a cme program provided by louisiana regional physician hospital organization december 7, 2011...

A CME Program Provided by Louisiana Regional

Physician Hospital Organization

December 7, 2011

Presented by Health Care Consulting Services, Inc. PO Box 572 Medina, Ohio 44258-0572

Speaker: Joanne Byron, CEO

About the SpeakerAbout the Speaker

212.07.2011 Speaker: Joanne Byron

Joanne Byron, LPN, BSNH, CCA, CHA, CHCO, CIBS, CMC, COBS,CPC, CPC-I, CMCO,

PCS

Joanne has over thirty five years of consulting, auditing and coding experience with expertise defending clients during Probes, ZPIC and other government investigations and audits. She is an experienced instructor in coding and documentation, developing coding and practice management training programs for hospital systems and community colleges.

Joanne serves on the National Certification Exam Board for the American Institute of Healthcare Compliance as well as CEO of Health Care Consulting Services, Inc.

Disclaimer / DisclosureDisclaimer / Disclosure


Joanne Byron, LPN, BSNH, CCA, CHA, CHCO, CIBS, CMC, COBS,CPC, CPC-

I, CMCO, PCS

Joanne Byron has declared no relevant financial or commercial interests to disclose.

Improve documentation standards for inpatient/outpatient E&M services to reduce risk of overpayments.

Understanding high-risk E&M areas targeted by the Office of Inspector General for fraud and/or abuse.

Coding Inpatient services accurately - review 99222, 99223, 99232, & 99233

Avoiding noncompliance when billing Non-physician providers as “incident to”

Split/Shared Care in the hospitalObservation codesCritical care codesPitfalls of templatesCMS Audit ProgramInternet Resource List

Program Objectives


General principles of E/M documentation

Evaluation and Management (E&M) happens to be highly audited by insurance companies and government agencies due to proven overpayment projected conducted by CMS (such as CERT).

Because there is high usage of E&M codes by primary care physicians and medical specialties, if an audit reveals even the slightest upcoding, it can be extrapolated into enormous overpayment amounts!


Reduce OverpaymentRisk

It is vital to understand the complexities of E&M documentation and coding rules to avoid high extrapolations.

Use the information from today’s program to help implement an internal auditing program in your office.


Starting with the “basics”If it isn’t documented. . . Professional coders and audits understand – if

it isn’t documented, it didn’t happen. If it didn’t happen, it cannot be billed. If it is billed before being documented, there

are compliance issues. If documentation doesn’t meet medical

necessity for the level of service – higher levels of services will not be approved by insurance regarding of the amount of documentation and either downcoded or discovered on a retrospective audit.


Lets be clear. . .

Clear and concise medical record documentation is critical to providing patients with quality care and is required in order for you to receive accurate and timely payment for furnished services.


The physician’s primary focus? Patient diagnosis and treatment!

Your documentation is vital for patient’s continuity of care. There are clearly medical-legal implications when documentation lacks appropriate information.

However – another primary purpose of the medical record is for reimbursement. Without appropriate reimbursement for services rendered, your office cannot be financially viable.


Health care payers may require reasonable documentation to ensure that a service is consistent with the patient’s insurance coverage and to validate:

The site of service; The medical necessity and

appropriateness of the diagnostic and/or therapeutic services provided; and/or

That services furnished have been accurately reported.


There are general principles of medical record documentation that are applicable to all types of medical and surgical services in all settings.

While E/M services vary in several ways, such as the nature and amount of physician work required, the following items are appropriate:

The medical record should be complete and legible;


The documentation of each patient encounter should include:

Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results;

Assessment, clinical impression, or diagnosis;

Medical plan of care; and

Date and legible identity of the observer.


• If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred;

• Past and present diagnoses should be accessible to the treating and/or consulting physician;

• Appropriate health risk factors should be identified;

• The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented; and

• The diagnosis and treatment codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.


In order to maintain an accurate medical record, services should be documented during the encounter or as soon as practicable after the encounter.


What Counts?Quality – not Quantity

The provider must ensure that medical record documentation supports the level of service reported to a payer.

The volume of documentation should not be used to determine which specific level of service is billed. Unrelated or unnecessary documentation will be disregarded by the government, CMS or insurance auditor.


OIG & EMR (electronic medical records)The 2012 Office of Inspector General’s Work

Plan states that Medicare contractors have noted an increased frequency of medical records with identical documentation across services.

Medicare requires providers to select the code for the service based upon the content of the service and have documentation to support the level of service reported. (CMS’s Medicare Claims Processing Manual, Pub. No. 100-04, ch. 12, § 30.6.1.)

The OIG has added EMR and identical documentation to their list of investigations for

2012.

12.07.2011 Speaker: Joanne Byron 16

“Reasonable & Necessary” – according to payer guidelines

In addition to the individual requirements associated with the billing of a selected E/M code, in order to receive payment from Medicare for a service, the service must also be considered reasonable and necessary.


Reasonable & Necessary?The service must be documented to

demonstrate it has was:

❖ Furnished for the diagnosis, direct care (face-to-face), and treatment of the beneficiary’s medical condition (i.e., not provided mainly for the convenience of the beneficiary, provider, or supplier); and ❖ Compliant with the standards of good medical practice.


Medicare & Medical NecessityLocal and National Coverage Determinations

(LCDs and NCDs) are drafted by Medicare.These documents provide detailed information

regarding the definition of medical necessity for various types of services.

Your office should be using LCDs and NCDs daily prior to billing Medicare.

LCDs and NCDs provide information needed for the Beneficiary Notice Initiative for administration of ABNs (advanced beneficiary notices)


Following the RulesThe two common sets of codes that are

currently used for billing are: Current Procedural Terminology (CPT) codes and International Classification of Diseases (ICD) diagnosis and procedure codes.

There are strict guidelines and rules required when applying these codes to a claim for reimbursement.


The Improper Medicare Fee-For-Service Payments Report – November 2009, shows that 7.8 percent of the Medicare dollars paid did not comply with one or more Medicare coverage, coding, billing, or payment rules.

This equates to $24.1 billion in Medicare overpayments

and underpayments annually.12.07.2011 Speaker: Joanne Byron 21

Following the rules is required for compliance -

The following slides represent information from the 2012 Office of Inspector General’s Work Plan related to E&M services

E&M is a long-term target of interest to the Office of Inspector General.

Providers are responsible for ensuring that the codes they submit accurately reflect the services they provide.


E&M: Trends in CodingOIG 2012 Work Plan

The OIG will review E/M claims to identify trends in the coding of E/M services from 2000-2009.

The OIG will also identify providers that exhibited questionable billing for E/M services in 2009.

E/M codes represent the type, setting, and complexity of services provided and the patient status, such as new or established.

23Joanne Byron, AIHC 11/15/2011

E&M During Global Surgery Periods OIG 2012 Work Plan

The OIG will review industry practices related to the number of E/M services provided by physicians and reimbursed as part of the global surgery fee to determine whether the practices have changed since the global surgery fee concept was developed in 1992.

The criteria for global surgery policy are in CMS’s Medicare Claims Processing Manual, Pub. 100-04, ch. 12, § 40.


E&M: Use of Modifiers During Global Surgery Period

OIG 2012 Work Plan Investigation of certain claims modifier codes

during the global surgery period will be conducted to determine whether Medicare payments for claims with modifiers used during the global surgery period were in accordance with Medicare requirements.

Guidance for the use of modifiers for global surgeries is in CMS’s Medicare Claims Processing Manual, Pub. 100-04, ch. 12, § 30.


E&M: Potentially Inappropriate Payments OIG 2012 Work Plan

The OIG will assess the extent to which CMS made potentially inappropriate payments for E/M services and the consistency of E/M medical review determinations.

The OIG will also review multiple E/M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments.


Other High-Risk Areas related to E&M Services

When a CMS contractor audits your E&M records – other high risk items can easily become the focus – such as:

Lack of appropriate documentation to support injections (B12, chemotherapy, etc);

Lack of any record to support 36415 (phlebotomy services when lab specimen is sent to outside referral lab); and

Missing orders for diagnostic tests – to name just a few.


Let’s Review the 3 key elements to E&M

1) History (includes recording chief compliant and/or reason for each hospital visit – needed very day; history of present illness; review of systems; and Past, Family, and/or Social History)

2) Examination (using 1995 or 1997 guidelines)

3) Medical Decision Making (includes dx/management options; Amt/complexity of data reviewed; and Risk)


Recording the History Component under difficult circumstances

Many times hospitalists treat patients who are on ventilators or unable to respond.

When the history cannot be obtained directly from the patient – history can be obtained from another source – family member (perhaps upon hospital admission) or nurses notes (subsequent hospital visits).

This can apply to the office setting when treating patients who may not be good historians (dementia, retardation, etc) – always document the source, person providing the history, etc.


Start the note with the “CC”A Chief Complaint or “CC” is the first

item an insurance or Medicare Auditor will look for when reviewing and E&M service.

Each visit should clearly indicate the reason for today’s visit – and more specific than just “follow up”.

Record conditions which require your attention and treatment that day! 3012.07.2011 Speaker: Joanne Byron

Inpatient ConsiderationsWhat new problems are evident from

reviewing other physicians, consultants or nurses notes since your last visit?

Have other consulting physicians made record of conditions requiring your attention today?

What new conditions are evident from diagnostic lab results since your last visit? You are likely to have reviewed the chart prior to stepping into the hospital room! Record and/or document this information.


Chief Compliant “CC” Guidelines“While documentation of the CC is

required for all levels, the extent of information gathered for the remaining elements related to a patient’s history is dependent upon clinical judgment and the nature of the presenting problem.”

This is why recording the reason for the visit or the “chief complaint” each date of service (including daily hospital visits) is to very important for reimbursement compliance!


History of Present Illness (HPI) Documentation of how the patient has

progressed (or not) since your last visit.

Guidelines state : HPI is a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present.


HPI and higher levels of serviceFor higher levels of service, an extended HPI

should be recorded – this is according to both the 1995 and 1997 guidelines. At least four (4) elements of the HPI should be documented for the visit. Here is the list of items within the HPI category:

•Location•Quality•Severity•Duration•Timing

•Context•Modifying factors•Associated sign & symptoms


Review of Systems (ROS)ROS is an inventory of body systems obtained

by asking a series of questions in order to identify signs and/or symptoms that the patient may be experiencing or has experienced.


Complete ROSA complete ROS inquires about the system(s)

directly related to the problem(s) identified in the HPI plus all additional (minimum of ten) organ systems.

Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented.


Past, Family, and/or Social History

PFSH Past history including experiences with

illnesses, operations, injuries, and treatments;

Family history including a review of medical events, diseases, and hereditary conditions that may place the patient at risk; and

Social history including an age appropriate review of past and current activities.


Complete PFSH A complete PFSH is a review of two

or all three of the areas, depending on the category of E/M service.

A complete PFSH requires a review of all three history areas for services that, by their nature, include a comprehensive assessment or reassessment of the patient.


Add’l Note on Hx ComponentThe CC, ROS, and PFSH may be listed as

separate elements of history or they may be included in the description of the history of the present illness.


A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. You MUST make reference to the date of service of that previous information!

This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record.


Reminder about the historyIf the physician is unable to obtain a history

from the patient or other source, the record should describe the patient’s condition or other circumstance which precludes obtaining a history.


Documenting the Examination – another Key Element

As stated previously, there are two versions of the documentation guidelines – the 1995 version and the 1997 version. The most substantial differences between the two versions occur in the examination documentation section.

Either version of the documentation guidelines, not a combination of the two, may be used by the provider for a patient encounter.


4 levels of examination

Problem FocusedExpanded Problem Focused

DetailedComprehensive


An examination may involve several organ systems or a single organ system.

The type and extent of the examination performed is based upon clinical judgment, the patient’s history, and nature of the presenting problem(s).


1997 exam

The 1997 documentation guidelines describe two types of comprehensive examinations that can be performed during a patient’s visit:

general multi-system examination and

single organ examination.


Some important points that should be kept in mind when documenting general multi-system and single organ system examinations (in both the 1995 and the 1997 documentation guidelines) are:

(next slides)


Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented.

A notation of “abnormal” without elaboration is not sufficient.


Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or organ system(s) should be described.

A brief statement or notation indicating “negative” or “normal” is

sufficient to document normal findings related to unaffected area(s)

or asymptomatic organ system(s).


“MDM” Medical Decision Making or

Medical decision making refers to the complexity of

establishing a diagnosis and/or

selecting a management

option.4912.07.2011 Speaker: Joanne Byron

MDM is determined by considering the following factors:

The number of possible diagnoses and/or the number of management options that must be considered;

The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed; and

The risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the possible management options.


MDM is THE Key Element!

The complexity of the visit – the risk of significant complications, morbidity, mortality, comorbidities associated with the patient’s presenting problems which you evaluated and treated MUST support the level of history and examination.

In-other-word – the MDM really drives the level of service – with supporting history and exam.


Another element in E&M is

TIME

There are times when you are treating very ill patients where

counseling & coordination of care constitutes more than 50% of the

visit.5212.07.2011 Speaker: Joanne Byron

Time – can be used to select level of service

However, there may be times when counseling and/or coordination of care constitutes more than half of the visit - it is in these instances TIME is used to determine the level of service.

Time is reflected in the CPT code description.

Total visit time and counseling time must both be recorded in the progress note.


Utilizing Non-Physician Practitioners (NPPs) in the HospitalShare visits are

permitted by Medicare in the hospital setting.

Incident-to is not.


Shared visits require a note from BOTH the NPP and the physician – both notes are used to determine the level of service and ONE encounter is billed under the physician’s NPI number.


Both providers must have a face-to-face with the patient.

Both notes must be appropriately authenticated.

Incident-to is acceptable billing to Medicare in the office setting.

The physician must be present in the office suite (the physician who is reported on the claim form)

The NPP cannot treat or diagnose new problems or see new patients.

The NPP can treat established patients under a physician’s plan of care and bill the visit.

Shared/Split visits are not appropriate in the office setting.


Utilizing Non-Physician Practitioners (NPPs) in the Office

Critical Care – What Hospitalists Should Know

99291 and 99292 can only be reported when all the criteria for critical care services are met.

These critical care codes are NOT used simply because a patient is in the ICU.

Documentation must support that the physician delivered services and intervention to a critically ill or injured patient – let’s review Medicare’s wording:


Critical CareCritical care is defined as the direct delivery

by a physician(s) medical care for a critically ill or critically injured patient.

A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.


Critical care involves high complexity decision making to assess, manipulate, and support vital system functions(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.


Although critical care typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life threatening situations when these elements are not present.


Critical care is usually, but not always, given in a critical care area such as a coronary care unit, intensive care unit, respiratory care unit, or the emergency department.

However, payment may be made for critical care services provided in any location as long as the care provided meets the definition of critical care.


Chronic Illness and Critical Care: Examples of patients whose medical

condition may not warrant critical care services:

1) Daily management of a patient on chronic ventilator therapy does not meet the criteria for critical care unless the critical care is separately identifiable from the chronic long term management of the ventilator dependence.


2) Management of dialysis or care related to dialysis for a patient receiving ESRD hemodialysis does not meet the criteria for critical care unless the critical care is separately identifiable from the chronic long term management of the dialysis dependence (refer to Chapter 8, §160.4).


Critical Care Services and Full Attention of the Physician The duration of critical care services

to be reported is the time the physician spent evaluating, providing care and managing the critically ill or injured patient's care.

That time must be spent at the immediate bedside or elsewhere on the floor or unit so long as the physician is immediately available to the patient.


Critical Care Services and Qualified Non-Physician Practitioners (NPP) Critical care services may be provided by

qualified NPPs and reported for payment under the NPP’s National Provider Identifier (NPI) when the services meet the definition and requirements of critical care services.

The provision of critical care services must be within the scope of practice and licensure requirements for the State in which the qualified NPP practices and provides the service(s).


Critical Care Services and Physician Time Critical care is a time- based service, and for

each date and encounter entry, the physician's progress note(s) shall document the total time that critical care services were provided.

The CPT critical care codes 99291 and 99292 are used to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured patient, even if the time spent by the physician on that date is not continuous.


Critical Care CriteriaNon-continuous time for medically necessary

critical care services may be aggregated.

Reporting CPT code 99291 is a prerequisite to reporting CPT code 99292.

Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician (§30.6.5).


Split/Shared Services Billing is Prohibited for Critical Care Codes

A split/shared E/M service performed by a physician and a qualified NPP of the same group practice (or employed by the same employer) cannot be reported as a critical care service.

Critical care services are reflective of the care and management of a critically ill or critically injured patient by an individual physician or qualified non-physician practitioner for the specified reportable period of time.


Unlike other E/M services where a split/shared service is allowed the critical care service reported shall reflect the evaluation, treatment and management of a patient by an individual physician or qualified non-physician practitioner and shall not be representative of a combined service between a physician and a qualified NPP.


Report Billing Units Correctly!

The CPT code 99291 (critical care, first hour) is used to report the services of a physician providing full attention to a critically ill or critically injured patient from 30-74 minutes on a given date.

Only one unit of CPT code 99291 may be billed by a physician for a patient on a given date.


Total Duration of Critical Care Codes Less than 30 minutes

99232 or 99233 or other appropriate E/M code

30 - 74 minutes 99291 x 1

75 - 104 minutes 99291 x 1 and 99292 x 1

105 - 134 minutes 99291 x1 and 99292 x 2

135 - 164 minutes 99291 x 1 and 99292 x 3

165 - 194 minutes 99291 x 1 and 99292 x 4

194 minutes or longer 99291 – 99292 as appropriate (per the above illustrations)


Critical Care Services Provided by Physicians in Group Practice(s)

Medically necessary critical care services provided on the same calendar date to the same patient by physicians representing different medical specialties that are not duplicative services are payable.

The medical specialists may be from the same group practice or from different group practices.


Services Bundled into Critical CareThe interpretation of cardiac output

measurements (CPT 93561, 93562);

Chest x-rays, professional component (CPT 71010, 71015, 71020);

Blood draw for specimen (CPT 36415); Blood gases, and information data stored in

computers (e.g., ECGs, blood pressures, hematologic data-CPT 99090);

List continued, next slide


Gastric intubation (CPT 43752, 91105);

Pulse oximetry (CPT 94760, 94761, 94762); Temporary transcutaneous pacing (CPT

92953); Ventilator management (CPT 94002 – 94004,

94660, 94662); and Vascular access procedures (CPT 36000,

36410, 36415, 36591, 36600). 7412.07.2011 Speaker: Joanne Byron

Ventilator Management Medicare recognizes the ventilator codes (CPT

codes 94002 - 94004, 94660 and 94662) as physician services payable under the physician fee schedule.

Medicare Part B under the physician fee schedule does not pay for ventilator management services in addition to an evaluation and management service (e.g., critical care services, CPT codes 99291 - 99292) on the same day for the patient even when the evaluation and management service is billed with CPT modifier -25.


Observation ServicesThe two key identifiers when billing

observation services to Medicare are:

1. The length of stay2. The number of calendar days

According to Medicare rules, if an observation stay is less than eight hours on the same calendar day, you must bill for the initial observation care only using Initial Observation Care codes 99218-99220


Admit/Discharge codes 99234-99236 are assigned based on supporting documentation.

Observation stays that span beyond one calendar day are coded using the Initial Observation Care codes on day one and Observation Discharge code 99217 on day two.


When an observation stay is greater than 48 hours, Subsequent Observation Care codes 99224-99226 are used for the interim days.

Medicare has instructed that these codes be reported by only the admitting physician, although CPT® guides us to use these for all physicians caring for the patient during subsequent observation days. Check with third-party payers for guidance.


Remember that all related outpatient E/M services on a given calendar day are included in the observation service. CPT® instructs:

“When observation status is initiated in the course of an encounter in another site of service (e.g., hospital ED,

physician’s office, nursing facility) all evaluations and management services provided by the supervising physician in conjunction with initiating observation status are considered part of the initial observation

care when performed on the same day.”


Documentation to secure correct hospitalist observation billing includes a dated and timed order, the reason for observation, and notations that support personal provision of services by the physician.

Document the total time spent to adhere to the Medicare eight-hour rule.


Reporting Observation HoursObservation time begins at the clock time

documented in the patient‘s medical record, which coincides with the time that observation care is initiated in accordance with a physician‘s order.


Hospitals should round to the nearest hour. For example, a patient who began receiving observation services at 3:03 p.m. according to the nurses‘ notes and was discharged to home at 9:45 p.m. when observation care and other outpatient services were completed, should have a ―7 placed in the units field of the reported observation HCPCS code.


Observation or Inpatient Care Services (Including Admission and Discharge Services on Same Day)

To report observation or inpatient hospital care services provided on a patient that is admitted and discharged on the same day use codes 99234-99236.

The physician shall satisfy the E/M documentation guidelines for furnishing observation care or inpatient hospital care. In addition to meeting the documentation requirements for history, examination, and medical decision making documentation in the medical record.


Documentation shall include:

Documentation stating the stay for observation care or inpatient hospital care involves 8 hours, but less than 24 hours;

Documentation identifying the billing physician was present and personally performed the services; and

Documentation identifying the order for observation services, progress notes, and discharge notes were written by the billing physician.


In the rare circumstance when a patient receives observation services for more than 2 calendar dates, the physician shall bill a visit furnished before the discharge date using the outpatient/office visit codes.

The physician may not use the subsequent hospital care codes since the patient is not an inpatient of the hospital.


CMS Contractor employed to identify suspected overpayments

Carriers and Medicare Administrative Contractors (MACs) conduct Medical Reviews (MR).

CMS employs Program Safeguard Contractors (PSCs) and Zone Program Integrity Contractors (ZPICs), which are responsible for identifying cases of suspected fraud and taking appropriate corrective actions.

PSCs are being replaced by ZPICs. The OIG has been investigating the

effectiveness of the ZPIC program and has issued a report of findings (Click Here)


CMS also employs . . . Recovery Audit Contractors (RACs) to

identify and correct underpayments and overpayments on a post payment basis, and . . .

The Comprehensive Error Rate Testing (CERT) contractor performs reviews on a small sample of Medicare Fee-For-Service (FFS) claims to produce an annual error rate.


Overview of the Medicare Pre and Post Payment Claim Review Programs


The first two programs (NCCI Edits and MUEs) review claims before they are paid (called prepayment review).

The second two programs (CERT and RAC) review claims after they are paid (called post payment review).

The MR program can perform both prepayment and post payment reviews.


National Correct Coding Initiatives (NCCI) Edits Performed by: Medicare Claims Processing

Contractors CMS developed the NCCI to promote national

correct coding methodologies and to control improper coding that leads to inappropriate payment in Medicare Part B claims.

The NCCI edits are automated prepayment edits. This means that as the submitted claim is processed by the Medicare claims processing contractor’s systems, the submitted procedures are analyzed to determine if they comply with the NCCI edit policy.


Processing systems test every pair of codes reported for the same date of service for the same beneficiary by the same provider against the NCCI edit tables.

If a pair of codes hits against an NCCI edit, the column two code of the edit pair is denied unless it is submitted with an NCCI associated modifier and the edit allows such modifiers.

Appropriate modifier usage (such as -25 and -59) is vital to avoid penalties if audited.


Medically Unlikely Edits (MUEs) Performed by: Medicare Claims

Processing Contractors To lower the Medicare FFS paid claims error

rate, CMS established units of service edits for Medicare Part B benefit claims, referred to as MUEs.

Just like the NCCI edit, the MUE edit is an automated prepayment edit that helps prevent inappropriate payments.


MUEs = violating units billed on the claim form

CMS develops MUEs based on anatomic considerations, HCPCS/CPT code descriptors, CPT coding instructions, established CMS policies, nature of service/procedure, nature of an analyte, nature of equipment, and clinical judgment.

Providers should not interpret MUE values as utilization guidelines. MUE values do not represent units of service that may be reported without concern about medical review


MUEs ProcessClaim lines that pass the MUE edits continue

to be processed.

Those claim lines that report units of service greater than the MUE value for the HCPCS code on the claim line are denied.

A claim line denial due to an MUE may be appealed. Providers may request modification of an MUE value by contacting the NCCI contractor.


Additional MUE Resources CR 6712– Medically Unlikely Edits (MUEs) Click Here

CCI Edits: Medically Unlikely Edits (MUEs) Click Here

CMS MUEs Page Click Here


Carrier/FI/MAC MR Program Performed by: Medicare Claims Processing

Contractors Through error rates produced by the CERT

Program, vulnerabilities identified through the RAC Program, analysis of claims data, and evaluation of other information (e.g., complaints), suspected billing problems are identified by Medicare claims processing contractors.

MR activities are targeted at identified problem areas appropriate for the severity of the problem.


If the Medicare claims processing contractor verifies that an error exists through a review of a small sample of claims, the contractor classifies the severity of the problem as minor, moderate, or significant and imposes corrective actions that are appropriate for the severity of the infraction.


Corrective Actions Resulting from MR can be 1 of 3 options:

Provider Notification/ Feedback

Prepayment review

Postpayment review12.07.2011 Speaker: Joanne Byron 98

Provider Notification/Feedback

Problems detected at minor, moderate, or significant levels will require the contractor to inform the provider of appropriate billing procedures.


Prepayment reviewPrepayment review consists of MR of a claim prior to payment. Providers with identified problems submitting correct claims may be placed on prepayment review, in which a percentage of their claims are subjected to MR before payment can be authorized.


Post-payment reviewPost payment review involves MR of

a claim after payment has been made.

Post payment review is commonly performed by using Statistically Valid Sampling.


Comprehensive Error Rate Testing (CERT) Program Performed by: CERT Review Contractor

(CERT RC) and CERT Documentation Contractor (CERT DC)

CMS uses the CERT Program to produce a national Medicare FFS error rate as required by the Improper Payments Elimination and Recovery Act.

CERT randomly selects a small sample of Medicare FFS claims.


CERT then reviews the claims and medical records from providers/suppliers who submitted them, and then reviews the claims for compliance with Medicare coverage, coding, and billing rules.

In 2009, the CERT contractor randomly sampled 99,500 claims from Medicare claims processing contractors during a one-year period.

This process was designed to pull a blind sample of claims each day from all of the claims providers submitted that day.


CERT contractors follows Medicare regulations, billing instructions, National Coverage Determinations (NCDs), coverage provisions in interpretive manuals, and the respective Medicare claims processing contractor’s Local Coverage Determinations (LCDs).

The CERT contractor does not develop or apply its own coverage, payment, or billing policies.


Paid Claims Error Rate This rate is based on dollars paid after the

Medicare contractor made its payment decision on the claim. This rate includes fully denied claims for FFS claims.

The paid claims error rate is the percentage of total dollars that all Medicare FFS contractors erroneously paid or denied and is a good indicator of how claim errors in the Medicare FFS Program impact the trust fund.

CMS calculates the gross rate by adding underpayments to overpayments and dividing that sum by total dollars paid.


Provider Compliance Error Rate This rate is based on how the claims looked when

they first arrived at the Medicare claims processing contractor before the contractor applied any edits or conducted any reviews.

The provider compliance error rate is a good indicator of how well the contractor is educating the provider community since it measures how well providers prepared claims for submission.

CMS does not collect covered charge data from provider facilities that submit claims to FIs or A/B MACs; therefore, current facility data is insufficient for calculating a provider compliance error rate.


Other Error Rates The CERT report may also describe other error

rates to provide the most specific information available to target problem areas.

Other error rates include error rates by service type and by provider type.

CERT has initiated four supplemental measures that will be reported annually, Power Mobility Devices (PMDs), Chiropractic Services, Pressure Reducing Support Surfaces, and Short Hospital Stays.


CERT Process The CERT post-pay medical review process

begins at the Medicare claims processing contractors.

After the claims have been processed, samples of the claims are selected for CERT review.

The CERT then uses information from the claims processing contractors to request documentation from the provider/supplier who submitted the sampled claim.


The claim and the supporting documentation are reviewed by CERT Program clinicians who determine whether the claim was submitted and paid appropriately.

The CERT Program collects additional information from the contractor for each claim considered to be in error via a feedback process.

Due to the sampling methodology, a small percentage of providers would be subject to CERT review.


However . . . provider claims that are selected for CERT

review are subject to potential post-pay payment denials, payment adjustments, or other administrative or legal actions depending upon the result of the review.

Claims can be adjusted or denied based on the CERT review and normal appeals rights and processes do apply.


Recovery Audit Contractor (RAC)

Performed by: Medicare FFS RAC Contractors

In March 2010, Congress again expanded the role of recovery audit contracting in the Affordable Care Act.

The Affordable Care Act expands the RAC Program to Medicaid and Medicare Parts C and D.


This change requires all states to establish individual Medicaid RAC Programs under their State plan or waiver.

In addition, the Affordable Care Act provision requires these RACs to also serve in a program integrity capacity, reviewing each Medicare Advantage and Part D plan’s anti-fraud plan.


RAC Process RACs apply statutes, regulations, CMS national

coverage, payment, and billing policies, as well as LCDs that have been developed by the Medicare claim processing contractors.

RACs do not develop or apply their own coverage, payment, or billing policies.

In general, RACs will not review a claim that has previously been reviewed by another entity.


RACs analyze claims data using their proprietary software, and identify claims that contain improper payments and those that likely contain improper payments.

If a RAC finds an improper payment, the RAC sends a file to the claims processing contractor to adjust the claim and payment are recouped.


In the case of claims that contain likely improper payments, the RAC requests the medical record from the provider, reviews the claim and medical record, and then makes a determination as to whether the claim contains an overpayment, an underpayment, or a correct payment.


If a denial or adjustment is indicated by the review of records, providers will receive overpayment/ underpayment notification letters.

Providers can appeal denials (including no documentation denials) following the normal appeal processes by submitting documentation supporting their claims.


Best AdviceKeep in mind reimbursement is one of the

primary purposes of the medical record.

Maintain records to support coordination of care while being compliance with medical necessity and other critical documentation criteria.

Contact internal audits periodically to review billing, coding and documentation compliance.

Stay abreast of coding guidelines and ensure billing staff are properly submitting claims.


A Word on TemplatesA word on templates… be

careful of cloning.

Make sure your documentation doesn’t sound repetitive from patient to patient.

Each medical record must be individualized for the specific patient.


Resources

Online CMS Internet Only Manuals Click Here

1995 and 1997 E&M Documentation Guidelines Click Here

Dr. Peter Jenson – E&M University Click Here


OIG Internet Resources


Advisory Opinions: Click Here

Fraud Alerts: Click Here

Compliance Guidance: Click Here

Open Letters: Click Here

Thank you for your time!

Speaker – Joanne Byron

Questions? Contact Joanne at Health Care Consulting Services, Inc by Email [email protected]

or call 330-241-5661Web site: www.hccsincorp.com


a cme program provided by louisiana regional physician hospital organization december 7, 2011...

Documents

joanne byron joanne

joanne byron slide

pcs joanne byron

ceo slide

management em

coding inpatient services

documentation doesnt

documentation standards