Nothing is so simple that it cannot be misunderstood Freeman Teague, Jr. The Medical Review Program Reasonable and Necessary Services CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Medicare Medical Review Program The Medical Review program is designed to promote a structured approach in the interpretation and implementation of Medicare policy. Medicare Contractors CMS contracts with Medicare Administrative Contractors to perform data analysis of claim data to identify atypical billing’ Objectives of the MR Program 1. Identifying and preventing inappropriate Medicare payments. 2. Using national and local data to identify potential problems that present the most risk to the Medicare program 3. Ensuring the appropriate payment of Medicare-covered services The Progressive Corrective Action (PCA) Process Includes: • Data analysis • Medical review of claims • Provider education and feedback Data Analysis • First step • Identification of aberrancies • Part of general surveillance • Conducted in response to information about specific problems Specific Service • Based on a specific service • An article is posted on the Palmetto GBA web site to notify the provider community of the probe • Random sampling among all providers billing the service in question • 100 total claims selected for review • Notify the provider community of the results Provider-Specific • Provider is notified via individual letter

• A predetermined percentage of claims billed will be selected for medical review every time the provider bills • Sampling of up to 40 claims • Provider notified of results via individual letter after claims are reviewed and processed Pre-Pay Review • A percentage of claims is selected after services are rendered and billed • An edit is established through the claims processing system (FISS) that selects the claims for review • Additional Documentation Requests (ADRs) are generated and medical records are reviewed before claim processing is completed Post-Pay Review • Involves claims that have previously paid through the processing system • When a post-pay review determination results in a denial of services, the claims will be adjusted or an overpayment letter is sent to recover the overpayment amount • Written notification of the results is sent to the provider upon completion of the review The Results of the Medical Review Medical review is discontinued or resumed based on data analysis of the reviewed and processed claims; which is expressed as a Charge Denial Rate (CDR) Charge Denial Rate Total $ charges denied For the claims reviewed Divided by Total $ charges For the claims reviewed and processed Multiplied by 100 = CDR

The Pen Is Mightier than the Sword “If the pen is mightier than the sword, in a duel I’ll let you have the pen” Steven Wright

"Go on doing with your pen what in other times was done with the sword." Thomas Jefferson, in a letter sent to Thomas Paine in 1796

"... many wearing rapiers are afraid of goose-quills and dare scarce come thither." From Hamlet, 1600, by Shakespeare

"The dashe of a Pen is more greevous than the counterbuse of a Launce." George Whetstone, 1582

"From this it is clear how much more cruel the pen may be than the sword." Robert Burton's The Anatomy of Melancholy, 1621

Without knowing the force of words it is impossible to know men Confucius

.

..

Another Example In a case reported in Lancet, a physician prescribed an asthmatic patient Amoxil, an

anti-infective. The pharmacist misinterpreted the word “amoxil,” written poorly in lower case on the prescription, and dispensed “daonil,” an anti-diabetic drug. This resulted in severe and dangerous hypoglycemia for the patient Results of a Study A study from the New England Journal of Medicine noted that in a sample of outpatient progress notes, 16% of all words were illegible. That means that almost one out of every six words could not be deciphered. Results of a Study The same study found that only 14% of the outpatient progress notes had legible signatures That means 86% of the time, other health care personnel participating in the care of the patient did not know whom to contact with inquiries about patient management, concerns, or in case of an emergency Signatures What is a Signature? A signature identifies somebody and it gives evidence of the intention (will) of an individual with regard to that document. The author affirms something to be true or genuine. Handwritten Signatures Can you figure out who this is?

Medicare Requirements Medicare requires the individual who ordered or provided services be clearly identified in the medical records.

Acceptable Handwritten Signatures • Legible full signature • Legible first initial and last name • Illegible signature over a typed or printed name

John Whigg, MD

• Illegible signature where the letterhead, addressograph or other information on the page indicates the identity of the signatory.

Local Physician's Office 234 Main Street, Hometown, USA

Ed U. Cate M.D Stu Dent M.D. (555) 123 4567 (555) 123 6789

Name Dee Cubitus Age 54 Address 456 First street Date March 23, 2008 _______________________ (Signature) Refill ____ Times Do Not Refill _____

Acceptable Handwritten Signatures • Illegible signature or initials NOT over a typed/printed name and NOT on letterhead, but the submitted documentation is accompanied by:

o Signature log o Attestation statement

• Initials over a typed or printed name • Unsigned handwritten note where other entries on the same page in the same handwriting are signed Illegible Handwriting Tips • Show your handwritten orders to the secretary or nurse before you leave. Find out what they can't read. • Ask someone else to identify one thing you do that makes your handwriting illegible, and practice not doing that. (For example, not closing "e's" .) See if legibility improves. • Put your contact information after your signature. Then at least someone can call you when he/she can't read what you wrote. Karen Hopper, M.D. Illegible Handwriting Tips • Print name underneath the signature • Use name stamp underneath the signature

Unacceptable Signatures • Illegible Signature or initials NOT over a typed/printed name, NOT on letterhead and the documentation is unaccompanied by:

o Signature log o Attestation statement

• Unsigned typed note with or without provider’s typed name • Unsigned handwritten note, the only entry on the page • “Signature on file” If the Signature is Illegible If the signature is illegible, signatures logs or attestation statements may be considered for payment purposes. Signature Log A signature log lists the typed or printed name of the author associated with initials or an illegible signature. The signature log might be included on the actual page where the initials or illegible signature are used or might be a separate document

63

DoofDoofDr. Heinz Doofenshmirtz

8/25/0810.

OODoc OckDr. Otto Octavius6/17/079.

BMCBonesDr. Bones McCoy3/16/067.

MM oreauDr. Moreau 4/15/068.

HJHenry JekyllDr. Jekyll10/2/056.

Signature Log

WWhoDr. Who1/24/055.

V.V.D.Dr. DoomDr. Victor Von Doom

11/20/0911.

J. DJohn DoolittleDr. Doolittle1/16/054.

Dr. Pepper12/5/043.

DHDOOGIEDr. Doogie Howser11/1/042.

VFDr. Victor Frankenst einDr. Frankenstein1/2/031.

InitialsSignatureName and CredentialsDate

Signature Attestation Statement “I, _____[print full name of the physician/practitioner]___, hereby attest that the medical record entry for _____[date of service]___ accurately reflects signatures/notations that I made in my capacity as _____[insert provider credentials, e.g., M.D.]___ when I treated/diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.” Signature Attestation Statement The attestation statement must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary. Additional Information The contractor reviewer shall contact the person or organization that billed the claim and ask them if they would like to submit an attestation statement or signature log within 20 calendar days.

Additional Information The 20 day timeframe begins once the contractor makes an actual phone contact with the provider or the date the request letter is received by the post office. Request Written requests will be mailed to: “Attention: Administrator/Compliance Officer”. The envelope will be stamped: “Urgent – Immediate Response Required”. The requested information must be received by Medical Review within 20 days of the envelope postmark Electronic Signatures Digitized Signature An electronic image of an individual’s handwritten signature reproduced in its identical form using a pen tablet.

Digital Signature An electronic method of a written signature that is typically generated by special encrypted software that allows for sole usage.

Acceptable Signature Examples • Chart 'Accepted By' with provider’s name • 'Electronically signed by' with provider’s name • 'Verified by' with provider’s name • 'Reviewed by' with provider’s name • 'Released by' with provider’s name • 'Signed by' with provider’s name • 'Signed before import by' with provider’s name • 'Signed: John Smith, M.D.' with provider’s name • Digitalized signature: Handwritten and scanned into the computer • 'This is an electronically verified report by John Smith, M.D.' • 'Authenticated by John Smith, M.D.' • 'Authorized by: John Smith, M.D.' • 'Digital Signature: John Smith, M.D.' • 'Confirmed by' with provider’s name • 'Closed by' with provider’s name • 'Finalized by' with provider’s name • 'Electronically approved by' with provider’s name

Unacceptable Signature Examples 'Signing physician' when provider's name is typed Example: Signing physician: ___________

John Smith, M.D.

'Confirmed by' when a provider's name is typed Example: Confirmed by: ____________

John Smith, M.D. 'Signed by' followed by provider's name typed and the signing line above, but done as part as the transcription 'This document has been electronically signed in the surgery department' with no provider name.

'Dictated by' when provider's name is typed Example: Dictated by: ____________

John Smith, M.D. ‘Signature on File’

Don’t Do it! Signature 'stamps' alone in medical records are no longer recognized as valid authentication for Medicare signature purposes. Watch Out for These! Order not dated No identifying physician information No beneficiary name What is Communication? Communication is a process of transferring information from one entity to another

. What are These Orders For?

Abbreviations A member of nursing staff who when he saw DOA on a patient's notes told the enquiring relative the patient was dead on arrival at hospital. On the ward however DOA meant date of admission and the patient was very much alive. Abbreviations HS D/C SQ

IU Trailing zero (5.0) Lack of lead zero (.5) HL HA SOB Incident To “Incident to” means the services or supplies are furnished as an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness. Services and supplies commonly furnished in physicians' offices are covered under the "incident to" provision. Where supplies are clearly of a type a physician is not expected to have on hand in his/her office or where services are of a type not considered medically appropriate to provide in the office setting, they would not be covered under the "incident to" provision. CMS Internet-only Manual (IOM) Pub. 100-02 Medicare Benefit Policy Manual, Chapter 15 Covered Medical and other Health Services, Section 60 Services and Supplies Furnished Incident to a Physician’s/NPP’s Professional Service For services to be covered "incident to" the services of a must be an integral, although incidental, part of the physician’s professional service commonly rendered without charge or included in the physician’s bill or a type commonly furnished in physician’s offices or clinics Furnished by the physician or auxiliary personnel under the physician’s direct supervision. CMS Internet-only Manual (IOM) Pub. 100-02 Medicare Benefit Policy Manual, Chapter 15 Covered Medical and other Health Services, Section 60 Services and Supplies Furnished Incident to a Physician’s/NPP’s Professional Service To be billed as "incident to," the services of Non-physicians must meet four criteria: 1. The services must be performed under a physician's "direct supervision" 2. The services must be performed by employees (including leased employees) of the

supervising physician, the physician's group or the physician's employee 3. The physician must initiate the course of treatment of which the NP's services are a

part 4. The physician must perform subsequent services of sufficient frequency to reflect the

physician's continuing active participation in managing the course of treatment

Five Key Concepts of “Incident-to” Professional service Location Employment relationship Incidental but physician/NPP performs initial service Supervision, direct

Established Patient “An established patient is one who has received professional services from the physician or

another physician of the same specialty who belongs to the same group practice, within the past three years.” (CPT, 2009) Established Plan of Care The personnel performing the incident-to service should: 1. Document the ‘link’ between their face-to-face service and the preceding physician service to which their service in incidental 2. Reference by date and location the precedent providers’ service that supports the active involvement of the physician 3. Legible record both their identity and credentials Direct Supervision – What it is 1. Physician readily available in the office suite 2. There must be a specific physician responsible for the supervision of the billed service

Direct Supervision – What it is Not Physician doing rounds at the hospital and the auxiliary staff performing the service in the office or the physician having lunch downtown and is available by phone. Supervising Physician The physician who performed the initial assessment and initiated the course of treatment does not need to be the physician supervising the incident-to service.

Scenarios for Services ‘Incident To’ Provider Services

A 65 year old established, male Medicare patient presents with headaches and dizziness to your office. He has been seen at the office previously, but this is a new condition. Physician is in the office but not available to see patient. The patient is seen by the NPP. The NPP evaluates the patient and begins treating him for hypertension. ______________________________________________________________________________________________________________________________________________________ An NPP works for an urologist part time, seeing patients at a hospital The urologist has leased space in the facility for three examination rooms While the physician is seeing patients in an adjoining exam room, the NPP examines a patient who is being treated for an ongoing urinary tract infection according to a plan of treatment established by the physician

____________________________________________________________________________________________________________________________________________________________

A physician's assistant (PA) is seeing a patient in a cardiology practice, while the supervising physician is called away to the hospital

The hospital is connected to the office building by a walkway. During the cardiologist’s absence, the PA performs a follow-up examination with a patient who had previously been seen by the cardiologist

___________________________________________________________________________________________________________________________________________________________

Six months ago, a patient was diagnosed with breast cancer and placed on a regimen of medication and diet The patient returns to the office and is seen by the NPP to assess her progress. The physician is out of the office attending a medical convention, but his partner is in the office

___________________________________________________________________________________________________________________________________________________________

If a new patient comes into the office and sees our physician assistant (PA), can our PA bill this as "incident to" the doctor, who is also in the office seeing patients? ______________________________________________________________________________________________________________________________________________________ Can hospital or nursing home visits, provided by a Nurse Practitioner, be billed as "incident to" her supervising doctor, as long as he is also in the facility seeing patients? _____________________________________________________________________________________________________________________________________________________

After an initial visit, what role should the physician have in a Medicare patient's ongoing care while the PA or NP see the patient "incident to"? ______________________________________________________________________________________________________________________________________________________ CMS Internet-only Manual (IOM) Pub. 100-02 Medicare Benefit Policy Manual, Chapter 15 Covered Medical and other Health Services, Section 60 Services and Supplies Furnished Incident to a Physician’s/NPP’s Professional Service Requirements The initial visit (for that condition) must be performed by the physician .This does not mean that on each occasion of an incidental service performed by an NPP, that the patient must also see the physician. It does mean, however, that there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the services being performed by the NPP is an incidental part. There must be direct personal supervision by the physician as an integral part of the physician’s personal in-office service. The physician must be physically present in the same office suite and be immediately available to render assistance if that becomes necessary. ‘Incident To’ Record Review

The reviewer needs to be able to discern why a claim was billed under the physician NPI as opposed to the NPP’s NPI. There needs to be evidence of a supervising physician present to justify ‘Incident to’ CERT (Comprehensive Error Rate Testing) What is CERT? The Comprehensive Error Rate Testing program, or CERT program, was designed to measure the accuracy of payments made by Medicare Contractors. CERT is like an “audit” of Medicare contractors. The CERT program was developed as a result of the Government Performance and Results Act of 1993. This Act established performance measurement standards for Federal agencies. What is CERT? There are 3 key error rates: 1. National paid claims error rate 2. Provider compliance error rate: measures how well providers prepared claims for submission 3. Paid claims error rate: % of dollars that contractors erroneously paid (measures how accurately each contractor paid claims) Total Population

North Carolina Unites States

Total Population 2009 Census

9,230,400 303,343,300

Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's March 2009 and 2010 Current Population Survey (CPS: Annual Social and Economic Supplements) Population Distribution by Age NC # NC % US # US % Children 18 and under

2,440,400 26% 79,305,700 26%

Adults 19-64 5,613,700 61% 185,424,200 61%

65+ 1,176,300 13% 38,613,300 13% 65-74 671,600 7% 20,953,000 7%

75+ 504,800 5% 17,660,300 6% Total 9,230,400 100% 303,343,300 100%

Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's March 2009 and 2010 Current Population Survey (CPS: Annual Social and Economic Supplements). Total Number of Medicare Beneficiaries, 2011 North Carolina # United States #

1,505,942 47,672,971

Mathematical Policy Research analysis of CMS State/County Market Penetration Files. Data are from March of the given year(s), except for 2006 which are from December 2005. 2007 data are from the July 2007 Medicare Enrollment Reports. In May 2008, CMS began releasing on a monthly basis the MA State/County Penetration Files that contain counts of Medicare eligibles by county. 2008, 2009, and 2010 data are from the July 2008, March 2009, and May 2010 MA State/County Penetration File, respectively. Starting in 2011, data are from KFF analysis of the State/County Penetration file,

OIG Study

Key Components

CERT Errors Error Code 31: Services Incorrectly Coded Error Code 21: Insufficient Documentation Error Code 25: Medically Unnecessary Service or Treatment

Services Incorrectly Coded The documentation submitted by the provider does not match the codes submitted: Service Modifier Diagnosis

Incorrect Coding For most of the coding errors, the medical reviewers determined that providers submitted documentation that supported a lower code than the code submitted. For some of the coding errors, the medical reviewers determined that the documentation supported a higher code than the code the provider submitted. Issues that lead to Incorrect Coding 1. Incomplete notes 2. Undocumented care 3. Missing test results 4. Post op complications not listed 5. Documentation not completed timely 6. Illegibility 7. Inconsistent documentation

1. Patient encounter 2. Review of medical record 3. Selection of diagnoses and procedure codes 4. Assignment of code number 5. Sequencing of codes Services Incorrectly Coded Example Submitted documentation included results of the CT scan of the head without, there was also no physician order submitted for contrast. The CT of head with contrast down coded from 70460 to 70450. This line submitted for CPT 81001 (Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with Microscopy). Provider submitted physician's order is for a "UA", the physician did not order a UA with microscopy. Supports code change to CPT 81003. Provider billed CPT 85025: blood count; complete (CBC), automated (HGB, HCT, RBC, WBC and platelet count) and automated differential WBC count. Documentation submitted includes the Emergency Room physician order which has CBC circled without circling

differential. Lab results were submitted for CBC with diff. Documentation supports code change from CPT 85025 to 85027. Evaluation and Management E/M services account for approximately 40 percent of the benefit dollars paid under Part B of the Medicare program. E/M Coding Errors • E/M service exceeds the patient’s documented needs • E/M service at levels higher than are medically reasonable and necessary regardless of the level to which the service is documented • E/M service coded lower, even though the documentation reflects otherwise • Multiple diagnoses listed, but documentation does not reflect evidence of being addressed

All CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. History Errors • Chief complaint and/or reason for the visit not clearly stated • History of Present Illness (HPI) description does not make the nature of the presenting problem clear • Past/Family/Social History (PFSH) that would be appropriate for the encounter is either absent or incomplete • Review of Systems (ROS) that would be appropriate for the encounter is either absent or incomplete or merely a listing of diagnoses

Physical Exam Errors • Absent or incomplete examination of the system(s) related to the presenting problem describing it as “normal” or “negative.” • Not understanding the difference between “Expanded Problem-Focused (EPF)” and “Detailed” examinations • The difference is not the number of systems examined. Two to seven systems are

required for both examinations. • The difference is the detail in which the examined systems are described

Medical Decision-Making (MDM) Do not count existent old diagnoses unless the record clearly demonstrates their presence increased physician work related to the encounter. Do not code MDM based solely on the severity of or number of presenting problems; decision-making also encompasses the numbers of and risk associated with diagnostic tests ordered/performed as well as the complexity of and risk associated with therapeutic options chosen.

Other E&M Errors • Failure to document the required level of key component work. • No evidence of a face-to-face encounter when E/M service is billed

• When coding subsequent hospital service, failure to pay attention to medical necessity and consider the nature of the presenting problem and the patient status

Other E&M Errors • E/M service(s) exceeds the patient’s documented needs • E/M service(s) at levels higher than are medically reasonable and necessary regardless of

the level to which the service is documented • E/M service(s) coded lower, even though the documentation reflects otherwise • Multiple diagnoses listed, but documentation does not reflect evidence of being addressed

Insufficient Documentation Insufficient documentation means that the provider did not include pertinent patient facts (e.g., the patient’s overall condition, diagnosis, and extent of services performed) in the medical record documentation submitted. Some common issues are: • Date of service not documented • Missing names, signatures, credentials • Documentation not supporting services billed • Chief complaint was not documented • Primary diagnosis was not documented

Example Provider submitted CPT code 99213. Documentation does not meet the Medicare requirement for a legible identifier. There is no handwritten or electronic signature on the submitted documentation Coded 74020 – “Submitted documentation consists of “dictated by”, unsigned copies of radiologist’s reports of findings. Missing are valid physician orders for the CT and X-ray examinations. Missing from radiologists reports are handwritten or electronic signatures which would identify the legible provider as required. Medically Unnecessary Services Medically Unnecessary Services includes situations where the review staff identifies enough documentation in the medical record to make an informed decision that the services billed to Medicare were not medically necessary. In the case of inpatient claims, determinations are also made with regard to the level of care; for example, in some instances another setting besides inpatient care may have been more appropriate. If a MAC determines that a hospital admission was unnecessary due to not meeting an acute level of care, the entire payment for the admission is denied.

General Principles of Documentation Who –Performing, supervising and referring practitioners What (and how many) –Services and quantities of services performed Where –Place of service When –Date of service Why –Medical necessity and diagnosis

Keys to Proper Documentation • Understand the Guidelines • Perform the Service • Document What You Did (according to the guidelines) • Bill what you documented • Collect what you billed

Accurate Coding and Documentation is Important