NAMAS Weekly Auditing Tips for Members

Transcription

1 NAMAS Weekly Auditing Tips for Members (2014 Samples)

2 1/10/14 Give Credit for Managed Conditions One area where auditors struggle is correct assignment in medical decision making when patients have multiple chronic conditions and/or are currently in inpatient status. Our physicians do a great job of telling us everything that is going on with the patient, but not all of these items may be managed by the provider you are auditing. It is important to only give credit in the medical decision making for those items actively being managed by the audited physician. In some cases, this turns our job into detective rather than auditor. You may have to look at other records in their inpatient stay to see what other specialists may be managing some of those conditions. For outpatient encounters, it will be done by reviewing notes from other specialists or looking to see if our physician is responsible for that issue. An easy answer, I find, is looking at the plan. If diabetes is listed in the assessment, but our 'plan' is to take x-rays of the chest to rule out pneumonia, did we manage the diabetes during that encounter or is this essentially past medical history? If it's listed in the assessment, it should have a correlating plan. That plan may be something like "continue on current medications," but it is your clue that the physician is responsible for that condition or sign/symptom. If ever in doubt, ask the physician. You can review the notes with the provider to help explain what they did during the encounter. 1/17/14 Oftentimes, when we are conducting audits of evaluation and management services (E&M), we tend to focus on over-coding and overlook visits that are under-coded by providers. It is important to realize that under-coding is also risky behavior, from both compliance and profitability perspectives. The Office of the Inspector General (OIG) has warned that intentionally under-coding visits in order to minimize risk may be looked at as an incentive (or inducement) for a patient to utilize a particular provider as their financial responsibilities may be decreased. So, while intentional under-coding may result in more compliance risk, it could also lead to financial unraveling. If a provider under-codes established patient visits by just one level, it may only represent $30 per occurrence; but if it happens 10 times/week, that's $300 and could exceed $15,000/year. As auditors, we must focus on both under- and over-valuation of professional services. E&M services should be selected based on the intensity (and overall medical necessity) of the visit.

3 1/24/14 -Reporting Laparoscopic Service When Specified CPT Codes Do Not Exist When auditing surgical services that are performed laparoscopically (through a laparoscope), keep in mind that a laparoscopy code should be reported. If you find that an "open" procedure code is reported in these situations, credit should not be given as this would represent incorrect coding. A common misconception is that when a laparoscopy code is not available in CPT, a provider should report the closest open procedure code. When a procedure is performed laparoscopically, it should be reported as such, even if that requires the provider to employ an unlisted laparoscopy code (e.g., unlisted laparoscopic procedure, appendix). Before assigning the final CPT code, providers should always consult Category II and Category III codes to determine if an accurate code exists. If it does not, rather than assigning an open code, the provider should select the anatomically appropriate unlisted laparoscopy code and document each of the following to assist an auditor reviewing a claim or a payer processing the claim: the difficulty of the case the patient's diagnosis the risk of complications the equipment required to perform the surgery the amount of time and effort required to complete the procedure When payors require documentation to properly process the claim, the provider should also provide a cover letter suggesting that the CPT was carefully interrogated and no specific laparopscopic code could be located. The submitted charge should be based upon the closest code that does exist with an explanation as to why that code most closely reflects the work effort and time for the unlisted code.

4 2/21/14 The Importance of Documenting Comprehensive Histories and Physical Examinations In order to support the comprehensive level of history, the provider must document the reason for the visit (chief complaint), at least four (4) elements of the History of the Present Illness (HPI) [or the status of 3+ chronic/inactive conditions] and a minimum of ten (10) Reviews of Systems (ROS), and at least one (1) element from each of the patient's past history, social history, and family history [exceptions apply where we only need to capture 2/3 elements for established patients, subsequent inpatients and emergency department services]. A comprehensive examination, according to the 1995 examination guidelines require that documentation exists specific to a minimum of eight (8) organ systems. Both a comprehensive history and a comprehensive examination are required for the following levels of service to name a few: * and (new patient outpatient visits) * and (outpatient consultations) * and (inpatient consultations) * and (initial hospital observation) * and (initial hospital care) For example, CPT code (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: a comprehensive history; A comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Physicians typically spend 70 minutes at the bedside and on the patient's hospital floor or unit and this would never be supported in the absence of a comprehensive history and a comprehensive examination other than when counseling and coordination dominate the visit. While auditing many of the above mentioned codes, we have realized that providers often fall short of documenting the necessary criteria. An auditor must always confirm that each of these criteria are met to support any of the above mentioned CPT codes.

5 2/28/14 Auditing E&M Services When Smoking Cessation is Performed on the Same Date CMS allows for two (2) "quit attempts" per year, up to four (4) sessions per attempt. As many of us know, the codes for smoking cessation are time-based codes that require proper documentation of time in the medical record. Furthermore, in addition to time being documented, providers must be careful when reporting CPT codes G0436 or G0437, or along with E&M service codes (e.g., 992xx). Smoking Cessation, Preventive (G minutes & G0437 >10 minutes) are reserved forpatients who do not have signs or symptoms of tobacco-related disease. Medicare Part B will pay these services when certain conditions of coverage are met. The ICD-9 diagnosis codes that should be reported for these individuals are (non-dependent tobacco use disorder) or V15.82 (history of tobacco use). The CMS rule suggests that Medicare will allow 2 individual tobacco cessation counseling attempts per year during which each attempt can include up to four intermediate or intensive sessions, for a maximum benefit of up to eight sessions per year. Smoking Cessation for active smoking related illness ( minutes & >10 minutes) are reserved for patients who have symptoms related to their current tobacco use and should be reported with CPT codes (intermediate) and (intensive) for their counseling efforts.documentation requires the total amount of time spent during the counseling portion of the visit. An E&M service is only supported in addition if the modifier -25 is utilized to demonstrate that a "significant, separately identifiable" service was performed. While auditing such encounters, it is necessary to be sure that the documented time spent in smoking cessation counseling is distinctly documented. Without sufficient time documentation, the services should be disallowed. While auditing these types of service for our clients, we find that the appropriate ICD-9 codes are not properly "linked" to the individual codes, or that the time spent in counseling is not specifically documented. Be on the lookout for proper time documentation and accuracy of primary ICD-9-CM codes. Of note: Coding these services will change with the implementation of ICD-10-CM. Refer to the following codes for ICD-10 application: Z72.0 -Tobacco use (ICD-9-CM equivalent 305.1) Z History of tobacco use (ICD-9-CM equivalent V15.82) Resource: CMS MLN/MLNMattersArticles/downloads/MM7133.p

6 3/7/14 MEDICAL DECISION MAKING = MEDICAL NECESSITY Established patient E&M Guidelines allow that we may drop the lowest documented portion of the encounter (history, exam, or medical decision making), but how can an auditor disallow the medical decision making when it helps define the level of service of the patient. For this reason, some Medicare Carriers are now allowing that the lowest documented area of the encounter may be dropped, but that all 3 components must be minimally documented for each patient encounter unless billed under the rules and guidelines of time based services. Check the Medicare Carrier Guidance for the Region you are auditing, and be sure of their specific rules on this matter. Medical decision making and medical necessity walk hand-in-hand so auditors should always be careful if they do drop this section as the lowest documented component in the level of service code selection.

7 3/14/14 Properly Auditing, The Use of Modifiers 62, 80, 82, and AS The following modifiers are often reported on claims when they are not appropriate and auditors should always pay careful attention to the RBRVS (Medicare physician fee schedule) to determine which modifiers are suitable with various CPT codes. The modifiers used to report assistant-at-surgery and co-surgery are oftentimes confused by provider, biller, coders, etc., and it is extremely important to understand the differences, both from compliance and reimbursement perspectives. Let's clearly define the modifiers first. Modifier 62 (Two Surgeons or Co-Surgery): Requires that both surgeons author an operative report detailing the specific portions(s) of the case they performed. The other co-surgeon should also be identified in each operative report. Medicare allows the procedure at 62.5% of the allowed amount (125% total expenditure). Refer to RBRVS to determine if co-surgeons are allowed and if so, if the two-specialty requirement exists. Documentation of medical necessity may be requested. Modifier 80 and 82 (Assistant at Surgery, Assistant at Surgery When Resident Is Unavailable): Both of these modifiers are used to report assistant at surgery; the latter (-82) is only applicable in teaching hospitals to demonstrate that a "qualified resident" was not available to assist. Payment is allowed at 16% of the allowed amount for Medicare. The assistant must be noted in the primary surgeon's operative note but is not required to dictate a separate report. Refer to RBRVS to determine if co-surgeons are allowed and if so, if the two-specialty requirement exists. Modifier AS (NPP Assistant at Surgery [e.g., Physician Assistant]): This HCPCS II modifier is intended for use when a nonphysician practitioner assists at surgery. Medicare reimburses modifier -AS at 13.6% of the allowed amount (85% of the 16% allowed for MD assist services). So, when auditing assistant at surgery claims, be sure to first determine whether the cosurgery or assistant at surgery modifiers apply. Second, be sure the appropriate documentation does exist (e.g., separate operative notes for co-surgeons, (modifier - 62). Next, be aware of the payer's policy as it relates to co-surgery or assistant at surgery for the particular codes in question. And lastly, be aware of the payment rules that exist.

8 3/28/14 Auditing Nuts & Bolts A review of an E&M Encounter for a family practice group had the following findings in each key component: CC: Cough and Congestion HPI: Included all 4 required elements, and demonstrated a patient with a 3-day history of fever, cough/congestion, and upper respiratory symptoms. The patient states that symptoms are of moderate severity. ROS: Included 2 systems properly documented PFSH: Patient has history of frequent URIs Exam: Included constitutional, eyes, detailed ENT, and respiratory system, all conveyed as a laundry list of "normal" symptomology Assessment: Included a pulse oximetry test Plan of Care: URI; the patient was given antibiotics with very little additional information. ANALYSIS: Based on the HPI of a patient with moderate symptoms and a 3-day history of sickness and fever, and the fact that the provider performed a pulse oximetry test, we would "assume" the patient's level of complexity would be at least moderate. However, in this note as it was audited, the provider did not connect those dots. In the formal analysis, the patient had a respiratory exam that was essentially normal, and while the patient did have valid complaints of severity, what was the provider's thinking or reasoning to support the pulse ox? Did the patient's respiratory status lead the provider to feel that checking their oxygenation was a needed testing? If these dots had been connected to relate the complexity of a patient with previous history of recurrent infection, along with a 3-day history of fever and symptoms, then a higher level of severity would be supported. All in all, although the documentation components did meet the level, the medical complexity of an acute problem with complicating factors was just not exhibited within the plan of care. If there had been one simple sentence to tie it all together, it would have been supported. Be sure that when auditing your notes you are evaluating on the premise of medical necessity and not just the documentation components.

9 4/4/14 Incident-To The incident-to rules have not changed, but what is always a variable is the interpretation of the rules. This tip is not about the incident-to rules, but rather about auditing these services. Incident-to services require active involvement by both the non-physician provider (NPP) and the supervising physician (SP). If both did NOT have the active role that is set forth by CMS, the incident-to service would not have been met. It is the same premise of establishing medical necessity as any other service. Let's review auditing with consideration of these rules. The first golden rule of incident-to is the physician must be on-site. For new patients and established patients with new problems, this is relatively easy for the auditor to find by verifying the physician documentation of their face-to-face encounter with the patient. Therefore, the documentation should reflect what "work" of the encounter the SP performed that validates that he/she was on-site. When auditing the note, documentatin indicating the involvement of the SP must be found. CMS policy indicates that the SP must initiate the plan of care for new patients and established patients with new problems. Therefore, the documentation should include wording/statement that indicates the SP developed the plan of care. The SP must remain an "active" role in the patient's ongoing care. While CMS National Guidance does not adequately define the active role, some of the local carriers more clearly define this. It is a benchmark that active involvement would include the patient seeing the SP every 3rd visit. CMS rules do NOT require the SP to sign off on all of the NPP's charts billed incident-to even though in many instance their involvement is required. Be sure and check out your MAC for more information. Noridian has a great full page of information including a chart that is very easy to follow for incident-to validation. 4/11/14 Documentation Cloning EHRs allow for templating and copy/paste functionality to help with provider documentation. This can cause questions about medical necessity and authenticity of the documentation. Auditors should look for these issues when reviewing medical records. Look for familiarity as you move from patient to patient for possible incorrect utilization of templating, and evaluate commonality in documentation from visit to visit of the same patient for possible invalid "carryforward" documentation. REMEMBER- Using functions such as these within an EHR are not necessarily a violation as long as the documentation is modified per patient entry to be patient and visit specific.

10 4/18/14 Auditing Provider Signatures Verify when auditing EHRs that the appropriate signatures are present (this goes for notes and orders). EHRs can allow for ancillary staff to contribute to the documentation process; however, certain rules apply as to what is permitted for ancillary staff assisting the provider versus scribes in the medical practice. In either case, providers should be aware and continually reminded that they are ultimately responsible for ALL elements of the documentation, and before they "lock" a note or physically sign a dictated report, a proper review of each component is strongly recommended. 4/25/14 Which came first, the code or the service? AMA created CPT codes to describe services. When those services are E&M visits, auditors, coders, and physicians sometime forget that the code describes a service, instead of the service meeting the requirements of a code. Physicians should complete all medically necessary steps of a visit to evaluate and manage a patient's illness or injury. Then they should document all of the services performed. Talk with your physician about the difference between medically necessary visit elements and documentation and what must be documented "to get a level." Although it is good to understand what elements are included in an E&M code level, do not let higher codes and potentially higher reimbursement drive up the elements performed in a service or in documentation. Remember that the service came first, not the code. This audit tip is part of E&M Coding Clear & Simple by F.A. Davis Company

11 5/2/14 Auditing Infusion Services: The updates to the infusion code set are not new, but this area still seems to be troublesome for many providers and coders. There is a specific hierarchy for proper reporting of these codes, and add-on services must be appended appropriately. The primary code should always represent the intended infusion service of the encounter, with the appropriate add-on codes representing additional infusions, push services, etc., provided to the patient. When auditing infusion services, an auditor must be keenly aware of ensuring that the code choices for proper hierarchy are chosen, along with the appropriate add-on service codes, but of MOST importance are the start and stop times. These codes represent time-based services and not including time would create non-billable services. In many audits we have found that the time is not documented to best reflect the actual delivery process of the infusion service. Additionally, special attention should be noted when infusion services are billed with E&M services on the same date for scrutiny needed to verify both services. 5/9/14 Documentation of Time with Evaluation and Management Services: Time is built into the E/M codes so physicians are told to base their E/M selection on the 3 components: History, Exam and Medical Decision Making. Times are listed in the CPT manual with each level of service as a guideline only. If a provider spends more than 50% of a face-to-face visit counseling and/or coordinating patient's care, the provider can code the visit based on time spent even if the History, Exam and MDM elements are lacking. Time must be documented as well as the detailed description of the circumstance (counseling patient or coordinating care). For example: 55 minutes spent with patient, 30 minutes was spent in discussion with patient and family regarding palliative care. Prolonged service codes can be reported in addition to an E/M code when the length of time a provider spends with a patient in an outpatient setting exceeds greater than 30 minutes beyond the typical for the level of service selected.

12 5/16/14-The Importance of Reviewing Lab Tests When auditing medical records, it is vital to know what lab tests were ordered, why they were ordered (medical necessity) and what the tests results indicate. It is not the responsibility or role of a coder or auditor to interpret lab results; however, it is our responsibility to have the clinical background and knowledge to understand the results (normal/abnormal) associated with any tests which were ordered. It is also our responsibility to determine medical necessity associated with those tests. A Complete Blood Count and Comprehensive Metabolic Panel are two of the most widely ordered lab tests. As always, be mindful when auditing "organ or disease-oriented panels"; no two or more panels should be ordered together that include any of the same constituent tests from the same patient collection. If the group of tests overlaps two or more panels, report the panel that incorporated the greater number of tests to fulfill the code definition. You can report the remaining tests using individual test codes. Attached you will note a PDF attachment that includes "normal" lab values. These lab values and disorders are only guidelines, with normal ranges varying from facility to facility, but we felt that providing this resource to assist you in auditing would be helpful. 5/23/14-Reporting Laparoscopic Service When Specific CPT Codes Do Not Exist When auditing surgical services that are performed laparoscopically (through a laparoscope), keep in mind that a laparoscopy code should be reported. If you find that an "open" procedure code is reported in these situations, credit should not be given as this would represent incorrect coding. A common misconception is that when a laparoscopy code is not available in CPT, a provider should report the closest open procedure code. When a procedure is performed laparoscopically, it should be reported as such, even if that requires the provider to employ an unlisted laparoscopy code (e.g., unlisted laparoscopic procedure, appendix). Before assigning the final CPT code, providers should always consult Category II and Category III codes to determine if an accurate code exists. If it does not, rather than assigning an open code, the provider should select the anatomically appropriate unlisted laparoscopy code and document each of the following to assist an auditor reviewing a claim or a payer processing the claim: the difficulty of the case the patient's diagnosis the risk of complications the equipment required to perform the surgery the amount of time and effort required to complete the procedure When payors require documentation to properly process the claim, the provider should also provide a cover letter suggesting the CPT was carefully interrogated and that no specific laparoscopic code could be located. The submitted charge should be based upon the closest code that does exist with an explanation as to why that code most closely reflects the work effort and time for the unlisted code.

13 5/30/14 Record Evaluation More scrutiny is on the way! USA Today (5/29, Kennedy) reports that HHS' Inspector General is set to release a report Thursday revealing that Medicare "paid out $6.7 billion in 2010 for health care visits that were improperly coded or lacked documentation". Since this represents such a LARGE amount of the total Medicare budget for these services (21%), Senator Bill Nelson (D-FL), head of the Senate Special Committee on the Aging, is calling for more scrutiny in processing and evaluation of services. This news tip is relevant to 2010 claims, but how are your services documentation and billing today? Would they stand up to such review? If proper auditing and monitoring was performed on your services in 2010, then newsbreaks such as this would not be as concerning. Do you have a Compliance Plan with an ACTIVE auditing and monitoring plan implemented? Having a defined plan in writing will give guidance so that a proper plan of approach can be constructed to put feet in motion on your monitoring. 6/6/14 Medical NecessityToday's tip is based on a question submitted by a member this week: QUESTION: We keep hitting this wall, losing payment because the medical necessity is not documented in the results of the service. My understanding is that we can use the documentation by the provider that led up to the decision to do the radiology service, but can that include the documentation within the encounter note as well (that the documentation in the providers note can be used). Can you weigh in on this? ANSWER: Within the medical decision-making process, there are three different components. First there is the number of diagnoses and/or management options to be considered. Next comes the amount and or complexity of data to be reviewed. This is the area where a provider is given credit for ordering and or reviewing of diagnostic tests. Essentially, if the provider does nothing in terms of ordering and/or reviewing diagnostic tests, they get zero points in that category. If they order and or review 1 lab or 100 labs, they get one point. The same would apply to tests the medicine section of CPT or the pathology and laboratory section of CPT. The last category of medical decision-making is overall risk. We would suggest you refer to the table of risk to assess overall risk in consideration for the overall complexity of medical decision-making. Of those three elements of the decision-making process, two are required to qualify for a particular complexity.

14 6/13/14 Prescription Drug Management in the Table of Risk Submitted by Sarah San Pedro Prescription drug management has to do with drugs that can only be attained through a physician order (prescription) and are managed by the physician. The physician assigns a liability and amount of responsibility to assess for patient risk when a patient receives these medications, therefore a higher level is warranted with moderate risk. Over-the-counter medications, even at a prescription dose, are still a lower level of risk based on the classification and management process of the medication. The fact that a prescription was written for an over-the-counter medicine is not enough to warrant it as prescription drug management. This also applies to medications where the insurance will pay if a prescription is written; the logistics of writing an Rx alone do not allow for the consideration of this drug as prescription management. Review the documentation content for an actual management process. If the provider gives the patient a prescription for Prilosec to "manage" their chronic upper gastric complaints, there is management involved and not merely script writing. Be sure to evaluate the records thoroughly and not just automatically give credit for all prescriptions written. 6/20/14 On January 6, 2014, the Medicare system began checking the following claims to ensure that the ordering and referring providers are enrolled in Medicare and that they have a valid national provider identifier (NPI): Part B clinical laboratories Part B imaging centers Part B durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) Part A home health agencies. Without this information, claims will be denied and not paid. When auditing these types of services, be sure that you are validating that the referring/ordering physician on the claim form matches the listed referring/ordering provider in the documentation. It is also suggested that the auditor verify the provider's status on the OIG Exclusions database as this has become a new, hot topic area for scrutiny. For complete details about the above, go to SE1305 at Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1305.pdf. To access the OIG Exclusions Database, visit:

15 6/27/14-This week's auditing tip comes from a member's question. Question: When a physician is asked to see a patient in the ER by the ER physician, should ER codes ( ) be used, or should we bill POS ER with an outpatient E&M code? If that is the case, should we bill an established or new patient E&M? There seems to be quite a bit of discrepancy in how these services are coded. Answer: This is a very good question and you are right, it is an area with quite a bit of controversy. According to CPT Assistant, any provider may use the codes , but that is speaking to how the codes may be used and is not necessarily the official guidance that all providers seeing patients in the ED should use. Here is the quote: Question: Is use of the emergency department services code series ( ) only limited to emergency department physicians? AMA Comment: It is important to recognize that the listing of a service or procedure and its code number in a specific section of the CPT codebook does not restrict its use to a specific specialty group. Any procedure or service in any section of the CPT codebook may be used to designate the services rendered by any qualified physician or other qualified health care professional; therefore, the emergency department services code series ( ) is not limited to emergency department physicians American Medical Association Additionally, it is noted that many carriers have specific guidance/policies in this area. If both the ED provider and the visiting provider bill with the ED code, the claim may default to the unspoken rule that the first one who gets their claim in is the one who gets paid, leaving the other provider to get denied. That leads to political issues between providers and/or the hospital. In most instances, the visiting provider meets the guidelines as a consultant, a provider who is being asked to see the patient for their opinion regarding the patient's needs. In other instances, the visiting provider is there to admit the patient. Both of these instances rule out the need for both providers to use the ED codes. The handful of cases we are left to discuss are the Medicare patients, whose providers are technically consultants, but Medicare does not recognized the consult code any longer. In these situations, instead of the visiting provider using the ED codes and having conflicts of service, according to the E&M rules, it would also be appropriate to use the codes with the POS of ER. These codes not only represent office-based services, but also outpatient services, as long as the carrier did not have any conflicting policies. NAMAS cannot provide you with a crystal clear answer to this controversial scenario, but we can point you to the process of elimination as noted above and further suggest you check all carrier rules (commercial and otherwise) regarding any specific policies they may adhere to. You may also consider constructing an internal compliance policy as to how your practice addresses these scenarios for consistency in your billing practices.

16 7/4/14 Clarification to June 27th Auditing Tip Last week's "auditing tip" regarding the proper use of the Emergency Department (ED) evaluation and management codes ( ) requires further clarification. As a result of the moratorium placed on consultation codes by CMS in 2010, the use of alternative codes has become a point of debate that continues to cause considerable confusion. While it is noted that CPT codes may apply to multiple outpatient settings (not just the office setting; POS #11), CMS does indicate in their Claims Processing Manual, Chapter 12, Section that a provider treating a patient as a consultant in the ED (for encounters NOT leading to an inpatient admission) should report the service using a code from the ED series of CPT (codes ) using POS code #23 (emergency department). We realize that numerous errors in provider reporting and/or claims processing have occurred as a result of this often debated issue but again, we must fall back on CMS guidance and established policy. In the event that your claims are submitted in accordance with the CMS issued policy, we suggest investigating the claims for accuracy and initiating the appeals and grievances extended by the various payers. We all know that CMS is the standard, but various payers may have conflicting points of view. For example, some plans continue to allow for consultations to be reported and in these cases, we suggest submitting claims to those payers accordingly.

17 7/11/14 Medical Necessity in the PFSH When reviewing E&M services, documentation guidelines allow us to give credit for PFSH (past family social history) for most any relevant statement. For example: Past Medical History: Negative Diabetes Family History: Negative Diabetes Social History: 2 drinks per bedtime This would satisfy a complete PFSH. However, when placing an emphasis on medical necessity, a PFSH that is more "complimentary" to the chief complaint may better demonstrate the complexity of the patient. For example: A patient presents for right foot pain for 4 days. She has been using Advil but still complains of achiness and numbness. Past Medical History: No previous fracture or injury to the right foot Family History: Negative for RA or gout Social History: Walks 1-3 miles daily While the PFSH is still negative of pertinent findings and remains comprehensive in nature, it now meets documentation guidelines and helps to better reflect the medical necessity and complexity associated with the patient's complaint. When providing education on audit findings, auditors should encourage providers to address the standard components of documentation guidelines in a more complex manner so the medical necessity will be more clearly evident. This does not take any extra time or effort, but the results will lead to an encounter rich in medical necessity. 7/18/14 SIGNATURE REQUIREMENTS If a physician signature is not legible on an order or progress note, the provider may submit an attestation statement or a signature log (individual or group) to support his or her identity. This typed listing includes a provider's name with a corresponding handwritten signature. It is always best if providers submit a complete medical record with appropriate signature documentation initially to avoid delays in review completion, but in instances of error or oversight, the attestation statement may be used. CMS has many rules and guidelines pertaining to provider signatures including the acceptance of an original record which contains a printed signature below the illegible signature. On July 7, 2014, MLN (Medicare Learning Network) released an updated bulletin regarding signature guidelines. This bulletin included a comprehensive listing of resources and guidelines regarding provider signatures. This always seems like an easy topic to address, but oftentimes it can be the cornerstone of causing claims processing delays through the audit process. Be sure you refer to the guidelines and are including this review through your day-to-day audit and compliance efforts. MLN July 2014 Signature Requirement Release

18 7/25/14 Utilization Patterns All medical auditors and compliance professionals are familiar with the buzz term "utilization patterns" which is taking the place of the antiquated term "bell curve." Why the reason for the updated verbiage? Utilization data gives us far more information about our providers' billing and coding processes than merely a curve to equate them to. A provider's utilization is the cornerstone of review processes by carriers as they monitor all areas of provider services. E&M services represent the largest target for carrier audits because of the following reasons: E&M represents the largest volume of claims billed regardless of specialty. E&M services are relatively straightforward to audit. Tracking of utilization is easy to trend. For these reasons, it has become more necessary for practices to track their providers' utilization far beyond a spiking bell curve analysis. Utilization patterns should be monitored on a consistent basis for all providers in an effort to review their trending and identify the overall practice trending to evaluate providers who may be outliers, This information will help to create a more thorough approach for internal auditing of documentation and coding. Adopting a new Compliance Policy that incorporates a utilization review would be a worthwhile investment in furthering the compliance health of your practice. Consider the following components when creating such a policy: Frequency of utilization review Percentage over/under that will trigger internal review Review process to be implemented as a prospective or retrospective audit Duration of the audit Impact (if any) on the provider due to substantially high variances, continued substantial variances, etc...

19 8/1/14 BILLING AUDITS When thinking of auditing, we tend to immediately consider the need for auditing of documentation and coding, but not as often thinking of how important it is to also perform billing audits. Billing audits should not only include the portions of the review that are performed in the standard coding audits such as modifier usage and diagnosis linkage, etc... A good billing audit should review the billing process from inception to collection. When performing your next audit consider adding a billing audit and focus on a solid review to include a random sampling of daily billing close packets. In reviewing the daily close the auditor should consider reviewing the following: The updated schedule showing all cancellations, no-shows, add-ons, and all other modifications should be maintained with daily close packet. This schedule should be compared to the sign-in sheet. Misconduct can occur by front office staff by removing a patient from the schedule and omitting their billing and/or payment. Compare all deposit details to the actual payment posting daily close report. This will ensure that all payments were not only appropriately posted, but also accounted for. Be sure to include a comparison of the deposits slips to either a deposit receipt or the checking statement from the bank. Compare the daily services provided (or a sampling of) to the daily charges report to ensure all charges have been appropriately entered. Practices rarely balance their charges and often times services may be billed incorrectly or completely missed. It is recommend that all billing staff create adjustment request forms and only the billing manager or practice manager have the authority to perform the write-off (with the exception being contractual adjustments through EOB posting). These requests should be balanced to the daily close adjustment report. AR should be reviewed for proper collection techniques and any inappropriate adjustments made in an effort to manipulate the AR totals of the practice. This outline does a good job of giving some guidance on an adequate billing review, but be advised there are many other facets that you should be auditing. Keep in mind that the billers of the practice are the gateway to the reimbursement and the cash flow of the group. In some instances, billers may feel undue pressure to act in inappropriate and sometimes even fraudulent manners in an effort to increase the revenues of a practice. Regular auditing of the billing practices will further safeguard a practice from such inappropriate actions. REMINDER: Just because a practice uses the resources of an outside billing firm does not negate this need, rather often times it is a more critical area of needed review.

20 8/8/14 Auditing Home Visit Services Home visits are a service in which the industry is seeing increased utilization, most notably in the rural settings. The documentation requirements for these services vary from the E&M services that we standardly audit through compliance reviews. All E&M services require medical necessity to support the encounter, and home visits are of course no different. When reviewing the home visit, we are additionally validating the reason (i.e., medical necessity) the visit needed to be performed in the home setting, and regardless of whether this has been established in previous encounters or not, this point would need to be substantiated in each encounter. Home visit services (CPT code range ) are provided in the beneficiary's private residence, and these codes should not be used when the service is of such nature that it could have been provided by a visiting nurse/home health services agency under the home health benefit. Coding and Documentation Guidelines: A diagnosis that supports the mere presence of inactive or chronic conditions does not constitute medical necessity in any type of place of service and, most importantly, not for the home visit. There must be a chief complaint that includes specific reasonable need for the home visit during EACH encounter. Therefore, when auditing these services, the documentation of each beneficiary encounter must include the following: Reason for the encounter and relevant history Physical examination findings and prior diagnostic test results (as applicable to the patient history) Assessment, clinical impression, and diagnosis Medical plan of care including how the visit will help the performance of the beneficiary A payable diagnosis alone does not support medical necessity of ANY service. Medical necessity must exist for each individual visit. The visit will be regarded as a social visit unless the medical record clearly documents medical necessity. Noted problems that exist within the caring of patients in this place of service relate to confusion by other providers in the use of this E&M category. For example, if one provider bills the service as a home encounter, while another bills their service provided for the same diagnosis, same condition and same episode of care as domiciliary services regardless of the billed site of service, this could constitute concurrent or duplicative care resulting in denied services. If laboratory and diagnostic tests are performed during the course of a home visit, they must meet Medicare's reasonable and necessary criteria. Medical reasons for repeated testing must be clearly documented. Performance of multiple or common tests without clear evidence of medical need of the beneficiary or changes in the treatment regimen based on the lab tests would not be considered reasonable and necessary as mandated by 42CFR If the results of the testing will not change the medical management or result in surgery, there is no medical necessity for the procedures. In these cases, the testing would not be medically necessary.

21 8/15/14 Auditing Lab Services Lab services are rather straightforward in coding, billing, and ordering of the services, but are you sure of what you should request and review when performing an audit? THE ORDER: All lab services should have an order that identifies the specific testing needed. The only sort of deviation that should ever be considered from such is when ALL of the tests for which the provider wrote an order are part of a full panel. No one should change orders of the provider to represent a panel if ANY of the testing elements of the panel are not included in the order. The order may be represented within the documentation of the E&M encounter and would not necessarily require a separate order to be written. THE MEDICAL NECESSITY: The medical necessity of the lab order is mainly supported by the diagnosis, AND applicable documentation to support the diagnosis is present and needing further testing within the documentation of the encounter. A diagnosis that supports each lab test should be documented in the encounter and reported with the claim billing. THE FINDINGS: It would be expected that the findings of the ordered labs be noted within the patient's chart. Depending on the type of labs and the setup of the practice, the results of the testing may not be available during the patient encounter and, therefore, the findings of the testing would be elsewhere in the chart. The provider should always sign off (initial at minimum) testing that they reviewed. When auditing lab services, be sure to validate that the order is noted, the diagnosis and medical necessity support the service, and the findings are noted and reviewed. 8/22/14 -X (EPSU)MODIFIERS CMS released on August 15, 2014, new modifiers that will be effective January 1, These will be used as a subset in order to prevent errors in billing and claims processing of services reported with the - 59 modifier. According to the CMS release, CERT Audits have noted that over $2.4 billion have been paid in 2013 for instances in which modifier -59 was part of the reported services, and there is a projected error rate of those to be XX%. The high error rate has triggered the creation of the four new modifiers listed below: XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service This implementation will not mean that the -59 modifier will not be valid for use, but it does mean that its use will be limited. Even current NCCI policy states that prior to appending the -59 modifier, all other modifier options should be considered for use. The creation of the -X (EPSU) modifiers will enforce this. For the CMS transmittal on these modifiers, click here for the PDF download.

22 8/29/14 Dietician Services as an Incident-to Service As a result of this past weeks NAMAS Member Webinar, we have received multiple questions about the services performed by a Dietician. The directed questions have been, "Can a dietitian's services be performed and billed incident-to a supervising physician?" The answer is noted in the Internet-Only Manual (IOM) - "Medicare Claims Processing Manual," Publication (Pub.) , Chapter 4, Section A (page 235 for quick access). Services performed by a dietitian are NOT billable as incident-to services. The IOM specifically states: "The above codes can be paid if submitted by a registered dietitian or nutrition professional who meet the specified requirements; or a hospital that has received reassigned benefits from a registered dietitian or nutritionist. These services cannot be paid 'incident to' physician services". This guidelines is based on the rules set forth for MNT (Medical Nutrition Therapy) Services provided through code set of Effective in October of 2002 the benefits for MNT services were updated and additional coverage's were included. At this time the direct credentialing of dietitian and nutritional professionals meeting the Medicare regulations as defined in the same IOM link above in Section A (page 233). As these professionals are required to direct bill under their own NPI their services will only be reimbursed at the 85% pay allowance, but unfortunately there is no other form of resolution. MNT services are not a more common service performed, but it appears that there may be many questions surrounding the topic. NAMAS is interested to know if you, our members, feel that a webinar training on this topic would be beneficial.

23 9/5/14 NCCI Policy Manual States: The Physician Must... Well, here it is, the resource that you have been looking for to point out to your providers! Many have ed us asking, Where can I find it in writing that my provider should not downcode as a "safety net"? The NCCI Policy Manual includes this information and very specifically addresses each element, downcoding, upcoding, and the proper use of units of service. Here is a quick snippet of the information: Physicians must avoid downcoding. If a HCPCS/CPT code exists that describes the services performed, the physician must report this code rather than report a less comprehensive code with other codes describing the services not included in the less comprehensive code. Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all services described by that code have been performed. Physicians must report units of service correctly. Each HCPCS/CPT code has a defined unit of service for reporting purposes. A physician should not report units of service for a HCPCS/CPT code using a criterion that differs from the code's defined unit of service. Two weeks ago, the auditing tip of the week provided you with the link to download this policy manual because of its resource value. Make sure you have this manual and refer to the policies, often, even if just for a quick brush-up.

24 9/12/14 Auditing the Past, Family, Social History Documentation When auditing an Evaluation and Management service, the history element requires past medical, family and social history, (or one or two of those). This tip explains what needs to be documented and the rules around using a history that was previously documented. To count the components of the history, documentation should be present in the Past Medical, Social and Family History. This doesn't count: Social history: none. Everyone has social history. Many auditors and payers do not allow, "Family history non-contributory." CMS has not stated whether it considers that adequate, when admitting an elderly patient to the hospital. Some payers have specifically stated they do not count "Family history non-contributory," while some are silent. The words noncontributory, unremarkable or negative do not indicate what was addressed. Did the nurse or physician ask specific conditions? (for example, any family history of coronary artery disease?) If for some reason you cannot obtain the family history, the documentation must support the reason why (e.g., the patient was adopted). The guidelines do allow a clinician to use a history previously obtained for today's note as long as the date and location of the previous note is mentioned. The clinician must indicate that the history was reviewed and there are no changes. For example: "The remainder of the past medical, family and social history is unchanged from their previous admission of January 16, I reviewed this with the patient and there are no changes." In an electronic medical record, the past medical, family and social history is brought forward from previous visits. This counts as long as the billing provider reviews this information with the patient and indicates that. There may be a prompt that says, "Past medical history--reviewed and unchanged."