ii. Local Carrier Determinations (LCD s) d. Surgical codes i. Co-management coding 11. Coding Changes a. ICD-10 i. Importance of accurate selection of codes ii. Review of 2018 updates iii. Anticipated 2019 changes 3

4 Attachment A: Documentation of codes History History of Present Illness (HPI) *Physician must personally complete/record *Brief / extended * HPI Elements to Describe Complaint: Location Quality Severity Timing Duration Context Modifying Associated factors signs/symptoms Review of Systems (ROS) *No standard ROS for optometrists *Problem pertinent / extended / complete * ROS Commonly Reviewed Systems: Respiratory Cardiovascular Endocrine Gastrointestinal Genitourinary Muscoskeletal Hematologic/Lymphatic Ears/Nose/Throat Integumentary Neurological Psychiatric Constitutional Allergic/Immunologic Eyes (2 brief assessments of mental status) Past (medical), Family and Social History (PFSH) *Past medical history *Family History *Social History *Pertinent / complete Determining Level of History: HPI ROS PFSH Problem Focused Brief N/A N/A Expanded Problem Focused Brief Problem Pertinent N/A Detailed Extended Extended Pertinent Comprehensive Extended Complete Complete 4

5 Physical Exam Twelve physical exam elements: Visual acuity Gross visual field testing Ocular motility including primary gaze Conjunctiva (bulbar/palpebral) Ocular adnexae Pupil / iris Cornea Anterior chamber Crystalline lens Intraocular pressure Optic disc (dilated) Posterior segment (dilated) Two brief assessments of mental status Determining Level of Physical Exam *Problem Focused / expanded problem focused / detailed / comprehensive Medical Decision Making (MDM) AOA Clinical Practice Guidelines Level of complexity determined by 3 factors: *Number of possible diagnoses / treatment options *Amount and complexity of data to acquire/review *Risk of complications, morbidity and/or mortality *Straightforward / low complexity / moderate complexity / high complexity Determining Level of MDM: Number of possible diagnoses / treatment options Amount and complexity of data Risk of complications, morbidity and/or mortality Straightforward Low Complexity Moderate Complexity High Complexity Minimal Limited Multiple Extensive Minimal or none Limited Moderate Extensive Minimal Low Moderate High 5

6 Determining Category of Service / E&M Code New Patient: **Must meet or exceed 3 of 3 in the column** History Problem Expanded PF Detailed Comprehensive Comprehensive Focused (PF) Physical Exam Problem Expanded PF Detailed Comprehensive Comprehensive Focused (PF) MDM Straightforward Straightforward Low Complexity Moderate Complexity High Complexity Established Patient: **Must meet or exceed 2 of 3 in the column** History N/A Problem Expanded PF Detailed Comprehensive Focused (PF) Physical Exam N/A Problem Expanded PF Detailed Comprehensive Focused (PF) MDM N/A Straightforward Low Complexity Moderate Complexity High Complexity 6

7 Table 1: Commonly Used Place of Service Codes Place of Service Code Place of Service Name Place of Service Description 11 Office 12 Home 13 Assisted Living Facility 14 Group Home 21 Inpatient Hospital 22 Outpatient Hospital Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis. Location, other than a hospital or other facility, where the patient receives care in a private residence. Congregate residential facility with selfcontained living units providing assessment of each resident s needs and on-site support 24 hours a day, 7 days a week, with the capacity to deliver or arrange for services including some health care and other services. A residence, with shared living areas, where clients receive supervision and other services such as social and/or behavioral services, custodial service, and minimal services (e.g. medication administration). A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions. A portion of a hospital which provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. 24 Ambulatory Surgical Center A freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis. 31 Skilled Nursing Facility 32 Nursing Facility A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital. A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals. 7

8 33 Custodial Care Facility A facility which provides room, board and other personal assistance services, generally on a longterm basis, and which does not include a medical component. 34 Hospice A facility, other than a patient's home, in which palliative and supportive care for terminally ill patients and their families are provided. 54 Intermediate Care Facility/Mentally Retarded A facility which primarily provides health-related care and services above the level of custodial care to mentally retarded individuals but does not provide the level of care or treatment available in a hospital or SNF. Table 2: Commonly Used Modifiers 24 Unrelated evaluation and management service by the same physician during a postoperative period 25 Significant, separately identifiable evaluation and management service by the same physician on the day of a procedure 50 Bilateral procedure performed at the same session on an anatomical site 51 Multiple surgeries performed on the same day, during the same surgical session 52 Reduced service reports a partially reduced or eliminated service or procedure 55 Indicates a physician, other than the surgeon, is billing for part of the outpatient postoperative care 79 Unrelated procedure by the same physician during the post-operative period GW Service not related to the hospice patient s terminal condition RT / LT E1/E2/ E3/E4 Right / Left E1 = upper left eyelid E2 = lower left eyelid E3 = upper right eyelid E4 = lower right eyelid 8

9 ABN-Related Modifiers GA Waiver of Liability Statement on File Indicates that the patient has signed an ABN for services and material that may be denied by Medicare (retain this in patient s record). Patient responsible if denied by Medicare Example: provider believes scanning laser is warranted every 3 months for a glaucoma patient but carrier limits it to twice a year GY Notice of Liability Not Issued Used to obtain a denial on a non-covered service Item or service statutorily excluded or does not meet the definition of any Medicare benefit ABN not an issue Example: beneficiary wants to get new eyeglasses and wants a denial through Medicare for secondary payer purposes GZ Item or Service Expected To Be Denied as Not Reasonable and Necessary Used when the physician wants to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary But they did not get a signed ABN (likely an error or patient refused) Cannot bill patient if denied by Medicare GX Notice of Liability Issued To indicate an ABN was signed and patient told service is not covered but they requested the claim be submitted Medicare will automatically reject claims with GX modifier applied to covered charges Medical Review Programs Comprehensive Error Rate Testing (CERT) o Improve accuracy of Medicare payments o Method for CMS to look at paid claim error rate o Random claims- audit- recoup dollars- report to CMS Recovery Audit Contractors (RAC) o Now called Recovery Auditor o To identify improper over/under payments o Post-payment audit to prevent future errors in payment Zone Program Integrity Contractors (ZPIC) o Targeted to outliers typically reviewed o Customized investigation in response to a flag o Focuses on Fraud and Abuse Carrier Reviews o Not common- typically outliers selected for review or random selection o Target potentially overused/misused codes 9

10 CERT o o o o CERT is designed to determine if providers are submitting claims accurately and if Medicare carriers are processing claims accurately Produces a statistically valid analysis of improper payment rate Randomly selects a sample of claims from all Medicare contractors Determines if the claim or service is processed correctly and is in compliance with all applicable requirements o LCD s / NCD s / Medicare Coverage Regulations / Federal Guidelines o Reviews claims along with medical records to see if the documentation supports all services billed o Read the request letter very carefully and respond with ALL documentation, including doctor s original orders for treatment, care plans, records for all services billed for the dates of service in question o Do not ignore a CERT o Response time = 70 days (fax preferred method of response) o Reported results revealed significant errors with E & M codes: o Missing progress notes o Missing orders o Missing or illegible signatures o Incorrect coding o Overpayments from claim errors must be recovered o Decision can be appealed o There are 5 levels of appeal o Can appeal up to 120 days from date of claim adjustment The Recovery Audit Contractors Program (RAC) o Post-payment audit to prevent future errors in payment o There are multiple circumstances that can result in improper payments, including payment for items or services that do not meet Medicare s coverage and medical necessity criteria, payment for items that are incorrectly coded, and payment for services where the supporting documentation submitted did not support the ordered service. o Every fiscal year each Medicare Administrative Contractor (MAC) is required to complete an Error Rate Reduction Plan (ERRP), which includes agency-level strategies to clarify CMS policies and implement new initiatives to reduce improper payments. The Recovery Audit program is another valuable tool to assist CMS in the identification and recovery of improper payments. Medicare Provider Utilization and Payment Data: Reports/Medicare-Provider-Charge-Data/Physician-and-Other-Supplier2014.html Medicare Utilization for Part B by Specialty: Reports/MedicareFeeforSvcPartsAB/MedicareUtilizationforPartB.html 10