risk-based physician e&m compliance: using data to achieve … · 2015-09-11 · “coding...

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Copyright © 2015 Deloitte Development LLC. All rights reserved.

Risk-Based Physician E&M Compliance: Using data to achieve efficiency and lower overall risk

Health Care Compliance Association

September 11, 2015

Cathi KaiserDirector of Billing ComplianceBrigham and Women’s Healthcare

Christine AnusbigianSpecialist Leader, Regulatory, Forensics and Compliance Deloitte Advisory

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• Background

• Evaluating external risks

• Internal monitoring

• Assessing current structure and development of policies and procedures

• Risk based auditing approach

• Other coding topics to consider

• Reporting the audit results

• Corrective action plan and follow-up

• Questions/discussion

Overview


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Background

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Why?

• Increase in complexity around auditing and monitoring due to:

• Separate physician groups being merged into hospital entities

• Different systems used for electronic records and billing as well as practices using paper records

A risk-based compliance approach enables resources to be targeted to the areas where they are most needed and will prove most effective. It involves a series of steps to identify and assess non-compliance risks and then apply appropriate compliance measures to control these risks.

Using a risk-based approach for auditing and

monitoring for physician groups


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• Improved compliance outcomes

• Efficiency gains

• Reduced business compliance costs

• Greater business support for compliance measures

Source: Guide to Better Regulation, June 2008

Risk based compliance auditing/monitoring

approach - Benefits


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• The Office of the Inspector General (OIG) has published an OIG Compliance Program for Individual and Small Group Physician Practices which highlights the compliance risk areas for physicians.(1)

• A compliance program is one that is structured to DETECT, PREVENT

and CORRECT violations

• Focus on auditing and monitoring is one of the seven elements of a compliance program

• Ongoing routine processes should be established in order to detect new risk areas and identify internal areas of vulnerability real time

• Coding and billing is one of the key risk areas for physician practices. Auditing and monitoring efforts should be designed to address the coding/billing areas most vulnerable to potential errors

(1) https://oig.hhs.gov/compliance/compliance-guidance/index.asp

Evaluating and identifying risks


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• Billed services not provided or not documented

• Services not reasonable and necessary, or covered

• Improper current procedural terminology (CPT) code selection

• Double billing

• Failure to use modifiers properly

• Upcoding

• Misrepresenting diagnosis to justify services

Coding and billing

Example coding and billing compliance risks

• Billing Medicare/Medicaid for investigation research, medications, and procedures without proper authorization

• Routine waiver of copayments and deductibles, regardless of need

• Balance billing

• Inadequate resolution of overpayments (e.g., credit balances)

• Discounts and professional courtesy


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Evaluating external risks

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88Copyright © 2015 Deloitte Development LLC. All rights reserved.

Landscape for Federal and State monitoring programs

CARRIER

RACs

FiscalIntermediary

Growing

AuditSynergies

Data Sharing betweenContractors

Extrapolation?

Facility Denial Mapping

to Professional Services?

M A C

DEPARTMENT OF TREASURY

Other FederalAgencies

OIG

ZIPICs

PSCs

Other State Agencies

MCFUs

MICs

FBI

HEAT


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External sources to monitor risk

Annual CPT,

HCPCS and

diagnosis

coding

changes

Fraud alerts

Corporate

Integrity

Agreements

(CIA) /

Certification

of Compliance

Agreement

(CCA)

deficiencies

OIG reports

Center for

Medicare and

Medicaid

Services (CMS)

Comprehensive

Error Rate

Testing (CERT)

reports


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• Identifies new areas of focus, while continuing to focus on high risk target areas for Part B physician services.

• Focus areas specific to physicians include:

• Place of service coding errors

• Anesthesia services

• Chiropractor services

• Ophthalmology services

OIG work plan for fiscal year 2015


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OIG reports

Sources: OIG, Coding Trends of Medicare Evaluation and Management Services, May 2012 OEI-04-10-001. http://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf

“Coding Trends of Medicare Evaluation and Management Services”

• Between 2001 and 2010, Medicare payments for Part B increased by 43%.

Medicare payments for E/M services increased by 48%

Physicians increased billing of higher level E/M codes in all E/M visit types

• In 2009, two entities paid over $10 million to settle allegations they fraudulently billed Medicare for E/M services.


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Coding trends of Medicare evaluation and management services

OIG reports

DHHS, OIG Coding Trends of Medical Evaluation and Management Services, May 2012


Sources: OIG, Coding Trends of Medicare Evaluation and Management Services, May 2012 OEI-04-10-001. http://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf

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OIG reports (continued)

“Not All Recommended Fraud Safeguards Have Been Implemented in Hospital EHR Technology”

Cautions that EHR technology can make it easier to commit fraudKey risks involve:

• Copy and pasting

• Overdocumentation


Sources:. OEI01-11-00570 OIG Not all recommended Safeguards Have Been Implemented in Hospital EHR Technology, December 2013, http://oig.hhs.gov/oei/reports/oei-01-11-00570.pdf

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OIG reports (continued)

“Prevalence and Qualifications of Nonphysicians who Performed Medicare Physician Services”

• Physicians billing for more than 24 hours

• Found unqualified non-physicians

• Can only be identified by review of medical records

• Concerns about quality of care


Source: OIG, OIE-09-06-00430. Prevalence and Qualifications of Non-physicians Who Performed Medicare Physician Services http://oig.hhs.gov/oei/reports/oei-09-06-00430.pdf

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NGS CERT

E&M errors can also be avoided if the billing providers do not:

• bill a higher level when a lower level of service is warranted; the volume of documentation should not be the primary factor upon which a specific level of service is billed;

• bill a higher level of service when only one component is exceeded; all components must be met or exceeded to use a higher level of service code;

• bill the same level of subsequent hospital visit codes without reviewing the medical records; the components must be met or exceeded, for each visit, to use the same level of care code.

http://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/pages/complianceandaudits/cert/cert-supporting/denied%20and%20adjusted%20evaluation%20and%20management%20codes/!


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Internal monitoring

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Internal monitoring

(RAC, MAC, CERT, OIG, MIC, other).

These can include routine additional documentation

requests, prepayment reviews, post-payment audits,

etc.

Medical record requests

Repeated denials for the same type of claim error

may be considered submission of false claims.

Denials

Audit trails can be monitored to identify copy and

pasting, late documentation or late signing of

records.

At least one Medicare administrative contractor

(MAC) has instituted a policy of denial of payment

when cloned documentation is discovered.

EMR

Benchmarking of billing patterns by physician by

specialty and comparison to other physicians within

your system or use of outside data, such as CMS or

other commercially available data can allow a

practice to identify physicians that are outliers in

comparison to their peers.

Billing patterns


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Assessing current coding structure and development of policies and procedures

Copyright © 2015 Deloitte Development LLC. All rights reserved.19

Initial steps in developing a risk based policy

Physician use of the EMR

If denials are tracked and if so, what are the top denial reasons

Documenting professional coding structure and oversight, including current coding staff size

Process for providing feedback on clinical documentation

Services currently coded by physicians vs. coders for the

different types of professional services provided across the

health system

Documenting the process for providing feedback on clinical documentation, coding and regulatory changes relevant to physicians and coders

How physician service modifiers are added to claims

Diagnosis codes assignment and documentation

Residents and nonphysican practitioners part of the practice

Use of nonphysician practitioners and how their services are billed

Gain an understandingof these areas

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Questions to ask

• What E&M guidelines will you follow – 95 versus 97?

• How are errors tracked (Claim, CPT, diagnosis, lost charges for example)

• What accuracy rate is expected?

• What is the remediation policy for those physicians that fail the audit?

• How often are physicians audited?

• What type and when is training required?

• What is the process for picking a sample including retrospective versus

prospective?

• What are examples of scorecards used for tracking error rates?

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Risk based auditing approach

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Key Questions

Physician specific:

• Have the physicians had an initial baseline audit?

• How long have the physicians been a part of the organization?

• Is there a specialty focused area that is more susceptible to errors

• Look at physician billing history- how many RVUs were billed last year? 2 years ago? Has there been a significant uptick in RVUs with the same number of patients?

EMR:

• Does the EMR allow physician to copy and paste prior notes?

• Are “canned statements” available?

• Can same note be copied patient to patient?

• Can the IT department provide information regarding whether sections of a record were copied or merged from other records? These programs should have an audit trail that should be viewed if copying/cloning is suspected.

• Is compliance involved in review and approval of any templates utilized?

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Baseline audits

Benchmarking data could identify

providers with the following patterns:

Physicians with a high number of services per

day

Physicians with high denial rates

Attempts to unbundle or bill services that may not be medically necessary

High overall relative value units (RVUs)

Billing procedures that others of the same

specialty are not billing

High volume of certain modifiers billed, such as

modifiers -25 and -59

Always using the same E&M code

Routinely billing high level E&M codes

Execute a baseline audit when physicians and physician coders join your organization


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What may be seen in a coding audit:

• EMRs that can generate large blocks of canned text

• Users trained to set up canned statements without involvement of compliance and other stakeholders in the configuration and management of these fields

A few examples of what we have seen in medical records:

• Patients being described as “their” rather than his or her, so a reader cannot tell by reading the record whether the patient was a man or a woman

• Discrepancies within a record, where the history / review of systems does not match the physical exam. For example, review of systems says no edema, but the exam shows significant edema, or discrepancies around shortness of breath, muscle weakness, etc.

• Very long detail history (copied over) that is not relevant to the problem that the patient came in for (e.g., patient comes in for sore throat and the history includes family history, detailed history of surgeries etc.)


Examples (continued):

• Physical exams that don’t describe what the physician looked at or the amount of detail of the organ system examined. There is a list of body parts/ organ systems and “negative” is entered for the exam results.

• For some EMRs the printed note does not show who entered each piece of information (e.g., what was entered by a nurse or the physician) and what information is old and copied over or newly entered.

• Listing of every drug the patient was prescribed listed under medications and it is not clear which medications the patient is currently taking.

• Disconnect between chief complaint and level of exam (99214 for a “review of lab results”)

• Redundant sections: for example, bullets that repeat: Example: Constitutional: no fatigue, no fever, no chills, no weight change, no fatigue, no fever


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Examples (continued):

• Vague references; for example references to medications- “Failed over the counter therapy” or “Failed antibiotic therapy”

• In review of systems (or any list) - similar formatting between patients for lists that can be “tweaked” with a single macro:

• Patient 1: Constitutional: no fever, no chills, no weight change, no fatigue

• Patient 2: Constitutional: c/o fever, c/o chills, c/o weight change, c/o fatigue

• Changes in font or sections of the note IN ALL CAPS LIKE THEY WERE ADDED IN A SEPARATE SESSION


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Other coding topics to consider

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Coding topics

Topic Information

Inpatient E&M Many practices limit coding reviews to office records as these are more often electronic and easier to access.

Physician Quality Reporting System (PQRS) codes and e-prescribing codes

While the payment impact is not on a claim by claim basis, incorrect codes can be considered a false claim and the payment incentives provided for reporting quality codes could be at risk if these are not accurately reported.

If the physicians work with fellows, residents and medical students

Compliance with guidelines around teaching physicians should be audited. Medicare patient records should be audited, as well as Medicaid or other payors which may have different requirements.

Use of non-physician practitioners (NPP)

Compliance with Medicare’s “incident to’ billing, billing under the NPP’s name, and/or billing under the Medicare “shared service” rule.

Site of service on the claim

Billing for wrong site of service has been an area of focus for the OIG.

Anesthesia Use of AA modifier personally performed anesthesia is on the 2014 OIG work plan.


• Reporting requirements can be challenging

• 210 measures on which to select for physician reporting

• Unique calculations of patient percentages within each measure

• Reporting methods:

• Claim-by-claim

• Registry

• EHR-based reporting

• Timing of reports are unique to measure (6 month or 12 month cycle)

• Coding errors can threaten eligibility for incentive payment/punitive deduction

• Failure to report accurate and valid CPT/HCPCS codes

• Failure to report accurate and valid QDCs (quality data codes)

• Mismatching of QDCs and diagnosis and/or procedure codes

• No feedback process of reporting quality measures

• Potential for False Claims Act liability

PQRS risk areas

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Nonphysician practitioners – examples of audit finding

Incident to

• NPP is not part of the practice billing for the service (i.e., is not an expense of the practice)

• Services inappropriately billed as incident to in the emergency department, outpatient hospital or inpatient hospital setting

• Teaching physician rules followed for NPPs

• “Incident to” requirements not met

Split/shared E&M

• Lack of documentation by physicians where required (e.g., split / shared visit)

NPPs billing on their own

• Lack of documentation of required supervision or collaboration by physicians

• NPP practicing outside their scope of practice

General

• Inaccurate coding

• Billing system errors


Anesthesia billing risks

Use of AA modifier personally performed anesthesia is on the 2014 OIG work plan

The following modifiers are used when billing for anesthesia services:

For anesthesiologists:

– AA – Physician anesthesiologist personally performing anesthesia services (Paid at 100%)

– QK – Physician anesthesiologist medically directing 2,3, or 4 CRNAs/AAs (Paid at 50%)

– QY – Medical direction of one CRNA/AA by an anesthesiologist (paid at 50%)

For CRNAs/AAs:

– QX – CRNA/AA medically directed by an anesthesiologist (paid at 50%)

– QZ – CRNA/AA without medical direction by a physician (paid at 100%)

For all providers:

– QS - Monitored anesthesiology care services

In unusual circumstances when it is medically necessary for both the qualified nonphysician anesthetist and the anesthesiologist to be completely and fully involved during a procedure, full payment for the services of each provider is allowed. The physician would report using the “AA” modifier and the qualified nonphysician anesthetist would use “QZ,” or the modifier for a nonmedically directed case.

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Anesthesia billing risks (continued)

Medical direction of anesthesia services

– Maximum number of cases a physician can medically direct : 4

– Medically directing physicians cannot simultaneously medically direct and provide “personally performed” services at the same time

• For example, injecting an epidural steroid on a patient while medically directing CRNAs.

Time is a major consideration in reimbursement for anesthesia services

– Only report time that services are actually being provided.

– Separately billable services (nerve blocks, arterial or central lines placed prior to induction of anesthesia) should not be reported with total anesthesia time

Unbundling services

– Pre-and post-anesthesia visits are part of the anesthesia service.

• Separately reported preoperative or postoperative E&M visits should document that they are not routine pre-op or post-op care

– Postoperative epidural morphine in an existing catheter is not separately billable in patients who received spinal anesthesia

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Reporting the audit results

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Audit results

Different ways to quantify errors

Diagnosis coding errors

Procedure coding errors

Number of claims with an

error

RVU error rate

Financial error rate

Number of billed services with an error

The coder or physician who is the focus of the audit should be provided the audit results


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• Some providers use calculations that take into account the severity of the error

• For example, a two, three or four level E&M variance can be considered to be more significant than a one level variance in the calculations.

• Variances showing upcoding (or overcoded) claims more serious than claims that are undercoded.

Calculations


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Assign Point Values to Findings

Make Them Relative to the “Risk”

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Points Score Description

Corrective Intervention Re-Audit Frequency

0 Passed – Excellent Written Education via Email – No Meeting

Every 2 years

1-4 Passed Written Education via Email – No Meeting

Every 2 years

5-13 Passed Written Education via Email – Meeting at AuditorDiscretion

Annual

14-17 Passed with Education

Written Education and 1:1 Meeting with MD & Auditor

Semi-Annual

18+ Not Passed Written Education and 1:1 Meeting with MD & Auditor

Quarterly

Audit Result Protocols, Corrective

Interventions & Re-Audit Frequency

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Dear Dr. _______ :

I have completed a review of a sample of your services and would like to provide you with a summary of the results. Based on the review findings an individual chart review session with you will not be required.

Observations from your audit:

Five E/M services were over coded by one level. The documentation did not support the

higher level of service which was billed and an adequate time statement was not

documented, therefore the visits could not be billed based on time.

I have attached two documents to this email. The first is a cover letter outlining general information pertaining to your audit and the second attachment provides a high level CPT-4 coding summary of your results. I have also attached to this email a documentation guideline grid to assist you in your code selection.

Although your points do not require a meeting I would be more than happy to review these or any other questions you may have. Please let me know if you would like to review these together.

Sample Education Email to Clinician

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Sample Provider Audit Report –

Summary View

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Sample Provider Audit Report –

Graphed View

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• A score card that takes into account the impact of each error type allows focused educational efforts and re-audits on identified high risk coding and billing practices.

• Providers with the highest error rates and with more overcoding or unsupported charges would be those where educational efforts and re-auditing would be prioritized.

• For example, tracking documentation gaps such as history (no review of systems), medical decision making (old records reviewed but no summary provided would allow educators to assist physicians improve their documentation.

• Another scorecard using RVU variance takes into account both E&M and procedures

Score card use


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Score card example


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Score card example (continued)


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Corrective action plan and follow-up

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Corrective actions

Corrective actions should be taken whenever noncompliance is identified.

The corrective action plan should be created after the physicians have been given the chance to appeal/discuss and respond to initial audit results.

Overpayments should be returned, if applicable

Additional training may need to occur immediately after the results are discussed with the physicians and/or coders


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• The compliance team is a resource to the organization by not only identifying non-compliant claims and issues that need to be corrected, but also by helping to educate physicians and coders on new documentation criteria; new codes; revised coding and billing guidelines, etc.

• Given today’s regulatory environment and the ongoing changes in healthcare including living in the world of electronic medical records to the transition to ICD-10, a proactive approach to auditing and monitoring may help your organization stay out of the scrutiny of the regulators and enforcers.

The role of the compliance department


Questions/discussion

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Contact information

Christine Anusbigian, MBA, CHC

Specialist Leader, Health Sciences, Risk & Regulatory Services

Deloitte Advisory

Email: [email protected]

Phone: 313-396-5857

Catherine R. Kaiser

Director of Billing Compliance

Brigham and Women's Healthcare

75 Francis Street

Boston, MA 02115

Phone: 617-582-0096

Email: [email protected]


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risk-based physician e&m compliance: using data to achieve … · 2015-09-11 · “coding...

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