Advanced E/M Compliance: Risk Areas for Physician Practices March - - PowerPoint PPT Presentation
NJ HFMA CARE and Physician Practice Issues Forum Advanced E/M Compliance: Risk Areas for Physician Practices March 10, 2015 Gretchen Segado, Manager EY Fraud Investigations and Dispute Services +1 (215) 841-0377 Gretchen.Segado@ey.com Agenda
NJ HFMA CARE and Physician Practice Issues Forum
March 10, 2015 Gretchen Segado, Manager EY Fraud Investigations and Dispute Services +1 (215) 841-0377 Gretchen.Segado@ey.com
Page 2
►
Climate
►
E&M risk areas
►
New vs established patients
►
Place of service
►
Working with Non-physician Practitioners
►
Time based billing
►
EHR issues
►
Improving E&M compliance
►
Monitoring E&M trends
►
Minimizing your risk
Advanced E&M Compliance G.Segado
Page 3 Advanced E&M Compliance G.Segado
Page 4
Department of Health and Human Services Office of the Inspector General
► Medicare inappropriately paid $6.7 billion for claims for
E&M services in 2010 that were incorrectly coded and/or lacked documentation representing 21% of Medicare Part B payments for E&M services.
► 42% of claims for E/M services in 2010 were incorrectly
coded, which included both upcoding and downcoding (i.e., billing at levels higher and lower than warranted, respectively), and 19 percent were lacking documentation.
Advanced E&M Compliance G.Segado
Page 5
Department of Health and Human Services Office of the Inspector General
► Additionally, we found that claims from high-coding
physicians were more likely to be incorrectly coded or insufficiently documented than claims from other physicians.
► E&M services are 50% more likely to be paid in error than
Advanced E&M Compliance G.Segado
Page 6 Advanced E&M Compliance G.Segado
Page 7
► Has not received any professional services from the physician or
another physician of the same specialty, same group practice, within the past three years.
► Has received professional services from the physician or another
physician of the same specialty, same group practice, within the past three years.
Advanced E&M Compliance G.Segado
Page 8
► Office or other
Outpatient Services
► New and Established
Patients
► Hospital Observation
Services
► Initial Hospital Care ► Subsequent Hospital Care
► Hospital Inpatient
Services
► Initial Hospital Care ► Subsequent Hospital Care
► Consultations**
► Office of Other Outpatient
Consultation
► Inpatient Consultation
► Emergency Department
Services
► Critical Care Services ► Home Visits
► New or Established
► Preventive Visits
► New or Established
**Medicare does not recognize consultation codes
Advanced E&M Compliance G.Segado
Page 9
► a NEW patient who has not received any professional services,
i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years.
► if a professional component of a previous procedure is billed in
a 3 year time period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit.
► An interpretation of a diagnostic test, reading an x-ray or
EKG etc., in the absence of an E/M service or other face-to- face service with the patient does not affect the designation of a new patient.
Advanced E&M Compliance G.Segado
Page 10
Has the patient received any professional service from the physician or another physician in the group of the same specialty within the last three years?
Yes Exact same specialty? Yes Exact Same Subspecialty? If yes, established patient If no, new patient No New Patient No New patient. Advanced E&M Compliance G.Segado
Page 11
► Does your EHR have the ability to alert when a patient is
billed as a new patient when they have been seen during the past three years?
► Can your billing system edit a claim when a new patient
visit is billed on an established patient or vice versa
► Do you rely on patient “visit types” in a scheduling system
to pick your E&M codes?
Advanced E&M Compliance G.Segado
Page 12
► Place of Service coding errors have been identified on the
OIG Workplan frequently
► Jan 2005 audit by OIG found 88 of 100 claims billed with
POS Office that were performed in a facility setting
► POS Office has higher practice expense RVUs because of
the overhead costs
► Mismatching of POS to code category can lead to denials
► Emergency room visits are outpatient hospital POS not inpatient
► POS also is a key factor in correct billing of physician
extenders
► “Incident-to” services can only be billed in POS 11 (Office) ► Shared services never in POS 11
Advanced E&M Compliance G.Segado
Page 13
► Dr. Cardio has an office in the hospital complex. He pays
FMV value to lease the space, and the space is considered physician office space and is carved out of the hospital cost report.
► Mr. Jones sees Dr. Cardio every three months for CHF. ► While Mr. Jones is in the hospital recovering from a hip
replacement, its time for his regular visit with Dr. Cardio.
► Mr. Jones is wheeled down to see Dr. Cardio. ► How is this service billed??
Advanced E&M Compliance G.Segado
Page 14
► Is your EHR set up to capture the correct place of service
► Do you have non-physician practitioners in your practice?
If so, do they understand how to bill for their services based on the location in which they are practicing?
Advanced E&M Compliance G.Segado
Page 15
► Time must be documented for ALL CPT codes where time
is a required element, i.e. time is specified in the CPT description
► Hospital discharge day management, 30 minutes or less ► Critical care evaluation and management; first 30-74 minutes ► Medical team conference, 30 minutes or more
Advanced E&M Compliance G.Segado
Page 16
► For some E&M codes, services can be coded based on
elements documented or based on time.
► Providers can bill based on the face-to-face time spent in
counseling and coordinating care for a patient
► Physician must document amount of time spent ► Time spent in counseling and coordinating care must be
more than 50% of the total visit
► Document the content of the discussion or the
coordination(i.e. counseled patient on risks and benefits, dietary precautions, discussed surgical options, spoke with referring physician’s office, arranged for home health care)
Advanced E&M Compliance G.Segado
Page 17
► Documentation requirements:
1.
Total face-to-face time of the encounter
2.
Total counseling/coordination time
3.
Content of the counseling/coordination
► Start and stop times are not required ► Time spent performing procedures is not counted
Advanced E&M Compliance G.Segado
Page 18
► With some EHRs, time based documentation can become
just another “default”
► Does the EHR have a section where providers can
document time based services?
► How can the provider capture the content of the
counseling and coordination of care?
► If the EHR uses smart phrases or templates, have they
been reviewed by compliance?
Advanced E&M Compliance G.Segado
Page 19
► The medical record for each date of service should reflect in
indiv dividu idualiz ized documentation relevant to the medical necessity of the service or procedure rendered and/or patient care provided on that date of service
Advanced E&M Compliance G.Segado
Page 20
Eval aluatio ion and nd mana nagem emen ent serv services—In Inappr ppropr
te paymen ents
Billing and Payments. We will determine the extent to which selected payments for evaluation and management (E/M) services were inappropriate. We wi will also review multiple E/M servic vices associa iated wit with th the same providers and nd benefic icia iarie ies to to determine th the extent nt to to whi hich ch electronic or
pape per me medical cal records had had document ntation vu vulnerabil ilit
medical records with identical documentation across services. Medicare requires providers to select the billing code for the service on the basis of the content of the service and to have documentation to support the level of service reported.
(CMS’s Medicare HHS OIG Work Plan | FY 2014 Medicare Part A and Part B Page 18 Claims Processing Manual, Pub. No. 100-04,
US Department nt of Health and nd Human n Servi vices Of Office of the Ins nspe pector G Gene neral Workp kplan for for F FY2 Y2014
Advanced E&M Compliance G.Segado
Page 21
► Notes must contain all the information contributing to the level of service ► The risks…..
► Template inserts “Family history reviewed.” ► Upon auditing the note, information under the family history section was blank
► Are notes unique with patient specific documentation? ► If macros are used, is patient specific information included?
Advanced E&M Compliance G.Segado
Page 22
► Does each note stand alone? ► Does the note paint a picture of the patient’s condition? ► If I look at multiple notes from the same provider, how
alike are they?
Advanced E&M Compliance G.Segado
Page 23
► Documentation
by Exception
by Selection? (Self-populating fields)
► EHR systems with pre-populated normal values for EVERY organ system can result in
significantly higher levels of service being documented and billed, sometimes because the history and exam elements documented are not relevant to the patient’s presenting problem.
► Increases the potential for visits to look cloned ► Develop a policy to limit the number of elements that are pre-populated ► Click to check the value vs. pre-population
Advanced E&M Compliance G.Segado
Page 24
ated D Docum umentat ation o
ulat ation b by y Defaul ault
Advanced E&M Compliance G.Segado
Believe it or not, this comprehensive exam was done in an ED for a finger laceration
Page 25
► What is normal?? ► Normal can have different meaning based on frame of reference.
► Is it normal for this patient? ► Is it normal for the expected functioning of the organ system?
► Within normal limits or WNL (We never looked?)
Advanced E&M Compliance G.Segado
Page 26
Advanced E&M Compliance G.Segado
Page 27
examin ined medic ically ne necessary?
► Minimally, there must be the ability to mark an entry “not examined” (exam) or “not
asked” (ROS) or to default an entry to “blank” to be compliant.
► Some EHRs will put additional information in bold, CAPS, or in a different color to
show the provider’s additions
► Some providers don’t realize you can delete items pre-populated ► When an EHR prompts a provider to normal values, the provider may inadvertently
document an organ system as “normal” when the provider did not in fact examine the
individual organ systems may not have been asked due to a lack of relevance.
Advanced E&M Compliance G.Segado
Page 28 Advanced E&M Compliance G.Segado
Page 29
Advanced E&M Compliance G.Segado
►Copy and Paste: selecting data from an original or previous source to reproduce in another location ►Cut and Paste: removing or deleting the original source text or date to place in another location ►Copy Forward: copies a significant section of an entry or an entire prior note
Page 30
► Cut and paste should never be allowed because it alters the original source material ► Does the EHR allow copying and pasting of another providers work? another practice or
division?
► Some systems have the ability to limit this feature, but there are always workarounds.
► Is information independently confirmed? ► Typos have a funny way of showing up..
► “I have reviewed the patient’s prior lab work and imagining studies”
Advanced E&M Compliance G.Segado
Page 31
► Populating a note with outdated, conflicting, incomplete or inaccurate information ► Inability to identify the original author in the EHR
► What if the original entry was made by a medical student or RN? Would the provider be aware to
give that entry additional scrutiny?
► Notes that are repetitive, inconsistent or identical ► Note that are too long and contain irrelevant information ► False attribution of work performed by others incorporated into the current note
Advanced E&M Compliance G.Segado
Page 32
► When an EHR prompts a provider to normal values, the provider may inadvertently
document an organ system as “normal” when the provider did not in fact examine the
► When documenting the review of systems, questions about individual organ systems may
not have been asked due to a lack of relevance.
asked” (ROS) or to default an entry to “blank” ?
Advanced E&M Compliance G.Segado
Page 33
Advanced E&M Compliance G.Segado
Page 34
► Routine Auditing and Monitoring should be part of any
compliance program
► Apply a methodology of auditing that you can defend ► Build internal policies and procedures to clarify the grey areas of
coding
► Gather documentation from credible sources that support the
internal policies and procedures
►
CPT
►
CMS
►
MA
►
Third party payer guidelines, especially for E&M services
►
Standard audit tool
►
Benchmark analysis
► Hire staff with appropriate level of expertise, and invest in
continuing education, certification
Advanced E&M Compliance G.Segado
Page 35
► Medicare Documentation Guidelines:
►
Expanded Problem Focused – A limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s);
►
Detailed – An extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s);
► Novitas Documentation Guidelines
►
Detailed - 4 elements examined in 4 body areas or 4 organ systems
► American College of Emergency Physicians
Advanced E&M Compliance G.Segado Expanded problem focused 2-4 body areas or organ systems* Detailed 5-7 body areas or organ systems* *The numerical requirements for the Expanded Problem Focused Exam and the Detailed Exam were verbal instructions from CMS
Carrier policies vary regarding the definitions of Expanded Problem Focused and Detailed Exams.
Page 36
► Define how you will audit the exam portion of E&M
services for your practice
► Base it on the practices of your local Medicare carrier ► Develop written policy guidance ► Be consistent in the application of that guidance ► Other common grey areas to think about…..
► Calculating medical decision making- what is “with additional
work-up”
► Return visits only require two of three elements to code the
visit.
► Does your practice require one of these elements to be MDM?
Advanced E&M Compliance G.Segado
Page 37
► Invest in education
► Train your clinicians, once it not enough ► Have at least one person certified in coding by a national
► Train your support staff
► Get a second opinion
► Use external resources to verify that you don’t have any gaps
► Use technology
► Trending reports
Advanced E&M Compliance G.Segado
Page 38
Volume of E&M Services for January
99201 99202 99203 99204 99205 99211 99212 99213 99214 99215 Total Dr Tyler 1 10 65 25 52 153 Dr Jagger 16 15 30 20 15 32 27 155 Dr Nicks 150 150 Dr Crosby 3 12 32 21 10 2 4 27 33 144 Advanced E&M Compliance G.Segado
Page 39
Advanced E&M Compliance G.Segado
20 40 60 80 100 120 140 160 99201 99202 99203 99204 99205 99211 99212 99213 99214 99215 Dr Tyler Dr Jagger Dr Nicks Dr Crosby
Page 40
Advanced E&M Compliance G.Segado
CPT Code Description Volume >0 30020 Drainage abscess or hematoma, nasal septum 5 30100 Biopsy, Intranasal 6 30110 Excision, nasal polyps, simple 3 30140 Subcutaneous resection inferior turbinate 7 30200 Injection, turbinates, therapeutic 9 30300 Removal foreign body, Intranasal 18 45307 removal of foreign body, rectum 1 30465 Repair of nasal vestibular stenosis 5 31231 Nasal endoscopy, diagnostic 77 31233 Nasal endo, with maxillary sinusoscopy 6 31235 Nasal endo with sphenoid sinusoscopu 6 37220 Revascularization, edndovascular, open iliac artery 1 42400 Biopsy of the salivary gland, needle 4 42820 Tonsillectomy, younger than 12 16 42821 Tonsillectomy, age 12 or older 2