Performing your own internal coding audit

With RACs surrounding us and lots of talk lately about fraud and abuse issues, now might be a good time to conduct your own internal audit.  When you perform an internal, you’re comparing your physician’s billing records, claims, and medical records to verify expected treatment outcomes and medical necessity of services. In addition, you’ll look for appropriate documentation to support fees and reasonable charges for services your surgeons rendered. You want to find out if there are any compliance problems before an outside auditor does. The following are a few quick steps to help you conduct your own audit:

Involve the staff. Let every member of your practice know what you’re doing and why, and remind them that you aren’t trying to get anyone in trouble. Instead, you want to determine whether they’re bringing in the right amount of reimbursement and cutting out denials.

Select the charts. Most auditing specialists I know recommend that you review 10 to 15 records per physician at a minimum. I’ve seen the sample go as high as 50 charts per physician.

Examine the chart’s documentation. Read the documentation and determine which ICD-9 and CPT codes you think apply to the chart, then check which codes were actually assigned to the services. When in doubt, engage the services of an outside auditor.

Pay special attention to time-based coding. I know many physicians who code E/M services based on time with the patient. You have to have a believable reason that you had to provide the majority of the service on counseling/coordination of care to justify basing your E/M level on time.

Use a score sheet. Many MACs offer audit tool score sheet templates that can help you when auditing documentation. For instance, High-mark Medicare offers several templates on its Web site, such as the E/M worksheet at

www.highmarkmedicareservices.com/partb/reference/pdf/scoresheets/8985.pdf.

Educate. After the audit, show your physicians, other practitioners, coders, and billers what the outcome was so you can combat any problem areas.

Remember the goals of any good compliance program are the following:

Prevent – Detect - Correct

OIG targeting incident-to billing

In the midst of healthcare reform debates and new HIPAA mandates, the Office of the Inspector General (OIG) has released a new study^* of 'incident to' billing.  This study found that unqualified staff rendered 21% of all procedures and services. Specialties at greatest risk include:

 

ﾷ Ophthalmology

ﾷ Physical medicine and rehabilitation

ﾷ Orthopaedics, particularly those practices that provide physical therapy

ﾷ Cardiology

ﾷ Radiology

ﾷ Any practice that provides diagnostic imaging

ﾷ Any practice that uses nonphysician staff to provide E&M services

As a result of this August 2009 study, OIG and CMS will be working together to scrutinize nonphysician billing and to establish new credentialing guidelines for nonphysician providers.  

 

The Medical Group Management Association is holding a seminar on this subject on September 22^nd; click here for more details:

 

http://www.mgma.com/solutions/landing.aspx?cid=22714&id1=30187&mid=30187&kc=GAMC

Documenting E/M services

I ran across this documentation chart the other day; appears to be a pretty good one. Use it not only as a documentation tool, but an educational tool as well. Be prepared in case of an audit.

http://www.highmarkmedicareservices.com/partb/reference/pdf/scoresheets/8985.pdf

Using modifier 22

Generally modifier 22 is used sparingly--but that doesn’t mean you should never use this modifier at all. When a procedure may require significant additional time or effort that falls outside the range of services described by a particular CPT code--and no other CPT code better describes the work involved in the procedure--modifier 22 is your best option. Here are a few tips for using modifier 22.

Know When to Use Modifier 22

You should use modifier 22 “when the service(s) provided is greater than that usually required for the listed procedure,” according to CPT. However, neither CPT nor Medicare provides guidelines about what type of service merits its use--that’s up to you.

Support the ‘Increased’ Argument

CPT designed modifiers to represent the extra physician work involved in performing a procedure because of extenuating circumstances present in a patient encounter. Modifier 22 represents those extenuating circumstances that don’t merit using an additional or alternative CPT code, but instead raise the reimbursement for a given procedure. The key to collecting reimbursement for increased procedures is all in the documentation. Sometimes a physician will tell you he did “x, y and z,” but when you look in the documentation, the support isn’t there. Documentation is your chance to demonstrate the special circumstance that warrants modifier 22.

Also, don’t forget to add on the additional dollar amount that you are asking for by using the modifier. Payers just don’t pay you extra with this modifier; you need to say I am asking for ____ extra and this is why.

Count Time as a Vital Factor

Some experts suggest that you shouldn’t use modifier 22 unless the procedure takes at least twice as long as usual. Several memorandums from Medicare carriers indicate that time is an important factor when deciding to use this modifier.

Use Unlisted-Procedure Code as a Last Resort

Avoid making the mistake of using an unlisted-procedure code when you could use modifier 22. Some coders go this route because they realize the payer must manually review such claims and the carrier’s computer cannot automatically deny them. But you could be setting your practice up for missed reimbursement. Unlisted-procedure codes require the same amount of documentation as modifier 22

If Possible, Use CPT Codes Instead of a Modifier

Instead of attaching modifier 22 when a procedure is above and beyond its normal scope, you should consider reporting a CPT code that more specifically explains why the procedure was prolonged or increased.

Don’t Assign E/M Codes Based Solely on the Length of the Documentation

Coding an E/M visit based on the physician’s documentation is an art form -- but selecting a code simply based on the volume of documentation is just bad form. National Government Services (NGS), a Medicare payer in 26 states, recently published its "Post Pay Probe Results for Evaluation and Management Services" on its Web site.

The carrier noted that it downcoded subsequent hospital visit stays that several providers billed because the visits didn’t meet "policy documentation requirement guidelines." Interestingly, NGS indicated that some providers billed based on the amount of documentation rather than what the physician actually said in the documentation.

"The volume of documentation should not be the primary influence upon which a specific level of service is billed," NGS noted in its summary of findings.

The habit of coding based on the length of documentation is common. You should always base your code choice on the documentation’s content.