Take a Proactive Position on Medicare Audits, Part 2 of 2

Physicians must be highly knowledgeable coders

BY RIVA LEE ASBELL

As we saw last month in Part 1 of this twopart series, Medicare audits are triggered in various ways. One of the most common occurs when a provider overuses a given code or level of office visit/consultation. Sometimes you are just caught in a random CERT (Comprehensive Error Rate Testing) audit, like a random IRS audit. However, whistleblower (qui tam) audits are also on the rise. It only takes dialing an 800 number to get an investigation launched. Let's first review what you can do proactively.

Chart Documentation

It should be obvious by now that noncompliance with various aspects of chart documentation accounts for the bulk of the problem.

■ Your charts must be meticulously documented. This is best accomplished by using forced-entry chart examination forms and being compulsive about filling them in. The charts have to be designed in compliance with the 1997 Evaluation and Management Guidelines. Use the form on my Web site (www.rivaleeasbell.com) as a guide.

■ Legibility is critical, not only for data entry but for signatures as well. For Medicare, illegibility equates to "not performed" — and thus you will not be credited. Familiarize yourself with the American Medical Association/Health Care Financing Administration Documenta tion Guidelines for Evaluation and Management Services for using the E/M codes and with your contractor/carrier's requirements and the national requirements for the Ophthalmology Codes as found in the CPT (Current Procedural Terminology 2010).

■ Lack of medical necessity applies to coverage of the service as well as elements of the exam. Routine exams and screening exams are non-covered services. Any reason for the encounter/chief complaint that says "no complaints" or "routine check" or " annual exam" equals a non-covered service.

■ For E/M codes, with its emphasis on "bean counting" (which is intensifying in all types of audits), it is imperative to document negatives as well as positives. This holds true not only for exam findings but for history findings in the Review of Systems and Past Family Social History sections of the History as well.

■ Know your coding cold. Determine each code for each visit based on that visit, not on vague parameters such as, "I always code 92014 two times a year."

Physcian Involvement

With the audit environment heating up, physicians must be the most knowledgeable coders — this critical area cannot be left to members of the billing department or auxiliary staff. The ultimate responsibility and liability for upcoding, downcoding or erroneous coding belongs to the physician.

What is it that the OIG (Office of the Inspector General) is really looking to catch? It is not the occasional error that you might make, but rather patterns of coding abuse.

Examples of suspect patterns:

► Your staff might decide to code all level 4s and 5s for you because they see how busy a schedule you have.
► Your billing staff may decide that any time trypan blue is used, you should code for a complex cataract extraction.
► Your surgical coder might decide to add modifier 59 to break all bundles since you listed all the procedures on the surgical encounter sheet.

Physician Awareness

In so many practices, the physician is not even aware that copies of the medical records have been requested for audit. Any request for medical records must be shown to the physician and not simply honored by the staff.

Be sure your records are complete and legible; if not, add a typewritten note clearly indicating that this is an addendum. If additional tests were performed, include copies. Do whatever you can to enhance or clarify the record. You are the only one who can be the judge of this.

Remember, a poor result on a first case that is reviewed will result in further investigation.

Advice on Coding: Whom Do You Trust?

Even the experts make mistakes — but don't take advice from your buddies at medical meetings during coffee breaks. Just because they are getting away with something doesn't mean they will get away with it forever. Your most reliable source of information is from the national societies and reputable consultants.

It is a good idea to get a baseline audit from an external source that can also provide the entire practice with proper instruction. This may involve reformatting your chart.

After this educational experience takes place, performing monthly quality reviews that involve self-audits for each physician is a worthwhile practice. Nip problems as they are beginning and things will not get out of hand. The boxes on the examination form on my home page are for self-auditing and can be used for external auditing as well.

Table 1 provides a checklist of what should be done if you are audited (in addition to getting the appropriate help.)

Coding Diagnostic Tests

The most universal failure is not providing an "interpretation and report" for diagnostic tests as required in the CPT for such tests as visual fields, fundus photography, etc. A copy of the test is not sufficient — you must have an order for it in the chart and an interpretation and report of those findings.

Most interpretation and reports, particularly those generated by electronic medical records, do not meet the qualifications as outlined by Medicare. Read my article, "The Three C's — Interpretation and Report Requirements for Ophthalmic Diagnostic Testing" on my Web site and modify your interpretation and report as indicated.

Misuse of Modifiers

Modifiers engender payment for Medicare. Most physicians are beginning to realize that they can get extra dollars in various situations by appending modifiers. This is true, but it also engenders audits when used abusively.

Modifier 59 is used to break the bundles of the National Correct Coding Initiative (NCCI) and will definitely allow payment for such bundled items as a mechanical anterior vitrectomy performed with a cataract extraction. Continued use of this modifier in this manner will also trigger an audit. Do not routinely attempt to garner additional monies by breaking the NCCI bundles. Whether you feel it is fair or medically correct is not germane here; it is the law.

Surgical treatment for complications related to a surgery are billed using modifier 78, which allows payment at the intraoperative value, or 70% to 80% of the allowable. Do not use modifier 79 erroneously or by intent, which allows payment for unrelated problems at 100% of the allowable for these types of procedures.

Make sure there is a separately identifiable condition when using modifier 24 in the global period. Medical treatment for complications of a given surgery are covered the global period.

The DO List

► Implement meticulous chart documentation.
► Attend national ophthalmic specific coding conferences or use products from the national societies/stay abreast of developments.
► Insist that you review any and every request from Medicare for medical records and follow instructions in the Table when appropriate.
► Address patient complaints and employee concerns regarding reimbursement policies in a forthright and honest manner.
► Place an order in the chart for all diagnostic tests.

The DON'T List

► Code based on old habits.
► Take advice from your buddies — as well intended as it may be.
► Allow misdirected staff loyalties and emotions protect you from reality
► Unbundle services to increase revenue — you'll succeed temporarily — and then the boom will fall.
► Try to tackle a major audit yourself. Get professional legal and reimbursement consultant assistance (they are not the same and don't always have the same methodology).
► Be pennywise and dollar foolish. Don't use outdated coding tools such as old CPTs and ICD-9s. OM