Melody S. Irvine CPC, CPMA, CEMC, CFPC, CPC-I, CCS-P, CMRS

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Melody S. Irvine CPC, CPMA, CEMC, CFPC, CPC-I, CCS-P, CMRS This presentation is for general education purposes only.

not, legal advice or even particular business advice relevant to your personal or medical practice circumstances.

state, Medicare contractor or in a relevant carrier policies/contract and are open to interpretation.

to seek private counsel with your attorney to determine how these laws, regulations, policies and contractual terms

1 Melody S. Irvine CPC, CPMA, CEMC, CFPC, CPC-I, CCS-P, CMRS This presentation is for general education purposes only. The information contained in these materials, lecture, ideas and concepts presented is not intended to be, and is not, legal advice or even particular business advice relevant to your personal or medical practice circumstances. The laws, regulations and contractual terms regarding auditing that is presented in this lecture are published by state, Medicare contractor or in a relevant carrier policies/contract and are open to interpretation. It is your responsibility to evaluate relevant carrier medical policies and provider contract provisions as well as to seek private counsel with your attorney to determine how these laws, regulations, policies and contractual terms as well as the concepts discussed apply to your specific case before applying the concepts addressed in this presentation. Attendance at this presentation should not be construed as legal advise by the speaker nor will the information prevent any audits/fines or sanctions by any entity. Remaining for this presentation indicates your acknowledgement and agreement with the above. 1

2 Contents of an Auditing Compliance Plan Purpose Audits/Monitoring Frequency of Audits Non-compliant physicians/auditors Documentation requirements Medical Necessity Addendums Acronyms ABN Incident-to Signatures Buy in Follow along with the Sample Auditing Complain plan Didn t print?? Follow slides 2

Possible risk areas Incentives for unnecessary services Services/items provided are reasonable and necessary Documentation is correct and complete The OIG

3 Possible risk areas Incentives for unnecessary services Services/items provided are reasonable and necessary Documentation is correct and complete The OIG recommends auditing five or more medical records per federal payer (i.e., Medicare, Medicaid), or five to 10 random medical records per physician. It is not mandatory. 3

4 Inappropriate behavior Billing and reimbursement practices Risk/vulnerabilities of practice OIG Work Plan to identify your potential risk/vulnerabilities Identifies problems before an audit occurs Supports outside audits Support Due Diligence Establish guidelines per MAC/payer Support documentation and grey areas 4

All grey areas should be addressed in your auditing compliance plan History, Examination and MDM Everyone must be auditing/viewing grey areas the same What may not be grey to you could be to

5 All grey areas should be addressed in your auditing compliance plan History, Examination and MDM Everyone must be auditing/viewing grey areas the same What may not be grey to you could be to another person Grey areas must be reasonable Consistency is Crucial Inform providers to comply with laws, regulations and guidelines of: Government State Medicare contractor Practice compliance 5

New physicians/npp training: Documentation guidelines Failure to: Participate in training Failure to comply with documentation Sign statement certifying they have received, read and understand the

6 New physicians/npp training: Documentation guidelines Failure to: Participate in training Failure to comply with documentation Sign statement certifying they have received, read and understand the contents of the auditing compliance plan Period training/updates related to auditing and documentation Compliance with: CPT, ICD-9-CM, HCPCS, Billing, CCI edits, LCD s, OIG Work Plan, Audits for areas of concern Identify patterns/trends 6

Credential of auditors Tests administered to

auditing compliance plan External auditors to

7 Credential of auditors Tests administered to auditors CEU requirements Auditors must follow auditing compliance plan External auditors to monitor accuracy and performance How often should audits be performed? Depends on size of practice Monthly, quarterly, annually Important!!! Per OIG HEAT (Healthcare Fraud Prevention Enforcement and Action Team) Perform the number of audits identified by your compliance plan 7

8 Acceptable error rates and recommended follow-up audits Error Rate Schedule for follow-up audits 10% Annual 20% Five Months 30% Four Months 40% Three Months 50% Two months 40% or less One month Compare statistics to MAC providers of the same specialty MedicareFeeforSvcPartsAB/Downloads/ EMSpecialty08.pdf?agree=yes&next=Accept 8

99201 Practice Type Usage of Code General Surgery 26, 390 Family Practice 24,496 Dermatology 94,729 Physicians Assistant 14,149 Pain Management 533 Cardiology 1,782 99213

6,694,795 Written Reports: Patient name/date of service Providers name Level billed/level documentation supports Diagnosis billed/diagnosis documentation supports Any

9 99201 Practice Type Usage of Code General Surgery 26, 390 Family Practice 24,496 Dermatology 94,729 Physicians Assistant 14,149 Pain Management 533 Cardiology 1, Practice Type Usage of Code General Surgery 1,485,410 Family Practice 20,785,408 Dermatology 4,341,355 Physicians Assistant 1,685,810 Pain Management 190,537 Cardiology 6,694,795 Written Reports: Patient name/date of service Providers name Level billed/level documentation supports Diagnosis billed/diagnosis documentation supports Any coding/billing discrepancies Medical necessity Recommendations/concerns Auditor name Who they can contact concerning audit Reports sent to compliance office/medical director 9

privileges Suspension or termination of employment New verses Established

10 Disciplinary actions Additional education training Verbal counseling Prepayment audits Continuous violations Reduction, suspension or revocation of clinical privileges Suspension or termination of employment New verses Established Patients State if patient is new New to practice or initial visit Definition of a new patient 10

All components must be present to bill, if any component is missing it is non-billable History Examination Medical Decision Making Counseling documentation Time spent Detailed information of

11 All components must be present to bill, if any component is missing it is non-billable History Examination Medical Decision Making Counseling documentation Time spent Detailed information of counseling performed Coordination of Care Documentation of time, detail of coordination of care provided by physician and with other health care professionals Time Time documented, detail of conversation for time, condition, illness or disease counseling Show exactly how you want time to be documented 11

The medical record should clearly reflect the chief complaint Supports: Patient encounter Medical necessity of visit Three chronic illness?

12 The medical record should clearly reflect the chief complaint Supports: Patient encounter Medical necessity of visit Three chronic illness? Who can record the history? Ancillary staff Form completed by patient Must be reviewed by physician All others negative for ROS ROS must meet medical necessity Double dipping 12

13 Unobtainable history, how is it counted Unremarkable or non-contributory Normal or negative is permissible Past Medical, Family, Social History Documentation requirements Example: There is no change in the patients Past Medical, Family or Social History from their previous visit of 3 weeks ago on 03/03/2011 All others negative unacceptable All others negative acceptable Pertinent positives and negatives are documented, notation of all other systems reviewed and negative is accepted 13

14 Different views of MAC Contractors Allows counting an element of HPI more than once 3 Chronic used for 95 and/or 97 Need at least 1 element for HPI Non-contributory not acceptable Allow counting elements for multiple conditions Different views of MAC Contractors Non-contributory may be appropriate when referring to negative ROS Allow double dipping from HPI and ROS 14

15 Different views of MAC Contractors Non-contributory not allowed Non-contributory can be used to address Family History if not pertinent History obtained previously can be reviewed and updated No more than 1-2 years Different views of MAC Contractors Overall history guidelines Do not limit chief complaint to follow-up without identifying the problem Do not accept non-contributory Do not record unnecessary information is to elevate E/M level Property of Career Coders, LLC. All rights reserved. These materials may not be duplicated without the express written permission of Career Coders, LLC

Audits based on 95/97 or both Extend of examination must meet medical necessity Abnormal or relevant negative findings documented Acronyms that unacceptable HEENT Clarify the difference between

16 Audits based on 95/97 or both Extend of examination must meet medical necessity Abnormal or relevant negative findings documented Acronyms that unacceptable HEENT Clarify the difference between Expanded Problem Focused/Detailed What does Detailed mean? Examples: 1 BA/BS PF 2-7, no detail - EPF 2-7, one in detail (what does detail mean?) - Detail 8 + Comprehensive 1 BA/BS PF 2-4 EPF 5-7 Detailed 8+ Comprehensive 16

17 Will not receive credit for diagnosis not applicable to visit unless secondary Diagnosis must have relevance to treatments provided or ordered Charging for ordering of test & points for complexity Documenting interpretations History obtained from someone else, must be documented Reviewing of old records, must be documented and a brief summarization Discussion with other health care providers 17

18 Different views of MAC Contractors MDM not one of required element for 2 of 3. Based on medical necessity and physicians work Additional work-up stated as any work being done beyond the evaluation encounter Different views of MAC Contractors Prescription drug management does not require med changes or dosage changes Detailed explanation of MDM and presenting problem Old diagnosis not counted unless demonstrated to increase physicians work 18

Different views of MAC Contractors Definition of self-limited or minor under minimal risk or new problem with no work-up: Are you treating the condition?

19 Different views of MAC Contractors Definition of self-limited or minor under minimal risk or new problem with no work-up: Are you treating the condition? If this is in addition to a chief complaint did it affect your MDM for the chief complaint Each E/M should stand alone and cannot appear to be cloned Must meet Medical Necessity Be careful of templates not to over estimate MDM What if one of the components was not done? Billable as documented? 19

located) Fractures (bones, tendons, muscle, nerves) LT/RT Really important for ICD-10 Date of surgery Patient name and date of birth

20 Diagnosis used for billing, ordering of services: Supported in medical record Documented to the highest level of specificity Examples: Stages (ulcers, chronic kidney disease) Diabetes ( Type I, II, controlled, uncontrolled, insulin) Burns (TBS, degree of burns, where located) Fractures (bones, tendons, muscle, nerves) LT/RT Really important for ICD-10 Date of surgery Patient name and date of birth Surgeon Assistant surgeons/co-surgeons/interns Anesthesiologist Descriptions and details of the procedure Diagnosis pre-op and post-op Etc 20

21 Copying information from past encounter and passing it off as current documentation High risk for doctors OIG Work Plan Patients that have had at least 2 visits per month for 3 months. Checking for medical necessity Some do warrant frequent visits: Diabetes COPD 21

22 Requesting opinion from another provider Three R s Request Report Review Must meet criteria for consultation Not using work referral All claims meet medical necessity What does this mean in your practice? Procedures performed are reasonable and necessary Undercoding/Overcoding will be adjusted according to documentation 22

When medical decision making is the lowest of the three components Example: Comprehensive History Comprehensive Examination Low Medical Decision Making Undercoding/Overcoding OIG Work Plan

23 When medical decision making is the lowest of the three components Example: Comprehensive History Comprehensive Examination Low Medical Decision Making Undercoding/Overcoding OIG Work Plan Undercoding can be a red flag I hear this often I feel bad charging them more for the service even though I know I did the work How it affects facilities and physicians Reports do not reflect the seriousness of some conditions Underpayment 23

24 Difference What is considered appropriate time for addendum or late entry? 2 days 5 days 30 days or more Identify acronyms used by providers Make sure they are used uniformly Examples: BP HD Hodgkin s Disease High Density Lipoprotein 24

25 Reviewed by two people if illegible Unable to decipher not billable Certain modifiers should be audited Any other frequently used modifiers 25

26 Paper medical records are not permitted to leave the facility. Securely accessed EMR system with secure password. It is illegal to access any unauthorized or inappropriately access, review or view a patient s medical information without a direct need for medical diagnosis, treatment, auditing, or other lawful use. Who s responsibility? Presented to the patient before services are rendered ABN must be completely filled out Estimated cost to the patient Description of service Patient given ample amount of time to decide Diagnosis used must be in medical record 26

coding departments Review global CPT codes and confirm

27 I still want to bill it Example: Pulse ox May be part of vitals but may not be billable/payable Communication between billing and coding departments Review global CPT codes and confirm appropriate use of E/M services provided during the global surgery period 27

Scribe cannot see the patient in lieu of physician Documented information

28 Are all rules followed for incident-to billing Are supervising physicians in the office suite and immediately available? Scribe cannot see the patient in lieu of physician Documented information was obtained by scribe Physician statement the information was reviewed and verified by the physician 28

No stamped signature Original or electronic Attestation statements Must meet Medicare requirements Combination of documentation from resident

29 No stamped signature Original or electronic Attestation statements Must meet Medicare requirements Combination of documentation from resident and teaching physician Teaching physician must document their participation Incomplete or invalid documentation billed as a non-teaching setting 29

30 Payments for referrals or to induce referrals are considered illegal and will be closely monitored Physicians are not permitted to make any financial arrangements with outside entities Write-offs Verify co-payments and adjustments are properly written-off Contractual and non-contractual accounts 30

31 Place of Service Verify Place of Service codes are appropriate for services performed in ASC or outpatient department of a hospital Claim Denials Review claim denials for medical necessity of services/procedures or supplies 31

32 Identify and maintain a list of claims denied due to billing/coding errors Incorrect codes used Same provider Code linkage Help reduce non-payment of claims First Step External audit request must be reviewed by the Auditing Compliance Committee Auditing Compliance Committee must review the external audit request within XX days of notification 32

33 A committee for processing of external reviews: Person to identify the requests Copying of medical records Deadlines for submission of requests Follow-up Know the areas of the OIG Work Plan that affect your physicians specialty Update your compliance plan yearly to identified those key areas of OIG Work Plan Coding Patterns Identical documentation 33

34 Automatically select level Decipher medical necessity? Cloning Copy/paste Canned statements Diagnosis Chronic problems How are grey areas interpreted Know your MAC provider guidelines and make sure they are incorporated into your auditing compliance plan Physicians must be educated on your MAC guidelines Examples: Grey Area 95 or 97 guidelines 34

RI, VT AL, AZ, MN, ND, OR, SD, UT, WA, WY CA, HI, NV, OH, SC, WV AL, LA CO, NM, OK, TX, VA IL, IA, KS,

35 Cahaba Cigna First Coast Highmark NGS NHIC Noridian Palmetto Pinnacle Trailblazer WPS Contractor States AL, GA, TN, MS ID, NC FL, Puerto Rico, Virg Islands DE, DC, MY, NJ, PN IN, KY, NY MA, MN, NH, RI, VT AL, AZ, MN, ND, OR, SD, UT, WA, WY CA, HI, NV, OH, SC, WV AL, LA CO, NM, OK, TX, VA IL, IA, KS, MI, MN, NE, MO, WI Buy-in of all providers/auditors is key to success Doctors want it in writing Team effort 35

36 Written and executed by a Auditing Compliance Committee Certified coders Medical Director or other physician Compliance Officer Nursing Billing Manager Front Office Manager Success is not possible without good communication Coding/Billing Physicians Front Office Clinical staff Resolve problems without finger pointing 36

37 Ideas for Auditing Compliance Plan I want to see this in writing Help support you in outside audits Bottom line We must protect our physicians and ourselves CEU # 37

Advanced E/M Auditing: Secrets to Success

Advanced E/M Auditing: Secrets to Success Presented by Carrie Severson CPC, CPC-H, CPMA, CPC-I Senior Auditor, AAPC Client Services Why We Are Here OIG Report (OEI-04-10-00180) Coding Trends of Medicare