NAMAS Newsletter National Alliance of Medical Auditing Specialists Letter from the Founder of NAMAS July 2014 Volume 6, Issue 1 NAMAS is a division of DoctorsManagement, LLC Highlights: Refer-a-Friend Campaign 6th Annual Conference Information Announcements Coding Revolution Featured Product Inside this issue: Letter from the Founder 1 ICD-10? That is the Question! How and When To File A Payer Complaint 2 3 Medical Necessity 4 On behalf of the entire NAMAS team and our parent company DoctorsManagement, I would like to thank you for your continued participation in and promotion of NAMAS. We have an exciting lineup of webinar and roundtable events coming up in the second half of 2014. We have also finalized the agenda for our 6 th Annual NAMAS Auditing and Compliance Conference and this year proves to be one of our best yet. Our Pre-Conference event will be a repeatability and reliability study for auditors. Each auditor will walk away with a documented precision rating. Auditors who take advantage of this testing will be able to provide to their employers and/or potential new clients their validated precision rating. Individuals whose function is compliance in nature will want to take advantage of our other Pre-Conference offering, which is building an effective compliance plan. During this session, attendees will actually work together on constructing an appropriate compliance plan as well as a hands-on creation of core compliance policies needed for an effective compliance plan. NAMAS listened to our members and conference attendees requests to change the structure of the schedule to allow for travel the first morning of Conference and, most importantly, to allow Conference to conclude at noon on the last day to expedite outbound travel. Therefore, this year s conference will kick off Sunday at 1:00 p.m. and wrap up on Tuesday at 12:00 p.m. Sunday s half-day sessions will all be in a general session format. Monday will offer two break-out tracks with one track offering specialty-specific audit training while the other track offers training that is more generalized toward auditing and compliance. Tuesday s schedule includes mostly general sessions on topics that will greatly interest every auditor and compliance individual. Our 2014 faculty are some of the most well-known and respected names in the industry and we feel honored that they will be joining us this year. Make sure you take the time to review the full agenda on our website. We hope you are able to join us at Conference and for those of you that have not been able to attend in the past, you will find our relaxed style of conference, with all of the speakers accessible to each attendee, to be a far superior experience than any other conference you have attended. We look forward to seeing you there! HIPAA Myths 5 Provider Billing Audits 6 Properly Reporting Preoperative Clearance 7 Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA Founder/President of NAMAS Partner, DoctorsManagement, LLC
Page 2 ICD-10? That is the Question! To everyone s surprise, we have yet another ICD-10 delay. Many of us have asked, How did this delay in implementation of ICD-10 come to be in the SRG bill anyway? It has been stated that some payers were not ready for ICD-10 in time for 2014. Insurance carriers are likely campaign contributors; you can follow the money at that point. ICD-10 was added to the SRG bill (reimbursement issue), which was one likely to pass and not likely to be vetoed. The AMA has been another contributor to keeping the ICD-10 at bay for more than a decade and continues to urge lawmakers to stop the implementation. AMA initiated a 2014 cost study, conducted by Nachimson Advisors, that breaks down the cost to implement the ICD-10 code sets. The study shows that a typical small office may have costs well over $200,000 for training, vendor, software upgrades, testing and payment disruptions. In the meantime, providers are left scratching their heads not knowing what to do at this point. Many providers don t believe it will ever happen. As an auditor and coder, it is very frustrating, as a lot of time and money has been put into training and preparation. What is the next step? AHIMA confirms HHS continued transition to ICD-10. AHIMA encourages providers, coders and trainers to keep moving forward. Specifically, hospitals should continue to ensure that they will be able to handle all documentation associated with ICD-10. I don t see the delay as a stop sign. The positive approach is to embrace the extra year given to us to better prepare ourselves, our providers, and our software. Lynn Merz, HIA, CPC-I, CPMA, CPCO DoctorsManagement, LLC AHIMA Approved ICD-10-CM Trainer Certified AAPC ICD-10-CM Trainer
Page 3 How And When To File A Payer Complaint Unfortunately, physician offices often find themselves in what seems to be a hopeless situation regarding unpaid claims or unfavorable policy changes with commercial payers. Knowing what alternatives you have in filing complaints to and against payers is necessary. Timely Payment Practices may have unpaid claims even though the claims were submitted cleanly, resulting in a backlog of denials. In these circumstances, you do have clear rights. In almost every state, payers must pay clean claims in a timely manner or face fines from state regulators. Timely payment is anywhere from 15 days to 120 days, but states average between 30 to 45 days. If you haven't received payment from your payer before the payment window in your state expires, use your state s process and file a complaint with that regulatory body (often the State Insurance Commissioner). Once a complaint against a payer is initiated, the state regulatory organization opens an inquiry with the payer. The payer typically has a short period of time in which to research, respond, and correctly pay the claim before regulatory fines kick in. Policy Changes Perhaps you have received a notice regarding a sudden policy change that adversely affects you or your patients. In some cases, there is not much you can do to fight back. Payer contracts often stipulate that they make the policies and by signing the contract you agree to abide by those policies (even though they are likely to change as soon as you sign). However, you should always file a complaint to the payer if you disagree with any policy change, otherwise your silence equals acceptance. In some cases, policies are changed without the payer understanding the impact on its network. Feedback from providers and patients is crucial in getting harmful policy changes overturned or, at the least, putting payers on notice that frequent changes are no longer going uncontested. Before you file a complaint, make sure to take the time for due diligence on your part. You don't want to complain and then find out the payer never received the claim or had processed it properly according to its rules. Determine if the denial or nonpayment is due to a policy change by doing a policy search on the payer s website. If it is not due to a policy change and the payer is just slow to pay, then promptly file your complaint with the appropriate state regulatory organization. If it is due to a policy change you don t agree with, file your complaint directly with the payer. When filing a complaint to a payer, contact your assigned representative first. If you don't have an assigned representative, don't waste your time trying to track one down. Instead, go directly to the medical director at the plan. The payer s corporate website should provide you contact information for this individual or you can call the main phone number and ask for the name and contact information of the medical director assigned to your region. If you can't get the information you need, send your complaint to the attention of the payer's CEO at the corporate address. R. Kevin Townsend, CPME, CPC, CPMA DoctorsManagement, LLC Director of Revenue Cycle Management
Page 4 Medical Necessity The term medical necessity is thrown around a lot when conducting an audit. But what does it really mean from the eyes of Medicare or your commercial payers? Many auditors use the methodology of letting the medical decision making score drive the overall level of service. While several MACs require this to happen (for codes that only require two out of the three key components), several MACs have not stated this, and our CMS manuals do not state this either. What our CMS manual does state is very clear though: Medical necessity is the most important factor in selecting an E/M code. The following is an excerpt from the CMS Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.1: "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported." When auditing, remember that there must be a medically necessary reason to conduct the work being done. If the patient is presenting with mild symptoms of a sore throat and cough, is it medically necessary to check their gait and station and conduct cranial nerve testing? If you re not sure ask a provider. Based on the patient s other signs and symptoms, past medical history or chronic conditions, additional work may be appropriate for that individual. Communication with the provider is key to understand why the work done was performed. Additional helpful information from the CMS Manual directs us as auditors and our providers on how to correctly determine medical necessity: Medical necessity cannot be quantified using a points system. Determining the medically necessary level of service (LOS) involves many factors and is not the same from patient to patient and day to day. Medical necessity is determined through a culmination of vital factors, including, but not limited to: Clinical judgment, Standards of practice, Why the patient needs to be seen (chief complaint), Any acute exacerbations/onsets of medical conditions or injuries, The stability/acuity of the patient, Multiple medical co-morbidities, And the management of the patient for that specific DOS. With the increase of EHRs in our life, we re used to seeing over-documentation of areas, particularly in the history and often in the exam. As auditors, we need to call into question items that appear to be inflating a possible E/M code selection without any regard to medical necessity. We need to educate providers to conduct and document those items that were required to treat the patient, with a focus on how performing all that extra stuff won t change the allowed billable service. Regan Tyler, CPC, CPC-H, CPC-I, CPMA, CEMC DoctorsManagment, LLC Senior Consultant / NAMAS Instructor AHIMA Approved ICD-10-CM/PCS Trainer & ICD-10 Ambassador
Page 5 NAMAS wants to pay you! Refer your co-workers and friends to receive a $25 gift card today! Full Information Here NAMAS will be visiting cities across the U.S. with their Medical Auditing Boot Camp. Visit www.namas.co for a full schedule of the classes and more information. HIPAA Myths 1) Sign-in sheets in the medical office are not allowed. This is a myth and was a huge concern in 1998. Offices were scrambling to depersonalize patient information and still maintain organization within the office. In reality, the law does not prohibit the use of sign-in sheets. The law states it is not intended to impede the customary and essential practices in the office. However, offices are expected to exercise reasonable safeguards to protect personal information of the patients. 2) Calling patients by name in a waiting room is not allowed. This is a total exaggeration. You may call your patients by name to let them know it is their turn to be escorted to a room. You cannot, however, state what they are being seen for. For example, you cannot say, Mrs. Jones, the doctor is ready to see you for your toe fungus. 3) Patients prescriptions can only be picked up by the patient. Actually, a family member or friend can pick up your patient s prescription at the local drug store. Very often, doing so is in the patient s best interest and the public s. A pharmacy itself may have a policy in place for third-party prescription pickup it has nothing to do with HIPAA. 4) Patients can get free copies of their medical records from your practice. A patient certainly has the right to request a copy of their medical record from you, but the enactment of HIPAA does not make them the owner of the records; the practice is the responsible party for the records. You have 30 days to comply with such a request and you can also require that the patient cover the cost of copying and mailing the records. 5) If a patient refuses to sign an acknowledgement form, you cannot treat that patient. Refusing to sign the Acknowledgement of Privacy Practices form won t preclude that person from being your patient. You are only required to make a good faith effort to secure their signature; otherwise, it s business as usual. Note that this cuts both ways: You re not subject to liability if a patient doesn t sign, but you can t use that refusal as a reason to stop providing services.
Page 6 Provider Billing Audits Compliance has become as much a part of running a medical office as scheduling patients and ordering supplies, and in an environment of strict governmental oversight, provider billing audits are critical to running a successful practice. In 2000, the Office of Inspector General (OIG) began encouraging providers and hospitals to implement their recommended compliance plan model that includes the following seven elements: Monitoring and auditing Practice standards and procedures Designation of a compliance officer Training and education Response to detected offenses Open lines of communication Enforcement of the standards The first element listed is monitoring and auditing, which will often go hand-in-hand with the fourth element, training and education. No compliance plan can be effective without ongoing checks to make sure that we identify risks, monitor trends and educate on those areas. We need to identify our biggest issues and because of that it is critical to get a baseline on all providers generating charges in your practice. When a new provider is brought into your practice, it is important to meet with the provider and establish a relationship right out of the gate. We must remember that providers get very limited education on coding in medical school, and oftentimes, they only begin to learn how to code once they start seeing patients. It is also important not to overlook providers coming to your practice from another location. One should not assume that just because a physician has been doing this for a while that they do not need education. Providers may come from a practice where someone did all the coding for them and this is the first time they are expected to code for themselves. They may have coded for themselves but picked up some bad habits over the years or they may have come from another region where the rules are different, these are things you will want to identify early and educate them accordingly. You, as the auditor, will be a vital resource for them to gain knowledge about proper documentation and coding guidelines. An open line of communication between the auditor and the provider will ensure that they are getting the most accurate information from the most reputable sources. You should perform a baseline audit on a new provider in a timely fashion so they are not left to figure things out on their own. A new provider should spend a lot of time with you in the beginning, going over how to select appropriate evaluation and management levels as well as what codes in your practice are reported frequently and what codes should not be reported together. The provider should expect that after a baseline audit is performed, you will spend one-on-one time with them to go over the results and answer any questions they may have about the findings. Depending on how your compliance plan is structured, you may perform a prospective audit (one performed before the claims are submitted) or a retrospective audit (one performed after the claims have been paid). Either form of audit has its advantages and disadvantages, but what is most important is that you pick claims that are timely. Prospective audits will obviously need to be done on a rather short timetable so as not to hold claims in limbo while you are reviewing, educating and making changes. They will, however, limit any corrected claims you would need to file should there be edits that need to be made. You will want to make sure you have the resources available if this is the type of audit you feel is most appropriate for your practice. Retrospective audits will allow for more time and will give you information on how the payor processed the claim to have as part of your findings. These claims, however, would require you to submit corrections based on the audit findings, which could be costly and, depending on how many errors are identified, could throw a red flag to a payor of a potential issue with coding practices. Regardless of the methodology you select for performing your audits, the key is to keep them relevant and consistent. You will want to keep track of each provider s results and when they were audited so that you can schedule your follow-up audits appropriately. Make notations of problem areas that were reviewed so that when a follow-up audit is performed, you make sure that those issues have been corrected and continue to be coded appropriately. Identify new areas of risk by referring to the OIG work plan, which is published annually. This will give you an idea of additional items of concern that your compliance department should be aware of. Integrate these items into your annual risk assessments along with the items your organization has identified as internal issues. Keeping in constant correspondence with your providers, your billing department, your coders and your managers will ensure that no stone goes unturned and your audit plan is effective and efficient. Baseline audits of new providers and follow-up audits of your veteran providers will keep a constant presence of compliance and correct coding practices. Your invaluable feedback on a regular basis will allow for building a strong relationship with your providers. You will be greatly rewarded as you learn from them and track their progress. Sara San Pedro, CPC, CPMA, CEMC, CCP-P DoctorsManagement, LLC Senior Consultant and NAMAS Instructor AHIMA Approved ICD-10-CM/PCS Trainer & ICD-10 Ambassador
Page 7 Properly Reporting Preoperative Clearance Contrary to popular belief, preoperative clearance consultations are not required for all patients prior to surgery. It may be true that hospitals and surgery centers require certain preoperative services to be performed prior to the surgical event (e.g., EKG, chest x-ray); however, that is not to say that health insurance companies (including CMS) anticipate paying for preoperative visits for all patients prior to surgery. It is true that patients with underlying comorbidities or conditions (e.g., HTN, DM) may require a separate evaluation by another provider (such as the patient s primary care provider) to assess their abilities to tolerate surgery, anesthesia, etc., but it is not expected for all patients, especially those otherwise healthy patients who lack conditions for which they must be cleared. Simply put, Medicare does not pay for preoperative services on a routine basis. When there is not medical necessity for Medicare payment, providers will not be paid for routine services. Although it is not required, we suggest providers use an Advance Beneficiary Notice of Noncoverage (ABN) on a voluntary basis to notify the patient of Medicare's anticipated denial of the service. The -GY modifier may be used to indicate that the service is statutorily excluded. According to WPS Medicare, when billing for this service when the patient's condition requires the additional evaluation, the provider should submit the claim choosing the most accurate E/M service to reflect the level of services provided. This diagnosis information should have the first diagnosis as the illness, condition, or injury requiring the evaluation, the second showing a preoperative diagnosis code and then third, the reason for the surgery. Investigating the language used in the above statement suggests that providers are not to routinely select the same level of E&M service for all patients being provided medically necessary preoperative evaluations; rather, the level of service should be consistent with the complexity of medical decision making (and history and physical) for the visit. As we all know, Medicare no longer reimburses for consultation services (CPT codes 99241-99255) so it would be expected that established patient visits (e.g., 99212-99215) would be reported when performing pre-op clearance for Medicare patients. For other payers, CPT consultation codes may be considered but in either case, the most appropriate level of service would be that consistent with the overall intensity of the visit - in other words, the complexity of medical decision making. For example, if the patient had stable hypertension and stable diabetes at the time of clearance, one of the following levels of service would be supported based on the low complexity of medical decision making: 99213 (established patient) 99202 (new patient) 99242 (outpatient consultation) 99252 (inpatient consultation) When surgeons report surgical codes for reimbursement, it is not only the intra-operative portion of the service that is being claimed. Rather, payment for any given CPT surgical code includes preoperative assessment(s), intra-operative work, and associated post-operative time (e.g., 90 days for a major procedure, per the MPFS). A medically necessary preoperative visit performed by a provider other than the surgeon may be medically necessary so long as the patient has a documented reason for the visit (not simply patient presents for pre-op clearance for cataract surgery ). A patient with underlying cardiovascular or respiratory disease, for example, would likely require a preoperative evaluation; a healthy patient seeing a provider for a pre-op prior to a rotator cuff repair would likely not. Now that we have discussed the cases in which a preoperative clearance is medically necessary, let s discuss the proper diagnostic coding assignment. As mentioned above, the reason for which the patient is being cleared would be sequenced first (e.g., benign essential hypertension, ICD-9-CM code 401.1). Sequenced next would be the preoperative examination code, using one of the 5-digit ICD-9-CM codes listed below: V72.81 Preoperative cardiovascular examination V72.82 Preoperative respiratory examination V72.83 Other specified preoperative examination V72.84 Preoperative examination, unspecified Lastly, the provider is instructed to sequence the diagnosis for which the patient is having surgery, although some payers instruct providers not to list this diagnosis because it does not represent a condition being treated by the provider preoperatively clearing the patient for surgery. Remember, only medically necessary preoperative clearances are payable. John Burns, CPC, CPC-I, CEMC, CPMA DoctorsManagement, LLC AHIMA Approved ICD-10 Ambassador and ICD-10-CM/PCS Trainer NAMAS Instructor
Page 8 Revolution is the most comprehensive and complete code lookup and search engine on the market today! This product will include a full ICD-10 library and will have crosswalk capabilities from ICD-9 to the new ICD-10 codes. For a free 7-day all access pass to this most advanced coding and auditing tool to come to the market, please visit: www.codingrevolution.com Featured Product Date Topic 7/24/2014 General Surgery 8/7/2014 Compliance 8/21/2014 E&M 9/16/2014 Ophthalmology 9/25/2014 Audit Results 10/9/2014 Incident-to 10/23/2014 Cardiology 11/6/2014 ICD-10 11/17/2014 Ancillary Services Roundtables are virtual events in which a specified topic is discussed in the following format: 20 minutes reviewing the guidelines and rules specific to the topic NAMAS would like to welcome Panacea Healthcare Solutions books and products as a new NAMAS product offering. Please check them out on our website. 20 minutes answering submitted questions and/or auditing records specific to the session topic 10 minutes of open conversation regarding the topic in which NAMAS will be the moderator to assist in the conversational coordination 10 minutes of recap and review and to answer any further questions These events are 60 minutes in length and approved for 1 CPMA/CPC CEU through the AAPC. You may choose 1, 3 or 18 sessions. Click here to join or for more information on NAMAS Roundtables The NAMAS Auditor's Toolkit on jump drive is a useful resource for medical auditors. The 2 gigabyte jump drive contains PDF files of the following medical auditing reference materials: *Cardio Audit Tool 95 & 97 *ENT Audit Tool 95 & 97 *Eye Audit Tool 95 & 97 *General Multi-System Audit Tool 95/97 *GU Male Audit Tool 95 & 97 *GU Female Audit Tool 95 & 97 *Hem/Lymph/Immuno Audit Tool 95/97 *Musculoskeletal Audit Tool 95 & 97 *Neuro Audit Tool 95 & 97 *Psych Audit Tool 95 & 97 *Respiratory Audit Tool 95 & 97 *Skin Audit Tool 95 & 97 *Surgery Audit Tool *NAMAS Audit Tool 95 & 97 *CMS E&M guidelines *1995 Documentation Guidelines *1997 Documentation Guidelines *2013 OIG Work Plan Click here to order yours today!