AMERICAN OSTEOPATHIC ASSOCIATION

Transcription

1 AMERICAN OSTEOPATHIC ASSOCIATION October 10, 2012 Department of Practice Management and Delivery Innovations Presents: Audits and Denied Claims Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 1

2 NS1 Monica Horton, MPP Oversees the daily operation of the Department of Practice Management and Delivery Innovations Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 2

3 Yolanda Doss, MJ, RHIA Yolanda has a strong background in health law and health information management. She has extensive experience in the clinical practice management and regulatory areas. Yolanda can address questions and provide presentations regarding: Medicare compliance for the physicians office Fraud and abuse, HIPAA Non-physician providers, credentialing issues Medicare participation Managed Care participation Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 4

4 Sandra Peters, MHA Sandra has extensive experience in HIT-EMR, quality performance metrics, insurance and managed care contractual relationships, practice management, and physician office operations. Sandra can address questions related to: E-prescribing, Electronic medical records adoption and implementation Stimulus funding Starting, marketing, and growing a physician practice Addressing contractual issues with managed care companies. Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 5

5 Susan Niederkorn, MS, RHIA, CCS, AHIMA- Approved ICD-10 Trainer Susan has extensive experience in coding, audit, and compliance and is responsible for assisting physicians and their staff with their billing and coding educational needs. Susan can answer questions and provide presentations regarding: Correct coding and billing utilizing CPT-4, ICD-9 and ICD- 10 Compliance with the E/M documentation guidelines Proactive audit preparation Electronic health records Implementation of practice improvements Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 6

6 Kavin Williams, CPC Kavin has a wealth of knowledge and experience in national reimbursement policy development, auditing, and dispute resolution. Kavin can address questions and provide presentations regarding: Medicare Recovery Audit Contractor (RAC) and private sector audits, Collecting co-pays and deductibles, Assuring timely and appropriate payment Coverage policies and systems Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 7

7 Contact Information Monica Horton, MPP Yolanda Doss Sandra Peters Kavin T. Williams Susan Niederkorn Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 8

8 Audits NS2 Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 9

9 What Is An Audit? It s a tool used by public and private payors to determine if your documentation supports the services billed. Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 11

10 Who Are The Auditors? The Centers for Medicare and Medicaid Services (CMS) and its audit contractors. All private payors The Office of the Inspector General (OIG) The Department of Justice (DOJ) The Federal Bureau of Investigation (FBI) Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 12

11 Types of Audits Prepayment Audits Post-Payment Audits Random Sampling Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 13

12 Why Are Audits Initiated? Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 14

13 Suspicious Billing Patterns For example The physician is credentialed as a Primary Care Provider and a review of paid claims reveal an increase of claims billed for certain test, x-rays or unusual lab work. Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 15

14 Procedure Codes The payor may examine documentation for certain procedure codes. The payor may examine CPT Code for physicians that are credentialed as Internal Medicine in a certain state, in certain zip codes over a certain time period. Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 16

15 Outliers Your reporting of services are outside of what the payor defines as your peer group. Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 17

16 What Causes Most Audits For an OMM/OMT Specialist The use of Modifier-25 Reviewers not understanding the guidelines for reporting and E/M service and OMT on the same date. Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 18

17 OMT Survey The AMA RUC screened Harvard-valued codes with utilization over 100,000 and identified the osteopathic manipulative treatment (OMT) codes and as being potentially misvalued. Additionally, OMT codes 98925, and were brought forth through the Fourth CMS Five-Year Review of the Resource-Based Relative Value Scale (RBRVS). The members of the American Osteopathic Association (AOA) were identified as the dominant providers of OMT and was requested to survey the OMT codes to gather accurate and unbiased information for the relative value of the physician work involved in performing OMT. Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 19

18 OMT Survey On Tuesday October 19, 2010 the AOA hosted a RUC OMT Survey process educational webinar hosted by Dr. Joseph R. Schlecht. The webinar was attended by two hundred seventy five physicians On Monday October 25, 2010 the RUC standard 000 day global survey instrument was sent via to 5000 physicians. The RUC survey was scheduled to close on Monday November 15, On Friday July 1, 2011 the Centers for Medicare and Medicaid Services (CMS) published the Medicare Program: Five-Year Review of Work Relative Value Units Under the Physician Fee Schedule which provided CMS recommendations on an increased value for the OMT codes. Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 20

19 Description of Pre-Service Work The physician determines which osteopathic techniques (eg, HVLA, Muscle energy, Counterstrain, articulatory, etc) would be most appropriate for this patient, in what order the affected body regions need to be treated and whether those body regions should be treated with specific segmental or general technique approaches. The physician explains the intended procedure to the patient, answers any preliminary questions, and obtains verbal consent for the OMT. The patient is placed in the appropriate position on the treatment table for the initial technique and region(s) to be treated. Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 21

20 Description of Intra-Service Work Patient is initially in the supine position on the treatment table. Motion restrictions of identified joints are isolated through palpation and treated using a variety of techniques as follows: occipitoatlantal joint and sacrum are treated using muscle energy and counterstain techniques; right glenohumeral joint and pelvis are treated with articulatory technique; lumbar, thoracic, cervical and right ankle are treated with passive thrust (HVLA) technique; costal dysfunctions are treated using muscle energy technique. Patient position is changed as necessary for treatment of the individual somatic dysfunctions. Patient feedback and palpatory changes guide selection of further technique application as appropriate. Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 22

21 Description of Post-Service Work Post-care instructions related to the procedure are given, including side effects, treatment reactions, self-care, and follow-up. The procedure is documented in the medical record Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 23

22 OMT RVUs = = = = = = = = = = 1.46 Conversion Factor = $ Conversion Factor = $ Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 24

23 How To Respond To A Request For Documentation Reply to the audit notice in a timely fashion. Gather and submit Only the requested documentation. Be cooperative. You may want to conduct an internal audit. Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 25

24 How to Respond to the Audit Findings If the findings are not favorable: Attempt to discuss the findings with the reviewer. If necessary request redetermination. If necessary request a level one appeal. Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 26

25 Claim Denials Why was the claim denied How do you respond? Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 27

26 What Service(s)Was/Were Denied And Why? Review the E.O.B. and the Remark Code(s) Was the E/M service denied? Was the OMT denied? Did the remark code indicate bundling? Did the remark code indicate the diagnosis code could not be reported with the service? Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 28

27 Appeal Create a standard appeal letter in Microsoft word format to specifically address the reason for the denial. Provide supporting documentation. Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 29

28 Physician Documentation This is critical to your reimbursement If it was not documented it did not happen Clear and Legible, words to document by Chief complaint vs. Medical Decision Making (Which is the driver to most insurance auditors) Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 30

29 Documentation Guidelines 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; plan for care Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 31

30 Documentation Guidelines [Cont.] The patient s progress, response to and changes in treatment, and revisions of diagnosis should be documented. The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record. Hospital visits should be included in the patient s chart Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 32

31 Chief Complaint (CC) The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factors that is the reason for the encounter, usually stated in the patient s own words. Documentation Guidelines states that the medical record should clearly reflect the chief complaint Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 33

32 Medical Necessity This area is not black/white There are numerous definitions of medical necessity Linking the appropriate diagnosis to the appropriate procedure to support the necessity of the procedure performed is critical. Medicare defines medical necessity as services or items reasonable and necessary for the diagnosis or treatment of illness or injury to improve the functioning of a malformed body member. Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 34

33 Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 35

34 What If The Appeal Is Denied Contact the AOA s Sr. Manager of Public and Private Payment Advocacy for assistance. Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 36

35 Department Website Go to and sign in professional development. First time users will need their AOA member number to sign up. Click on Practice Management for the department website. There is also a Department address: practicemanagement@osteopathic.org. Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 37

36 What the Practice Management Website has for You Billing and Coding E/M documentation ICD-9-CM code updates OMT information Legal Litigation fund Updates on class action suits CMS/Medicare Links to local carrier information Information on each CPT code Enrollment information CMS Medlearn CCI link Fee schedules, new and prior Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 38

37 What the Practice Management Website has for You Preventive health services Demonstration projects CERT- fraud and abuse information HIPPA Managed care Osteopathic Advocacy Resources Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 39

38 Department CME Seminars Conducted in conjunction with state associations and specialty colleges. Seminars available include Medicare Compliance, HIPAA Privacy Compliance, Physician Payment, Documentation Guidelines and Coding. Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 40

39 Contact Us The Department of Practice Management and Delivery Innovations is focused on finding solutions that support physician practices in the areas of profitability, compliance and emerging practice models. Our staff team is comprised of experts with cutting-edge knowledge of coding, documentation, auditing, compliance, e-prescribing, health information technology, electronic health records and osteopathic office operations. We deliver timely information through webinars, on-demand webcasts and in person. For more information on how we can support affiliated organizations, colleges of osteopathic medicine, and osteopathic physicians contact Monica Horton at and (312) Billing & Coding for OMM: Addressing Practice Audits and Denied Claims - Williams 41