Posts Tagged Audit

Physicians Practice: How to Ensure Accurate Medical Coding

In small to midsized practices, failing to educate staff about correct coding may contribute to the practice’s downfall. Medical coding errors can be a huge source of lost revenue. A recent article in Physicians Practice reviews common billing and coding mistakes and offers suggestions on avoiding them. Several AAPC members were interviewed and quoted in the article as experts in the field, including Lynn Anderanin, CPC, CPC-I, COSC; Nancy Enos, CPC, CPMA, CPC-I, CEMC; Raemarie Jimenez, CPC, CPMA, CPPM, CPC-I, CANPC, CRHC; Debra Seyfried, CPC; and Cynthia Stewart, CPC, CPC-H, CPMA, CPC-I.

The solutions offered include:

  • Internal auditing
  • Dedicating staff to following up on denials
  • Verifying patients’ personal and insurance information
  • Reviewing how to correctly use modifiers
  • Teaching physicians what documentation is needed
  • Learning the most recent code changes

Read the full article.

April 3rd, 2013

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Advance: Take a Closer Look at the Audit Process

Performing an audit can be quite a cumbersome endeavor and is a heavy responsibility. Jaci Johnson, CPC, CPC-H, CPMA, CPC-I, CEMC, a member of the AAPC National Advisory Board, recently penned an article about the audit process for Advance for Health Information Professionals. In the article Ms. Johnson explains the different steps and considerations involved from the time someone in the practice decides to request an audit until the results are tabulated and presented. Her suggestions include accounting for the following questions.

  • Why is the audit being performed?
  • What is the audit time frame?
  • How many claims should be reviewed?
  • Which coding and documentation guidelines and rules must the auditor know?
  • Which reference tools should be used?
  • What are the signature requirements?
  • Have the dates of service been verified?
  • Who will receive the audit results?

Read the full article.

March 7th, 2013

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Get a Jump on 2013 Government Reviews

By Jillian Harrington, MHA, CPC, CPC-P, CPC-I, CCS-P

Use this year’s OIG Work Plan to control risk and keep physician compliance programs healthy.

When preparing to close out one calendar year and move to the next, it’s important to review your Medicare compliance efforts. A comprehensive auditing and monitoring program is crucial to yearly compliance planning. Developing a program includes identifying specific items that have been problematic for your medical practice or facility throughout the year. You can derive this information through auditing, by knowing general risk areas for your practice or facility, and from reviewing items discussed in the Office of Inspector General’s (OIG) Work Plan for Fiscal Year 2013 (Work Plan).

The OIG’s annual Work Plan lists specific areas of interest the government intends to investigate throughout the year. Having this information enables health care organizations to identify and correct potential compliance risks before they become a liability.

We’ll begin by examining Part 1: Medicare Part A and Part B as it pertains to the physician practice. Next month, we’ll take another look at this section, focusing on the items that pertain to hospitals.

Part 1: Part B

Many items affecting physician practices are found in the “Other Providers and Suppliers” portion of the Medicare Part A and Part B section. Only a few of these items are directed specifically at physicians, but you’ll want to broaden your focus to include those items that look at Part B services in general.

Assignment Rules and Excessive

“Noncompliance with Assignment Rules and Excessive Billing of Beneficiaries” is not a new item in the Work Plan, but it is important to review.

Start by reviewing your systems, and verifying that you have everything in place to write off appropriate amounts reflective of current Medicare fee schedule rates. Also make sure you are using Advanced Beneficiary Notices (ABNs) when appropriate, and have a solid process in place to use that important tool. For example, ensure you have a system for reviewing medical necessity for procedures and ancillary services performed in your office. This will give beneficiaries the opportunity to make an informed consumer decision about the services they’re about to or will soon receive. It also helps to ensure your practice will be appropriately paid for services rendered.

Place of Service

“Place-of-service Coding Errors” is another familiar item in the Work Plan, reinforcing the need for physician practices to review their place-of-service (POS) coding. The OIG will be looking specifically for services performed in an ambulatory surgery center (ASC) or a hospital outpatient department. In those settings, applying the incorrect POS code may result in an improper higher payment. You’ll want to pay special attention to your POS coding for hospital outpatient-based clinics, hospital outpatient surgeries, and ASC services; your POS code should match the actual place where the services were performed. For example, if your physician is providing services at a facility-based (provider-based) clinic, the POS code is 22 Outpatient hospital, not 11 Physician office. Although this may be the physicians’ main office location in some instances, this is still an outpatient hospital location and must be reported as such.

Anesthesia Services

Anesthesiology practices have a new item to examine specifically aimed at services coded with modifier AA Anesthesia services performed personally by anesthesiologist, or when an anesthesiologist assists a physician in the care of a single patient. The OIG will examine anesthesia services to determine whether they were personally performed and billed appropriately with modifier AA appended. Payment for medically directed anesthesia services billable with modifier QK Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals is 50 percent of the amount allowable for services reported with modifier AA.

Review your documentation and determine if it establishes that the anesthesiologist personally performed the services. If services were only directed by the anesthesiologist, and not personally performed, modifier AA would not be appropriate.

Ophthalmological Services

Ophthalmology practices have a new item to consider: The OIG is reviewing “questionable billing” in 2011 for ophthalmology services. The review includes analysis of specific geographic locations where providers have been problematic; although, at this time additional details have not been provided on location. There appears to have been an increase in the expenditure in Medicare dollars in ophthalmology and concern about potential fraud in the recent past; however, few details are provided on exactly how much. If the OIG finds issues with 2011 documentation, they will move forward into other documentation for providers with problematic records.

Due to the generic nature of this review, use it as an opportunity to take an overall look at your documentation. What are you doing well? Where are your risks? Review your use of incident-to guidelines regarding technologists in your office because this is always a concern under OIG review. Any areas that have been problematic for your practice in previous audits could be reviewed to verify the issues have been resolved.

Electrodiagnostic Testing

Several types of specialists perform various types of electrodiagnostic testing in their offices. The OIG has a new item in its Work Plan this year regarding inappropriate use of these tests. They will be reviewing questionable billing and looking at Medicare utilization rates by provider specialty, diagnosis, and geographic area for these services. There is concern specifically about using this testing for financial gain.

This gives providers who perform in-office electrodiagnostic testing an opportunity to review their records and determine how often these services are being performed. Are there any obvious patterns that could appear suspicious? Is there solid medical necessity on file for all patients who had testing? Is there documentation to support all testing performed? This could be a serious issue for practices, so detailed records will be vital.

Claims with G Modifiers

The OIG will be reviewing possible errors in instances when providers expected denials.

When a provider obtains an ABN, modifier GA Waiver of liability statement issued as required by payer policy or modifier GX Notice of liability issued, voluntary under payer policy (depending on whether the ABN was required or voluntary) is appended to the procedure code. In other instances, payments are not expected, and modifiers GY Item or service statutorily excluded, does not meet the definition of any Medicare benefit or for non-Medicare insurers, is not a contract benefit or GZ Item or service is expected to be denied as not reasonable and necessary is used. In those instances, the OIG has concerns contractors have made payments inappropriately. A previous review showed that $4 million in inappropriate payments were made on claims with modifiers GA and GZ appended.

Review services billed from your practice with those four modifiers. Have payments been made by the contractor? If so, was the payment refunded to the contractor? Were the modifiers applied appropriately originally? This is an important review item giving providers the opportunity to analyze modifier application processes, as well as refund processes.

These are only a few of the important items from this year’s Work Plan. It’s advisable to review the entire document. The Medicaid section is important to all providers who see Medicaid patients. The Public Health section includes reviews of research grant-related topics for providers who perform grant-funded research. There is great information throughout the Work Plan that can be used to help all health care entities control risk and maintain compliance.

Jillian Harrington, MHA, CPC, CPC-P, CPC-I, CCS-P, serves as a clinical technical editor for OptumInsight, and has nearly 20 years of experience in the health care industry. She is a former chief compliance officer and chief privacy official. She teaches CPT® coding as an approved AAPC instructor, and is a former member of AAPC’s ICD-10 curriculum development team. She holds a bachelor’s degree in health care administration from the State University of New York – Empire State College and a master’s degree in health systems administration from the Rochester Institute of Technology (RIT).

 

January 1st, 2013

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Overcome ICD-10-CM Documentation Challenges

By Jacqueline J. Stack, BSHA, CPC, CPC-I, CEMC, CFPC, CIMC, CPEDC

No doubt you’ve heard that moving to ICD-10-CM will give you more specific choices for coding diagnoses. This data-driven code set will enable us to code to the highest level of specificity. But our ability to do that will still rely on how well physicians and other health care practitioners document their services.

This isn’t a simple task because physicians do not typically document the way a codebook reads; they document for the care of the patient. Providers have their work cut out for them, too. Documenting for ICD-10-CM will be challenging because clinical documentation is used in many ways.
Clinical documentation is also used for:

  • Patient care
  • Accurate and timely reimbursement
  • Reporting statistical data to aide in quality reporting
  • Assisting with financial planning and clinical data
  • Protecting the physician, the patient, and the practice in a legal situation

As such, coders and physicians do not always “speak the same language.” To break the communication barrier, and code with the increased clinical specificity ICD-10-CM provides, coders will need a comprehensive understanding of the types of disease and disease processes being documented.

Learn the Language

Example: A four-year-old girl falls off the monkey bars, causing an injury to her left arm. Based on X-rays, the physician determines the child has a buckle fracture of the left arm.

A buckle fracture (also known as a torus or incomplete fracture) is a common type of bone break in children where one side of a bone buckles upon itself without affecting the other side. With a good knowledge of fractures, the coder is able to choose a code that accurately describes the encounter based on the provider’s documentation.

Educate Physicians

In addition to brushing up on your knowledge of anatomy and physiology (A&P), now is a good time to begin educating your providers on the new documentation requirements they will need to fulfill when ICD-10-CM is implemented on Oct. 1, 2014. Changing documentation neither requires providers to change the way they practice medicine, nor does it require extensive extra work. When the provider understands what the coder needs, he or she may be able to document the information by adding just a few key words.

Laterality, for example, is expanded in ICD-10-CM; for many diagnoses there are code choices for right, left, bilateral, and unspecified. By adding one word to his or her documentation, the physician enables the coder to select the diagnosis with the highest level of specificity.

Example: A 70-year-old patient is seen for decreased hearing. After examination, the physician determines the cause was impacted cerumen.

H61.2 Impacted cerumen

H61.20 Impacted cerumen, unspecified ear

H61.21 Impacted cerumen, right ear

H61.22 Impacted cerumen, left ear

H61.23 Impacted cerumen, bilateral

Based on the documentation, the appropriate code in this case is H61.20. Had the provider added one word to specify laterality, however, you would’ve been able to code to a higher level of specificity.

Audit Documentation

To figure out where your provider’s documentation is lacking, run a frequency report. Look at the top codes your providers use. You’ll start here and work your way down the list.

Pull documentation for the most often used code. Compare that documentation to the corresponding ICD-10-CM codes. Does the current documentation allow you to select an ICD-10-CM code to the highest level of specificity? If so, move on to the next code; if not, make a point to explain to your provider(s) what sort of documentation would help you code to a higher level of specificity. When you meet with a physician, bring your code books, so he or she can see what the documentation challenges are.

If you do not feel comfortable with coding ICD-10-CM or determining where documentation needs to be changed, you can hire a consultant to do a review for you. Another option is AAPC Physician Services: They can provide low cost documentation assessments for providers. The service includes a preliminary assessment of 10 dates of service, a detailed report of findings, a half hour of webinar or telephone training based on their assessment results, and a follow-up assessment a few months later, of another 10 dates of service to measure results.

ICD-10 Documentation Requirement Examples

Consider the following common diagnoses as examples of documentation requirements you’ll find when coding from ICD-10-CM.

Diabetes Mellitus:

The codes for diabetes mellitus have been expanded in ICD-10-CM. To code for diabetes, the following information needs to be included in the documentation:

  • Type of diabetes
  • Body system affected
  • Complication or manifestation
  • If type 2 diabetes, long-term insulin use

Example: Mary is being seen today for follow-up of her diabetes mellitus. She was diagnosed three years ago with type 2 diabetes mellitus, which has been well controlled with insulin.

In this example, we know that the patient is a type 2 diabetic and that she uses insulin long term to control her disease. This example would be coded:

E11.9
Type 2 diabetes mellitus without
complication

Z79.4 Long term (current) use of insulin

Obstetrics:

Documentation must include:

  • Trimester of pregnancy
  • Week of gestation

Example: Mrs. Smith presents to her OB for her monthly checkup. She is 33 weeks, four days gestation. This is her first pregnancy, and she is doing well.

In this example, Mrs. Smith is in her third trimester, at 33 weeks gestation of her first pregnancy. This example would be coded:

Z34.03 Encounter for supervision of normal first pregnancy, third trimester

Z3A.33 33 weeks gestation of pregnancy

Fractures: 

The provider must document:

  • Site
  • Laterality
  • Type
  • Location

Example: A 30-year-old woman presents to the emergency department (ED) for an initial visit for treatment of displaced transverse fracture left tibia.

In this example the documentation tells us the site, laterality, and type of fracture. It also was the patient’s initial visit, which is necessary information to code this to the highest level of specificity. This example would be coded:

S82.222A Displaced transverse fracture of shaft of left tibia, initial encounter for closed fracture

Injuries:

When coding for the initial encounter of an injury, the provider must document the following to code to the highest level of specificity:

  • External cause
  • Place of occurrence
  • Activity code
  • External cause status

Example: A 30-year-old woman presents to the ED for an initial visit for treatment of displaced transverse fracture left tibia. The patient was on the balcony of her home. She was leaning against the railing, the railing broke, and the patient fell.

The documentation in this example shows us the external cause, as well as the place of occurrence. The documentation did not tell us the activity or the external cause status. This example would be coded:

S82.222A

W13.0XXA Fall from, out of or through balcony, initial encounter

Y92.018 Other place in single-family (private) house as the place of occurrence of the external cause

Asthma:

The provider should document:

  • Type
  • Mild
  • Mild intermittent
  • Mild persistent
  • Moderate persistent
  • Severe
  • With or without acute exacerbation
  • With or without status asthmaticus

Example: A 7-year-old boy is seen by his physician for asthma follow up. The patient is doing well. He only occasionally has wheezing and coughing, and has used his rescue inhaler only a few times within the last six months. The physician diagnoses the patient with mild intermittent asthma.

This example would be coded:

J45.20 Mild intermittent asthma, uncomplicated

These examples show the documentation necessary to code ICD-10-CM to the highest level of specificity. Performing a documentation readiness assessment is essential for every practice. Work with your providers now to give them time to prepare for ICD-10-CM implementation and the new concepts they will need to understand.

Jackie Stack, BSHA, CPC, CPC-I, CEMC, CFPC, CIMC, CPEDC, is ICD-10 specialist at AAPC.

November 1st, 2012

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Know the 5 Levels of the Medicare Appeals Process

Legal mallet and stethoscopeBy Douglas J. Jorgensen, DO, CPC, FACOFP

If you disagree with a Medicare payer’s audit findings, you may appeal (see Exclusions on Medicare and Limitations on Payment, 42 C. F. R. Part 405, Subpart I). This is important because if Medicare successfully prosecutes you for fraud, you may face civil monetary penalties of $10,000-$15,000 per occurrence; and, if fraud is proven you also lose any protection you may have had under the statute of limitations.

The five levels of Medicare Appeals are:

Level 1: Redetermination (no minimum monetary limit) – You must appeal and request a redetermination in writing within 120 days of notification. If you do not request a redetermination within 30 days, Medicare will begin withholding moneys from your current accounts receivable (A/R), and could begin notifying the beneficiary’s secondary and tertiary payers.

Level 2: Reconsideration (no minimum) – You must submit a request for reconsideration in writing within 180 days of the redetermination’s failure notification. Sixty days from notice of failure to succeed at the Level 1 redetermination, Medicare will begin withholding A/R to settle what is “owed” for the alleged overpayment, and will begin notification of secondary and tertiary insurers.

Level 2 appeals are conducted by a qualified independent contractor (QIC). In a QIC, a panel of physicians uses its clinical experience to consider the medical, technical, and scientific evidence on record to assist in a final determination.

You must provide a clear explanation of why you disagree with the audit findings and its supporting evidence and/or documentation. Failure to present the evidence now may make it inadmissible when needed during subsequent appeals.

Level 3: Administrative Law Judge (ALJ) (minimum amount is $130 for 2012) – If the provider fails the first two levels, an ALJ hearing is set that’s typically done via teleconference. Request for an ALJ hearing must occur in writing within 60 days from notification of a failed reconsideration. Sometimes, the ALJ will hear evidence on the case(s) in question more globally; sometimes he or she will want to go over each case, one by one.

Specific reasons why the defense disagrees with the Level 1 and 2 findings, cogent arguments, and expert witness testimony at this level is helpful because the ALJ will often seek clarification from the expert why the provider documented a certain way, or may ask the expert to explain why the defense disagrees with the first two levels of appeal. Medicare may not show up, and instead let the evidence from the redetermination panel and reconsideration QIC stand on Medicare’s behalf.

Level 4: Medicare Appeals Council (MAC) (no monetary minimum) – The MAC review occurs in the Departmental Appeals Board of the federal U.S. Department of Health & Human Services (HHS). To advance to this level, you must provide a written objection within 60 days of the ALJ decision.

Your objection must clearly outline and explain specifically what elements of the ALJ decision you oppose. The MAC limits appeals to those in writing (no teleconferences), unless the provider does not have legal counsel (which is ill-advised, especially at this level).

Level 5: Federal Court of Appeals ($1,350 minimum for 2012) – To proceed to this level, you must appeal in writing within 60 days of the MAC determination.

Fact findings, written interpretations, or rules are deemed conclusive if they are supported by substantial evidence. At this level, the argument must be clear and well documented. Legal counsel and representation are strongly encouraged.

See “The Medicare Appeals Process: Five Levels to Protect Providers, Physicians, and Other Suppliers” for more information.

October 10th, 2012

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