Today, more and more physicians are being audited. One reason for the surge in audits is that the Health Care Financing Administration (HCFA) itself is being continuously audited by the government — and has been found to have grossly overpaid physicians, hospitals and durable medical equipment providers. To recoup some of the money it erroneously paid out, it has intensified the audit process.

The number of cases of criminal prosecution for health- care fraud has tripled in the last few years. Conviction rates have risen from 73% to 87%, and 54% of convicted defendants go to prison.

Some doctors say that confusing coding laws and government regulations about billing practices are to blame. One thing is certain: To stay safe, you need to know what’s correct and what’s not. Here, I’ll give you some pointers.

Three situations typically trigger an audit:

• Overutilization of a code or level of office visit/consultation
. This most common trigger includes overutilization of eye codes, such as too-frequent use of 92014. The carriers publish focused medical reviews in their Medicare Report when they suspect problems such as overutilization. When you see a review, be careful. Presently, for example, consultations are the topic of the Focused Medical Review in Pennsylvania.
• Random targeting
. Sometimes you’re just caught in a random audit, as with the IRS, because the carrier must audit a certain percentage of providers annually. Take care to follow all the suggestions in this article to help prepare yourself in the event of a random audit.
• Whistle-blowers
. Whistle-blower (qui tam) audits are on the rise. And with HCFA’s new consumer education initiative, which encourages patient and employee vigilance, they’re bound to increase.
Whistle-blowers are most often disgruntled employees. The increased publicity advertising financial rewards has made whistle-blowing attractive. Of course, in some cases, employees are genuinely angry at what they perceive to be deceit, fraud and bad medicine.
A series of audits of teaching physicians (Physicians at Teaching Hospitals, or PATH) was actually started by a whistle-blower — a disgruntled faculty member at the Department of Ophthalmology at the University of Florida at Gainesville. Although a few academic institutions have been exonerated, more have paid up handsomely, including the University of Pennsylvania, whose $30 million settlement was the first to be nationally publicized.

In fiscal year 1998, the Office of the Inspector General (OIG) audited Medicare claims and found that $3.2 billion dollars had been paid improperly to physicians. Even though there was an $8.7 billion decrease in documentation errors compared to the previous year, the errors that were found were costly enough to encourage continuance and, perhaps, intensification of physician audits.

Here’s a breakdown of the errors that accounted for the improper payments:

Obviously, the bulk of the problem stems from chart documentation issues. To protect yourself and your practice, be sure that you:

• Document well and legibly
. Your charts must be documented meticulously. Use forced entry chart forms and be compulsive about filling them in. Legibility is critical. In Medicare’s view, an illegible medical record reflects a service that was never provided, so you won’t be credited.
Apply the principles of "universal precautions." If you think of each chart as potential audit material and document that way, your documentation will excel.
• Don’t alter a medical record
. Instead, supplement it with an addition or comment, if you think it’s necessary. Note the date you inserted the additional material and initial or sign it. These additions can and should be submitted with the original material.
• Make sure information matches
. The documentation on the charge ticket (super bill) must match the information logged in the medical record. If you have epilated lashes, for example, with an office visit, don’t bill for the epilation unless it’s described in the chart entry for that day.
• Become familiar with the rules
. The proposed changes for the year 2000 are based on these dictates. Know your coding rules cold. Determine each code for each visit based on that visit, not on vague parameters such as, "I always code 92014 twice a year."
Familiarize yourself and your staff with the American Medical Association/Heath Care Financing Administration (AMA/HCFA) Documentation Guidelines for Evaluation and Management Services for using the Evaluation and Management (E/M) codes. Study your carrier’s requirements and the national requirements for ophthalmology codes, as found in the Current Procedural Terminology (CPT) for 1999.
• Document negatives as well as positives
. Particularly for E/M codes with the emphasis on "bean counting," it’s imperative to document negatives as well as positives. This should be done for both exam findings and history findings (in the Review of Systems and Past Family Social History sections of the History).
• Charge only for medically necessary services
. Both the service itself and elements of the exam will be scrutinized for medical necessity.
Routine exams and screening exams are noncovered services. Any time you list "no complaints" or "routine check" as the reason for the encounter/chief complaint, that service won’t be covered.
If you realize you’ve charged erroneously, rectify the mistake immediately and refund the money. Perform an internal audit to make sure that this was an isolated instance, not part of a pattern. Remember, it’s a pattern of similar mistakes that leads to an audit.
• Get involved
. To handle these documentation challenges, you — not your billing department or auxiliary staff — must be the coder. The responsibility and liability for upcoding, downcoding and erroneous coding is yours.
The OIG looks for patterns of abuse rather than for the occasional error. Your staff might think it’s helping you by coding everything at level 4 and 5 because staff members how hard you’re working, but don’t let that happen. Be aware of what’s going on. The code must fit the circumstances, not be influenced by social factors.
• Attend national ophthalmic-specific coding conferences
. Or use products available from the national societies, discussed below, to stay abreast of developments.
• Be approachable
. Address patient complaints and employee concerns regarding reimbursement policies in a forthright and honest manner. Patients who are well-treated, who receive full explanations and answers to their questions and who are generally satisfied are much less likely to be whistle-blowers. The same is true of employees.
• Know your rights
. Make sure that you know your rights and that your staff knows how to handle unusual situations, including demands that medical records be produced. Contact your attorney for advice.
• Compliance programs and self-audits
. Compliance programs are legal programs, large parts of which are self-audits. However, even without an officially instituted compliance program in your practice, you should self-audit regularly.

Here are some things you don’t want to do:

• Don’t take bad advice. Don’t take advice from your buddies at medical meetings. Just because they’re getting away with something now doesn’t mean they’ll get away with it forever. Your most reliable sources of information are national societies such as the American Society of Cataract and Refractive Surgery, the American Society of Ophthalmic Administrators and the American Academy of Ophthalmology. They’re involved with both the AMA and HCFA on an ongoing basis.

• Don’t forget to provide an "interpretation and report" for diagnostic tests. This is required in the CPT for such tests as visual fields and fundus photography. A copy of the test isn’t sufficient — an order for it must be included in the chart with an interpretation and report of findings.

• Don’t misuse modifiers. Most physicians are beginning to realize that they can get extra dollars by appending modifiers. However, abuse of this practice can lead to an audit.

Modifier -59 is used to break the bundles of the Correct Coding Initiative (CCI) and will allow payment for such bundled items as a mechanical anterior vitrectomy performed with a cataract extraction. Continued use of this modifier in this situation, however, will trigger an audit. Don’t routinely attempt to gather additional money by breaking the CCI bundles. Whether or not you feel it’s fair or medically correct doesn’t matter. It’s the law.

Complications related to a surgical procedure are billed using the -78 modifier, which allows payment at the intraoperative value, or 70% of the allowable. Don’t use the -79 modifier, which allows payment for unrelated problems at 100% of the allowable.

Make sure there’s a separately identifiable condition when using modifier -24 in the global period. Normal complications of a given surgery are covered in the global period.

• Don’t go it alone. Trying to tackle a major audit yourself is a mistake; get professional help.

• Don’t be penny-wise and dollar-foolish. Avoid outdated coding tools such as old CPT’s and ICD-9s. Always use current versions. These publications are updated annually. Also, make sure you use the current version of the CCI. (Version 5.1 is due out and effective as of April 1, 1999.)

The mere thought of an audit is enough to frighten many doctors. The key to avoiding one is to be wise, be careful, take charge and learn as much as you can. That should help keep you from becoming another casualty in the escalating fraud war.