Doris V. Branker, CPC, CPC-I, CEMC 1
Identify the common sources for missed reimbursement in the specialty practice Identify the common sources for reduced reimbursement in the specialty practice Identify common compliance risks for the specialty practice 2
Revenue from procedures typically represent a greater portion of reimbursement Scope of practice is more targeted Risk of financial provider liability is greater Capitation is less common 3
Part I 4
Demographic data collection and maintenance Insurance verification for all lines of business in the practice Program specific payer data (Humana HMO vs. Humana Medicare)** This is the ideal point for collection of this data 5
Not knowing payerspecific contract rates prevents Collection of accurate TOS money Identification of inappropriate payments Ability to make financially viable decisions* $$$ 6
Lack of knowledge of contract data prevents Adherence to payer/subpayer timeliness guidelines Early identification of payer specific issues and trends Escalation Process Know your state laws!!! Missed charges Internal controls Adjustment tracking and policies Timely correction of internal/external errors Reporting 7
Based on type of service: Copayments Coinsurances Vital for surgical practices Deductibles Non-covered Services Verification process should capture practice service level detail including: TOS/POS Office based surgery Ancillary services Imaging services 8
Non-covered services Advanced notification to patients Alternate codes for reporting of services Correct by CPT/ICD but incorrect based on payer written specifications Methodology for reporting modifiers Misreporting of packaged services Surgical package varies 9
Medications/Supplies Billing for fewer units of services than documented Not billing for administered medications Lack of reconciliation for all rendered services Surgical Schedule Office schedule Hospital call services* 10
Lack of resources Provider specialty board memberships AMA only LCD/NCDs Coding programs Medical society positions Use of outdated references/resources Manuals Provider bulletins Coverage Policies 11
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Misuse of modifiers* No knowledge of payer specific coverage policies Over-collection of TOS money based on billed rates Mid-level practitioner billing* Lack of internal reviews Lack of external reviews (unbiased) HCPCS billing* New provider billing E/M Services* 13
Know when modifiers are applicable Ensure documentation and medical necessity supports the use Do not apply for claim payment purposes only Do not add modifiers upon verbal advice from insurance representatives without understanding Refer to payer-specific instruction when applying modifiers (if it exists) Have a thorough understanding of AMA/CPT direction and intention in absence of payer guidance 14
Global period may be 0-90 days based on procedure Minor- 10 days* Decision for surgery included in surgical procedure payment unless significant and separately identifiable Total of 11 days Day of surgery + 10 days following= Global Major- 90 days* Decision to perform surgery separately billable w/modifier -57 Total of 92 days Day before surgery + Day of Surgery + 90 days after surgery = Global 15
Reflects one of the following related to global days 000- Minor procedures or endoscopies 010- Minor procedures or endoscopies 090- Major surgeries YYY- refer to local carrier for number of global days if not listed ZZZ- refer to primary CPT for global days (add-on codes) 16
Modifier 24 Use on an E/M service that is unrelated to the problem warranting the surgical procedure in global period Should be used for complications that are addressed with an E/M service* Modifier 25 Use on an E/M service when E/M is separately identifiable from the other service or procedure performed on same day Carve out pre-procedure work and if remaining elements equate to a billable E/M service, report w/modifier 17
Type of service Consultation vs. Referral New vs. Established Incident to vs. Split/Shared Level of care assignment 18
New Patient Providers following individual self-created vs. CPT definition of new patient Consultations billed when new/established patients visits are more appropriate Beware of Medicare requirements for consultation reporting** Some Commercial Medicare products are following this guidance 19
Incident to Applies to services rendered by NPP Applicable to physicians office/clinic settings only Must be integral part of services provided by provider Requires direct supervision by a physician May be billed under physician s number w/no loss in reimbursement Split/Shared Applies to ED/Hospital setting Billed under NPP if physician has NO face-toface encounter w/patient Billed under physician if face-to-face encounter and co-signature is performed 20
Quantity of documentation does not justify higher level of service in absence of medical necessity Do not use coding tools without review and understanding of documentation guidelines Record cloning increases likelihood of over reporting Remove the $$$ from the decision on code level If reporting based on time ensure the documentation supports the details of counseling/care coordination 21
Coding of Evaluation and Management Services We will review evaluation and management (E&M) claims to identify trends in the coding of E&M services. Medicare paid $25 billion for E&M services in 2009, representing 19 percent of all Medicare Part B payments. Pursuant to CMS s Medicare Claims Processing Manual, Pub. No. 100 04, ch. 12, 30.6.1, providers are responsible for ensuring that the codes they submit accurately reflect the services they provide. E&M codes represent the type, setting, and complexity of services provided and the patient status, such as new or established. We will review E&M claims to determine whether coding patterns vary by provider characteristics. Payments for Evaluation and Management Services We will review the extent of potentially inappropriate payments for E&M services and the consistency of E&M medical review determinations. CMS s Medicare Claims Processing Manual, Pub. No. 100 04, Ch. 12, 30.6.1 instructs providers to select the code for the service based upon the content of the service and says that documentation should support the level of service reported. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. We will also review multiple E&M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. 22
In order to meet all the general requirements for coverage under the incident-to provision, an FDA approved drug or biological must: Be of a form that is not usually selfadministered; Must be furnished by a physician; and Must be administered by the physician, or by auxiliary personnel employed by the physician and under the physician s personal supervision. Must represent an expense to the physician 23
Should be monitored at intervals regardless whether process in internal/external Billing companies or housed billing Smaller practices have a higher probability of erroneous practices Lack of internal training Lack of resources Unskilled staff 24
https://www.cms.gov/manuals/iom/list.asp http://oig.hhs.gov/publications/workplan/2 011/FY11_WorkPlan-All.pdf 25