A Physician Led Comprehensive Coding Compliance Program: Datamining to Disciplinary Action Plans. Optimizing revenue from a compliance perspective

Transcription

1 A Physician Led Comprehensive Coding Compliance Program: Datamining to Disciplinary Action Plans Keith Ponitz, M.D. October 16,2012 Agenda Background Optimizing revenue from a compliance perspective Mitigate the risk: Data mining and coding audits Role of physician in coding compliance

2 National Landscape Centers for Medicare and Medicaid Services (CMS): Spend $800 billion each year on medical care 19% total Federal budget Have over 100 million beneficiaries Medicare alone processes 4.4 million claims per day paid to 1.5 million providers Medicaid adds additional 2.5 billion claims annually National Landscape Office of Inspector General Department of Health and Human Services in first half of 2012 reported: $1.2 billion in recoveries 1,264 individual and entity exclusions 388 criminal actions and 164 civil actions

3 National Landscape Alphabet Soup of Fraud Stoppers HEAT HHS OIG, DOJ, CMS CMS CERT,PERM, RAC OIG MFCU ACA Center for Program Integrity In 2010, CMS created the Center for Program Integrity which targets the various causes of improper payments Mistake Inefficiency Bending the Rules Intentional Deception Error Waste Abuse Fraud Note: Government agencies are now focusing on errors as well as fraud

4 National Landscape Despite this governmental oversight OIG specifically states: Patient care is and should be the first priority of a physician practice Final Compliance Program Guidance for Individual and Small Group Physician Practices (PDF) (65FR59434; October 5, 2000) Optimizing Revenue: Compliance Perspective Receiving every penny you are entitled to and not a penny more and not a penny less

5 Patient Encounter to Medical Record Patient Encounter Physician sees the patient (this is the point that should determine reimbursement) Documentation written and/or electronic record of the encounter Patient Encounter to Medical Record Historically, not everything that occurred during the patient encounter was put into the medical record EMRs may put documentation in the medical record that did not occur

6 Purpose of Documentation Clinical documentation purposes include: Provider to provider communication Provider recollection of previous care delivered Coding documentation s purpose is to ensure proper reimbursement for the care provided Clinical Documentation Components of clinical documentation are well established and understood by physicians Examples: History and Physicals SOAP notes Follow logically from the care provided

7 Coding Documentation Coding documentation: Not intuitive to physicians Not emphasized in training programs Often use different definitions from those commonly used in the clinical setting Specific phrases not used in clinical care are often necessary to capture coding documentation requirements For these reasons, physicians have struggled to learn proper coding documentation Coding Documentation Example: Initial Hospital Care Assume Comprehensive History/Physical and High MDM are medically necessary Review of Systems - comprehensive ROS is needed and obtained but does not add to the clinical care: Doc: All systems have been reviewed and are negative except as previously noted Doc: Unremarkable, Negative or Noncontributory

8 Optimizing Revenue: Compliance perspective EMR: Input clinical, output coding Written: Template Mitigate the Compliance Risk Medicare Fraud Strike Force OIG Data Analytics

9 University Hospitals of Cleveland Large Integrated health care system Academic medical center Six community hospitals Employed academic faculty and community physicians Network of owned primary and specialty care practices ACO Mitigate the Risk Hospital Outsourced Hospital Coding Audits Engaged with third party vendor to aid with medical necessity Recently engaged three part time physician champions Physician Practices Data mining Coding Audits Evaluation and Management based on data mining New provider audits Ad hoc

10 Mitigate the Risk Data mining Identify CPT codes for review: E/M Identify benchmark: Medicare paid claims and Department/Division Identify risk tolerance: $25K billing and 60% highest level Physicians meeting certain criteria will be audited to ensure that documentation supports the level of coding billed Note: Outlier coding patterns do not imply coding errors Mitigate the Risk New Office Visit - Four Quarters Ending 04/30/2012 Department of Medicine SPECIALTY Medicine- Cardiology BILLING PROV CPT SUM UNIT SUM CHGS % per provider Nat'l Benchmark Difference Transplant Cardiologist $ 0 0% 0% 0% $ 0 0% 2% -2% $ % 16% -9% $789 3% 56% -53% $39,806 91% 26% 65% Transplant Cardiologist 119 $42,

11 Mitigate the Risk Coding Audits Intellicode software product 10 chart review of the specific CPT code Results and education provided to physicians Mitigate the Risk Coding Audits

12 Escalation Process Disciplinary Action Plan Meeting with chairman/faculty Plan to mitigate risk Mandatory templates Dictation 100% review Physician Leadership

13 Physician Leadership Keith Ponitz, M.D., University Hospitals of Cleveland Physician Compliance Officer Direct Line: (216)