Advanced Procedure Coding for Emergency Medicine January 15-16, 2015 Las Vegas, NV (*) Todd Thomas, CCS-P President, ERcoder, Inc; Oklahoma City, Oklahoma; Past-President, Oklahoma City Chapter, American Academy of Professional Coders; Member, ED Coding Alert Editorial Advisory Panel; Member, Coding and Nomenclature Advisory Committee, ACEP; 2009-10 Outstanding Speaker of the Year Award, ACEP Compliance Concerns: They Are Watching You! What You Need to Know to be Safe Analyze the escalating Medicare Audit trends including RAC, MAC, and CERT audits Describe areas of high compliance risk Identify potential audit triggers and targets Review the best defense and response strategies 1/15/2015 11:45:00 AM-12:45:00 AM TH-06 Las Vegas Ballroom DISCLOSURES: (*) Consulting Fees: ERcoder, Inc
They are Watching You! Todd Thomas, CCS-P Medicare Who is watching us? Medicare Administrative Contractors (MACs) Recovery Audit Contractors (RACs) Comprehensive Error Rate Testing (CERT) Zone Program Integrity Contractors (ZPICs) Health Care Fraud Prevention & Enforcement (HEAT)
Who is watching us? MACs are responsible primarily for processing and paying Medicare claims. MACs collaborate with CMS and other contractors to ensure that they pay claims correctly. MACs also educate providers on appropriate billing methods and are responsible for detecting and deterring fraud. Who is watching us? RACs detect and correct past improper payments (both overpayments and underpayments) so actions can be taken to prevent future improper payments. RACs analyze claims data using proprietary software to identify claims that contain improper payments, as well as those that contain likely improper payments. Medicare RACs are paid on percentage of the amount of the improper payment either recovered from providers (overpayments) or reimbursed to providers (underpayments).
Who is watching us? CERT contractors measure improper payments in the Medicare fee-for-service (FFS) program. CERT contractors select at random a sample of approximately 50,000 Medicare claims submitted to Carriers, Fiscal Intermediaries (FIs), and Medicare Administrative Contractors (MACs) during each reporting period. Documentation from providers who submitted these claims is then requested for review by CERT clinicians. CMS and CERT contractors analyze error rate data and produce a national Medicare FFS error rate. Who is watching us? ZPICs are responsible for identifying fraud in Medicare Parts A and B, as well as Part C and Part D. ZPICs are paid directly by CMS on a contractual basis. ZPICs investigate providers that have filed potentially fraudulent claims by a variety of methods, including prepayment and postpayment reviews and onsite audits. ZPICs are divided by geographic zone and can looki for billing trends or patterns across all Medicare claims that make a particular provider stand out from the other providers in that community.
Who is watching us? HEAT is a HHS/DOJ joint task force consisting of law enforcement agents, prosecutors, attorneys, auditors, evaluators, and other staff from DOJ and HHS. HEAT Strike Forces work with a number of entities including ZPICs to identify new issues and areas for increased oversight and fraud prevention. In 2011, HEAT resulted in the agencies recovering approximately $4.1 billion. The agencies were also responsible for the largest-ever federal healthcare fraud crackdown in 2011, which involved 115 defendants in nine cities for a $240 million Medicare fraud scheme. Medicaid Who is watching us? Medicaid Integrity Contractors (MICs) Payment Error Rate Measurement (PERM) Program Medicaid Recovery Audit Contractors (Medicaid RACs)
Who is watching us? MICs are paid on a contracted basis by CMS to review Medicaid, audit claims, identify overpayments, and educate providers/others on Medicaid integrity issues. Review-of-Provider MICs Education MICs Audit MICs Who is watching us? Review-of-Provider MICs - analyze claims to identify potential vulnerabilities; provide leads/target audits to Audit MICs; use data-driven (data mining) approaches to focus on aberrant billing practices; and work with the CMS Division of Fraud Research and Detection. Audit MICs - conduct post-payment audits, perform field audits and desk reviews, and identify overpayments.
Who is watching us? The PERM Program measures improper payments in Medicaid and the Children s Health Insurance Program (CHIP) and produces error rates for each program. CMS uses a national contracting strategy consisting of three contractors to perform statistical calculations, medical records collection and medical/data processing review of selected state Medicaid and CHIP and Managed Care claims. Groups of states are selected for PERM Program participation on a rotating basis once every three years. Who is watching us? Medicaid RACs were established by Congress as part of the Affordable Care Act as a result of the success of the Medicare RAC program. Medicaid agencies are required to contract with a qualified vendor to identify provider overpayments and underpayments and to recover overpayments.
Who is watching us? States must also develop processes for provider entities to appeal RAC determinations, and to coordinate RAC efforts with other Federal and state law enforcement agencies. CMS estimates that the Medicaid RAC program will facilitate a net savings of $2.13 billion over five years. Who is watching us? Private Insurance / Workers Comp / Auto Internal claims auditors Third Party Administrators
Be on alert Know who your local MAC, RAC, ZPIC, CERT, Etc contractors are Billing staff should know how to recognize records requests and inquiries from these contractors. What do to Respond as directed ASAP!! Review the documentation and coding and prepare a rebuttal in the event of a negative outcome. Appeal downcoding with supporting documentation and justification of coding.
Know the rules Know the coding guidelines and policies for your payer. Some payers have unique rules for E&M components. ROS Exam MDM Allergies as ROS "No known drug allergies or allergies in general are not considered part of the ROS. AMA/CPT publications have always indicated that these are elements of PFSH."
ROS all others negative "Due to a recent clarification from CMS, those systems addressed in the ROS must be individually documented. All systems reviewed should be documented, regardless of findings. It is no longer appropriate to just state "all other systems are negative" without specifically listing those systems reviewed. " -WPS (has been removed from their website) ROS all others negative Systems with positive or pertinent negative responses must be individually documented. It is acceptable to state all remaining systems are negative however all systems reviewed must be IDENTIFIED by either writing the name of the system or checking a box on a form etc. How else would one know how many systems were reviewed in order to determine if the ROS was pertinent, extended or complete? Obviously, if there is nothing positive or pertinently negative about the remaining systems the examiner need only identify as stated above.
ROS all others negative It is not written in the manual at the present time so it is carrier discretion. It will be in the manual at a future point. The phrase in the EMDGs states: For the remaining systems. This literally means for the remaining systems that were reviewed, therefore identification is required. But at this juncture until in the manual it is carrier discretion. This communication is intended for the use of the recipient only and may not be shared with any publication or listserve without the permission of the CMS Office of External Affairs. Information shared must be attributed to a "CMS official" and not with my name and position. Thank you PMH as ROS Question: If the past medical section states a chronic or current illness (that the provider is not treating), can it be used in the Review of Systems (ROS)? If the past medical section lists several conditions and there is no mention of controlled or uncontrolled, could this be used in the ROS? Answer: No, per both the 1995 and 1997 Evaluation and Management (E & M) Documentation Guidelines, "a Review of Systems is an inventory of body systems obtained through a series of questions seeking to identify signs or symptoms that the patient may be experiencing or has experienced." A past medical history would not contain a patient's pertinent positive and/or negative responses as related to the problems identified in the patient's history of the present illness.
PFS Hx When a Past, Family and/or Social History documentation has the terms "Noncontributory" or "negative", these are not considered appropriate documentation. Documentation of PFSH must include social and/or family history information, such as alcohol consumption, smoking history, occupation, or familial hereditary conditions -WPS Exam Problem Focused Expanded Problem Focused Detailed Comprehensive 1995 E&M DG a limited examination of the affected body area or organ system a limited examination of the affected body area or organ system and other symptomatic or related organ system(s). an extended examination of the affected body area(s) and other symptomatic or related organ system(s). a general multi system examination or complete examination of a single organ system. The medical record for a general multi system examination should include findings about 8 or more of the 12 organ systems. Numerical Interpretation 1 Body Area or Organ System 2 4 Body areas or systems 5 7 Body areas or systems 8 or more Organ systems
Examination The 2-4, 5-7 breakdown originated with then HCFA Medical Director, Bart McCann at the CPT Editorial Panel Advisory Committee meeting in November of 1995. Indicated that a new version of the DGs were to be released in 1996 that would reflect the 2-4, 5-7 to more clearly refine the exam requirements. Examination Many sources changed their version of the DGs to reflect the expected update that was never made official. Still sources, including many of the Medicare carriers, that use the numerical breakdown to assign a level to the exam.
NHIC Examination CIGNA E&M Tips Understand the difference between "Expanded Problem-Focused (EPF)" and "Limited" examination under 1995 guidelines. 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.
CMS unofficial response For the expanded problem focused exam a second body area/organ system must be examined. But an expanded problem focused exam and a detailed exam could also involve up to 7 body areas or organ systems. The difference in an EPF and a detailed is in the content of the exam and documentation, i.e., whether it is cursory or detailed in facts. This is a judgment call by the physician and also the reviewer. Novitas 4x4 Rule Under the 1995 guidelines both the expanded problem focused examination and the detailed examination provide for the examination of "up to 7 systems" or 7 body areas. This has led to variability in reviews utilizing the '95 guidelines, and required an interpretation for proper and consistent implementation of the E/M guidelines. By providing a tool (4 elements examined in 4 body areas or 4 organ systems satisfies a detailed examination) our reviewers and the physicians have a clinically derived tool to assist in implementing the E/M guidelines and decreasing one area of ambiguity. This is a tool that is consistent with the way medicine is practiced, as confirmed in Documentation Coding & Billing by Laxmaiah Manchikanti, M.D, and A Guide to Physical Examination by Barbara Bates, M D. And, it is a tool to reduce reviewer variability.
Novitas 4x4 Rule HGSA'S nurse reviewers follow the guidelines for auditing E/M services that are provided by CMS and the American Medical Association (AMA). This includes consideration of both the 1995 and 1997 guidelines, with the utilization of the guidelines that are most beneficial to the physician. Novitas 4x4 Rule We also instruct our nurse reviewers to use their clinical knowledge to infer from the medical record documentation what is the correct and appropriate level of care. Clinical inference overrides the "4 x 4" tool. It provides for an individual consideration, and makes the review of all services (including E/M examinations) fairer to the physician. Clinical inference is in keeping with CMS current instructions for reviewing all medical records. Again, our reviewers utilize either the '95 or the '97 guidelines when reviewing E/M services, and utilize the guidelines that benefits the provider.
MDM Controversies Additional work-up planned 2 Points for interps and/or 93010 Check box for Old records reviewed Discussion w/ another health care provider MDM variables Marshfield MDM scoring
MDM variables Trailblazer MDM scoring MDM Controversies
Determining Risk Areas You may have services that present a challenge to coders and should be closely monitored. Obs, Anesthesia, OMT, complex procedures Where coding rules have changed recently you will want to audit to assure that everyone is following the rules consistently by auditing specific coding choices You may want to monitor high $$ procedures Looking Closely at your Practice Risks You need to take a close look at your coding and documentation to be sure you will survive a third-party audit if you : Are admitting a higher number of patients, Are a trauma center and see a high number of high acuity patients, have better than average provider documentation,
Looking Closely at your Practice Risks are in a region where neighboring hospitals employ their ED physicians and don t work on improving their documentation, and/or; Have an in-house or neighboring urgent care centers that siphon off low to mid-acuity patients Have data available to demonstrate your facility s unique position within the region. Appeal, appeal, appeal Always file at least one appeal of any findings that lower the assigned E&M code or decrease the reimbursement for services rendered.
Automated review finding System edits check claims for evidence of improper coding or other mistakes Automated review finding
Automated review finding 36 claims listed on letter. 21 re: 10061 vs 10060 Filed appeals for 35 of the claims w/ 100% success. 1 claim was not appealed due inconsistent documentation of laceration length. Key Hot Spots in ED E&M E&M w/ Procedures 99283 vs 99284 99284 vs 99285 Medical necessity is the key. No longer a numbers game of counting elements.
E/M s with procedures Rationale for E&M with minor procedures Modifier -25 = significant, separately identifiable Differential diagnosis / MDM support additional service through E&M Risk (infection), pain management (not anesthetic which is included), diagnostic studies all separate from procedure package. Communicate NOPP Perform and document a descriptive HPI justifies NOPP supports Level of Risk for the presenting problem Patient and complaint specific HPI / ROS / Exam help communicate acuity Document rational / reason for diagnostic test. Protocol orders may not explain medical necessity Document reasonable differential diagnoses / clinical rationale as part of MDM.
Communicate NOPP Explain concerning diagnostic results that affect differential diagnosis or management of patient. Document consults / discussion with other providers and decisions made as a result. Repeat evaluations and rechecks demonstrate that the physicians higher level of concern. Patients discharged with specific follow-up instructions vs follow-up as needed Communicate NOPP Complicating factors = Increased complexity Infection Coumadin elevated BP severe pain Consultation extended ED course for observation of recovery/results Chronic conditions that affect treatment i.e. diabetic, etc. Living situation / social complications Clinical acuity / significance may not be obvious to a coder or auditor
Easy Targets for Refunds PA / NP services Insufficient MD documentation to support billing E&M as shared service. Billing MLP procedures as MD service. Teaching Physician Services There is not a one-size fits all attestation E&M, Procedures, Interpretations & Critical care all have different requirements. Easy Targets for Refunds Tissue adhesive repairs reported to Medicare as suture repair. Medicare requires G0168 Scribes in the ED Insufficient MD validation of scribe notes.
Todd Thomas (405) 749-2633 www.ercoder.com Todd@ERcoder.com