Reed Tinsley, CPA

Coding Trends of Medicare Evaluation and Management Services

In May 2012, the Department of Health and Human Services Office of Inspector General (OIG) issued a report entitled “Coding Trends of Medicare Evaluation and Management Services.” This study was conducted because between 2001 and 2010, Medicare payments for Part B goods and services increased by 43 percent, from $77 billion to $110 billion. During this same time, Medicare payments for evaluation and management (E/M) services increased by 48 percent, from $22.7 billion to $33.5 billion.

What did the Study find? From 2001 to 2010, physicians increased their billing of higher level E/M codes in all types of E/M services. Among these physicians, the OIG identified approximately 1,700 who consistently billed higher level E/M codes in 2010. Although these physicians differed from others in their billing of E/M codes, they practiced in nearly all States and represented similar specialties. The physicians who consistently billed higher level E/M codes also treated beneficiaries of similar ages and with similar diagnoses as those treated by other physicians.

CMS will conduct additional reviews of physicians who consistently bill higher level E/M codes to ensure that their claims are appropriate. If CMS determines that inappropriate claims have been paid, it will take steps to recover those overpayments. So my advice is to look closely at your physician practice's E/M patterns; if you think there might be an overcoding issue, have a sample of charts reviewed by an independent coding consultant to ensure the medical record documentation supports the level of E/M service billed.

The most common coding abuses by a physician practice

I was watching a special on CNBC about healthcare fraud and it reminded me again about the most common coding abuses by physicians and their billing staff. Compliance in coding and documentation are crucial in today's enforcement enviroment. Don't get yourself in trouble by being ignorant or complacent:

Upcoding Billing using a more expensive code that the service or item that was actually provided.

Unbundling Billing separately for services that are properly grouped together in a global code.

Lack of Medical Necessity Billing items or services to patients that they do not need.

Billing for Services Not Rendered Billing something that was not actually provided to the patient.

Billing for Worthless Services Billing for items or services that are of such low quality as to render them virtually worthless.

Duplicate Billing Billing two or more times for the same item or service.

Lack of Documentation The medical record cannot support the claim.

Physician coding reviews - increasing payments & reducing audit risk

Physicians with little enthusiasm for coding reviews of their practice become even less motivated when their perception is that the process does not always equate, due to a heavy managed care environment, to more income. This perception is not only unfounded, but dangerous. In fact, the higher the percentage of managed care billings, the greater the real need for a complete coding review. Not only can the process dramatically improve reimbursement and strengthen negotiating leverage, the practice also benefits by reducing the inherent risk of third party post-payment audits with properly priced, coded, and documented claim submissions. 

Amidst today’s climate of zealous fraud and abuse enforcement, the reality is that a medical practice must undertake a coding review, if for no other reason than to provide peace of mind should OIG auditors come to call. That prospect is all the more likely when you consider the OIG is hiring more agents for audits on as many as one-third of all physician practices. E&M services are now better clinically defined, and the E&M Documentation Guidelines give Medicare and other payers the ability to reduce or deny payments through post-payment audits.

The 2011 release of ICD-10-CM is now available.

The 2011 release of ICD-10-CM is now available. It replaces the December 2010 release.

The National Center for Health Statistics (NCHS), the Federal agency responsible for use of the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) in the United States, has developed a clinical modification of the classification for morbidity purposes. The ICD-10 is used to code and classify mortality data from death certificates, having replaced ICD-9 for this purpose as of January 1, 1999. ICD-10-CM is planned as the replacement for ICD-9-CM, volumes 1 and 2.

The ICD-10 is copyrighted by the World Health Organization (WHO), which owns and publishes the classification. WHO has authorized the development of an adaptation of ICD-10 for use in the United States for U.S. government purposes. As agreed, all modifications to the ICD-10 must conform to WHO conventions for the ICD. ICD-10-CM was developed following a thorough evaluation by a Technical Advisory Panel and extensive additional consultation with physician groups, clinical coders, and others to assure clinical accuracy and utility.

The entire draft of the Tabular List of ICD-10-CM, and the preliminary crosswalk between ICD-9-CM and ICD-10-CM were made available on the NCHS website for public comment. The public comment period ran from December 1997 through February 1998. The American Hospital Association and the American Health Information Management Association conducted a field test for ICD-10-CM in the summer of 2003, with a subsequent report  [PDF - 1.8 MB]. All comments and suggestions from the open comment period and the field test were reviewed, and additional modifications to ICD-10-CM were made based on these comments and suggestions. Additionally, new concepts have been added to ICD-10-CM based on the established update process for ICD-9-CM (the ICD-9-CM Coordination and Maintenance Committee) and the World Health Organization's ICD-10 (the Update and Revision Committee). This represents ICD-9-CM modifications from 2003-2009 and ICD-10 modifications from 2002-2008.

The clinical modification represents a significant improvement over ICD-9-CM and ICD-10. Specific improvements include: the addition of information relevant to ambulatory and managed care encounters; expanded injury codes; the creation of combination diagnosis/symptom codes to reduce the number of codes needed to fully describe a condition; the addition of  sixth and seventh characters; incorporation of common 4th and 5th digit subclassifications; laterality; and greater specificity in code assignment. The new structure will allow further expansion than was possible with ICD-9-CM.

Are You Billing Established Patient Visits Correctly

TrailBlazer (the MAC for Colorado, New Mexico, Oklahoma, Texas, and Virginia) recently identified potential improper utilization of established office visit services (codes 99211–99215) billed to Medicare. According to TrailBlazer, two widespread probe reviews were conducted to verify if this perceived improper utilization was actual or not. These reviews are called “widespread” becausedocumentation is evaluated from multiple providers. TrailBlazer used the Progressive Correction Action (PCA) process to identify a random sample of 200 claims (two reviews) containing established office visits with dates of service from January 1, 2010, through June 30, 2010. The selection of providers for this review was based on a scoring methodology that considered the following variables: 

• Distribution of claims volume for CPT codes 99211–99215.
• Distribution of paid dollars for CPT codes 99211–99215.
• Percent of claims billed with modifier 25.
• Percent of claims billed with CPT codes 99211–99215 billed as 99214/99215.
• Frequency of services per beneficiary for CPT codes 99211–99215 compared to the peer average. 

One probe review (100 claims) was conducted on selected providers in Virginia. The other probe review (100 claims) was conducted on selected providers in Colorado, New Mexico, Oklahoma and Texas. 

The Probe’s Findings 

Overall error rate for each probe review was: 

Virginia: 51.43 percent.

Colorado, New Mexico, Oklahoma and Texas: 91.32 percent.

Findings Conclusion - Medicare expects providers who bill these services to: 

• Bill an E/M service only when the service meets medical necessity requirements and document sufficiently to support the medical necessity of the E/M service billed. Medicare determines “medically reasonable and necessary” separately from determining the work described by a reported CPT code performed. The patient’s condition (severity, acuity, number of problems, etc.) is the key factor in determining medical necessity for Medicare payment for services.
• Bill the level of E/M service appropriate to treat the patient’s presenting problems. Documentation of E/M services billed for Medicare payment must ensure the patient’s clinical condition and reason for the service are documented in enough detail for a reasonable observer to understand the patient’s need and the practitioner’s thought process. The E/M code billed must reflect patient’s needs, work performed and medical necessity. Though an E/M service may code to a high level based on the documentation of key component work, it is inappropriate to request Medicare payment when the patient’s effective management does not require the code’s work.
• Medicare generally expects to see E/M services billed every three months for patients with chronic, stable conditions.
• Comply with the requirements for use of the 25 modifier. Modifier 25 is used when a significant, separately identifiable E/M service is performed by the same physician on the same day as a procedure or other service. The E/M service must meet the following criteria:
  • Must have been performed and documented according to CPT code requirements and statutes concerning coverage and payment.
  • Must be coded according to its medical necessity and documented CPT physician work.
  • Must be a separately identifiable service provided on the same day, on the same patient and by the same practitioner as a therapeutic medical/surgical and/or diagnostic medical/surgical procedure with either a zero- or 10-day global period. The E/M service may result in the decision to perform a zero- or 10-day global procedure when the need to perform the procedure was not planned, was not foreseeable and the condition for which the procedure was necessary could not have been determined to exist without having performed the E/M service (i.e., new problem or new, previously undisclosed event related to a known problem).
  • Must not have resulted in a decision to perform a major operative procedure (surgery). 
  • Must be a significant service, above and beyond the usual preoperative and postoperative work/care required by the therapeutic or diagnostic service also performed.

Is your physician practice ready for ICD-10?

At last week's annual meeting of the National Society of Certified Healthcare Business Consultants (www.nschbc.org), we had two excellent presentations on ICD-10, which begins implementation on 1-1-12. Quite frankly, I'm nervous. These are big changes and could severely impact the cash flow of any physician practice if you are not prepared.

To get you started, on January 12, 2011, CMS held a national provider call on “Preparing for ICD-10 Implementation in 2011.” From the audio of that event, CMS has created the following four podcasts:　 

• Welcome and ICD-10 Overview – Pat Brooks, CMS 
• Implementation Strategies for 2011 – Sue Bowman, AHIMA 
• Question and Answer Session, part 1 
• Question and Answer Session, part 2 

These podcasts are now available here in the downloads section.

Also, Frank Cohen will soon be publishing a ICD-10 survey that is designed to assess readiness amongst medical practices.  Please participate in this important survey: 

The link is https://www.surveymonkey.com/s/ICD10Awareness

RACs Identify High-Risk Vulnerabilities for Physicians

Recent RAC audits have detected two high risk vulnerabilities for physician claims are listed in Table 1 below. These claims were denied because the demonstration RACs determined that either a duplicate claim was billed and paid or the physician reported an incorrect number of units for Current Procedural Terminology (CPT) code billed based on the CPT code descriptor, reporting instructions in the CPT book, and/or other CMS local or national policy. 

Item	Provider Type	Improper Payment Amount (pre-appeal)	RAC Demonstration Findings
1	Physician	$6,635,558	Other Services with Excessive Units - Units billed exceeded the number of units per day based on the CPT code descriptor, reporting instructions in the CPT book, and/or other CMS local or national policy.
2	Physician	$1,094,751	Duplicate Claims - Physician billed and was paid for two claims for the same beneficiary, for the same date of service, same CPT code, and same physician.

For more information, go to: 

http://www.cms.gov/mlnmattersarticles/downloads/se1036.pdf

 

Auto Denial of Claim Line(s) Items Submitted With a GZ Modifier

In case you haven’t heard, CMS is establishing an automated edit to deny Part A and B claim line(s) items that contain a GZ modifier. The GZ modifier indicates that the provider does not have an ABN on file and believes the services will not be covered because they were not reasonable and necessary. In addition, the transmittals instruct contractors not to conduct complex medical review on lines with the modifier.

Pub. 100-04, Trans. 2148; Pub. 100-08, Trans. 366: CR 7228 (Feb. 4; eff. July 1/impl. July 5, 2011).

The RACs are coming, the RACs are coming....

Frank Cohen recently completed a RAC survey of physician medical practices. Of those responding, 100 were subject to a RAC audit sometime in the past. Of these, nearly 50% stated that the RAC auditor claimed to use some form of random sampling in requesting the records to be reviewed. Of the total, 74% stated that the audit resulted in an overpayment demand and of those, approximately 65% stated that they appealed the RAC decision on one or more of the records audited. Only 6% said that their appeal went as far as an administrative law judge but of those records that were appealed, approximately one third were reversed in the practice’s favor.  

Now, there are a couple of very significant issues raised as a result of this survey. First of all, the CERT study reported that, for 2009, 7.8% of all records reviewed were determined to have been paid in error (including those that were under paid), yet our survey reports that nearly 10 times that, or 74%, reported that the records reviewed were paid in error (in this case, only over payments were reported). Secondly, when appealed, the over payment decision on nearly one third (32.30%) of those records that were claimed to have been paid in error were reversed in the practice’s favor, meaning two things; first, the RAC auditors may have been way over zealous (or inappropriate) in their findings and second, there very well may be a huge cost for those that don’t appeal. 

Demographically speaking, 80% of respondents were medical practices and response came from 46 different states, with nearly 50% from FL, OH, NY, NC, OR, SC, CA, IL, GA and IN. 

For complete details of the survey, go to www.frankcohengroup.com and click on the Download tab.

Medicare immunization billing update

Effective for dates of service on or after October 1, 2010, Healthcare Common Procedure Coding System (HCPCS) codes Q2035, Q2036, Q2037, Q2038, and Q2039 will replace the Current Procedural Terminology (CPT) code 90658 (influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use) for Medicare payment purposes during the 2010-2011 influenza season; however, these HCPCS codes will not be recognized by the Medicare claims processing systems until January 1, 2011, when CPT code 90658 will no longer be recognized. Specifically for roster claims, Medicare systems are unable to process roster claims until February 7, 2011. Providers may submit their roster claims on an individual claim basis or hold their roster claims until February 7, 2011, and then submit as a roster bill at that time. 

Click this link for more information: 

http://www.cms.gov/MLNProducts/downloads/qr_immun_bill.pdf