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Edwin J. Polverino, D.O.. Audits Internal audits Private insurance company audits for quality and accuracy. Private insurance company audits for fraud.

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Presentation on theme: "Edwin J. Polverino, D.O.. Audits Internal audits Private insurance company audits for quality and accuracy. Private insurance company audits for fraud."— Presentation transcript:

1 Edwin J. Polverino, D.O.

2

3 Audits Internal audits Private insurance company audits for quality and accuracy. Private insurance company audits for fraud and abuse. Government audits for data collection, quality and accuracy. Government audits for fraud and abuse.

4 ZPIC’s The Centers for Medicare & Medicaid Services (CMS) have added a new contractor to the health care audit program. This program has replaced two other audit contractors and consolidated benefit integrity activities. This is called the “zone program integrity contractor” (ZPIC). This is a streamlined approach that is expected to lead increased enforcement activities in to 2011.

5 ZPIC’s ZPIC’s will be responsible for ensuring the integrity of all Medicare- related claims under Parts A & B. The objective is to identify, stop and prevent Medicare and Medicaid fraud, waste, and abuse and referring instances to the appropriate law enforcement. To carry out these objectives, they are authorized to conduct audits, interview beneficiaries and providers; initiate administrative sanctions; and refer providers to law enforcement.

6 ZPIC’s Audits are never random and a provider that is selected for a ZPIC audit should understand that they are under investigation for potential fraud or they are trying to determine if a fraud investigation should be opened. An audit could be initiated several ways: use of data analysis to detect high frequency of certain services as compared to local and national patterns, trends of billing, any other information suggesting the provider is an outlier compared to his peers and audits in response to complaints.

7 ZPIC’s These audits are typically un-announced or occur with little notice. Representatives from ZPIC will sometimes visit providers on-site to conduct audits. In addition to requesting records, they may conduct interviews with the provider’s employees.

8 ZPIC’s There are three potential outcomes after an audit: 1. Refer the provider to law enforcement (OIG) 2. Refer audit results including statistical calculation of an extrapolated overpayment to provider to MAC (Medicare Administrative for collection 3. Provider education NOTE THE WORD: “Provider” in the above possible outcomes. The law is clear on this issue, this means you, not your employer.

9 ZPIC’s Providers should expect to see a significant increase in audits. To avoid an audit: Ensure you are following all Medicare policies and procedures including any applicable coverage decisions. Document fully and completely all necessary elements before submitting claims to Medicare. Periodic internal audits.

10 ZPIC’s To ensure you have a plan in place if ZPIC shows up: Designate a point person Establish specific policies Create an intake and tracking system for the audit Develop and implement a compliance program Provide training for providers on an ongoing basis

11 Questions on ZPIC?

12 With ZPIC in mind Lets talk about correct coding…………..

13 Undercoding 33% of Primary Care physicians undercode Possible reasons for undercoding: fear of violating fraud and abuse laws & misunderstanding the E&M documentation guidelines By undercoding 30% of established visits per day, you could lose approximately $340 per day or $90,400 a year.

14 Established Patient A patient that has received prior care from the physician or another physician in the practice of the same specialty in the previous three years. See top right side of encounter form

15 Documentation Requirements HistoryProblem FocusedExpanded Problem FocusedDetailed ExamProblem FocusedExpanded Problem FocusedDetailed Decision Making StraightforwardLowModerate

16 Problem Focused (Straightforward) Expanded Problem Focused (Low) Level 3 – visit Detailed (Moderate) Level 4 – visit Comprehensive (High) HistoryHistory Chief Complaint 1 fact about present illness Chief Complaint 1 fact about present illness Review of 1 system Chief Complaint 4 facts about present illness Review of 2 or more systems 1 note about past, family, social history Chief Complaint 4 facts about present illness Review of at least 10 systems Past personal history Family History Social History ExamExam 1995 – One body area or system related to problem 1995 – 2-4 systems1995 – 5-7 systems1995 – 8 or more systems Decision Making Decision Making Number of Dx or Trmt Options: One self limited or minor problem (stable). Est. Problem (to examiner) stable,improved. Amount and/or Complexity of Data Reviewed. Risk of Complications: Minimal treatment options (minor problem – eg., cold or insect bite) Minimal or not testing (simple x- rays, EKG, lab via venipuncture, ultrasound) Minimal risk (rest, gargle, bandage, dressings, etc) Number of Dx. Or Trmt Options: Est. Problem (to examiner) worsening. 2 self limited or minor problems stable/worsening. Amount and/or Complexity of Data Reviewed. Risk of Complications: Limited treatment options (stable chronic illness, acute uncomplicated illness) Limited testing (x-rays w/ contrast, lab via arterial puncture, test w/o stress) Low risk ( over-the-counter drugs), physical therapy, minor surg. W/o risk factors) Number of Dx. Or Trmnt Options: New Problem (to examiner); no w/u planned. Amount and/or Complexity of Data Reviewed. Risk of Complications: Moderate treatment options ( 2 stable chronic illnesses, acute illness with systemic symptoms, chronic w/ exacerbation, new dx w/ uncertain prognosis. Moderate testing (stress tests, deep biopsy endoscopy or CV tests w/o risk factors) Moderate risk ( prescription drug management), closed fracture care, minor surgery w/ risk factors, major surgery w/o risk factors) Number of Dx. Or Trmnt Options: New Problem to examiner add. work up planned. Amount and/or Complexity of Data Reviewed. Risk of Complications: Extensive treatment options (life threatening illness, chronic illness w/ severe exacerbation, abrupt change in neurologic status) Extensive testing (Endoscopies or CV testing w/ contrast & high risk factors) High risk (major surgery w/ risk factors, drug therapy w/ monitoring)

17 Problem Focused (Straightforward) Expanded Problem Focused (Low) Level 3 – visit Detailed (Moderate) Level 4 – visit Comprehensive (High) HistoryHistory Chief Complaint 1 fact about present illness Chief Complaint 1 fact about present illness Review of 1 system Chief Complaint 4 facts about present illness Review of 2 or more systems 1 note about past, family, social history Chief Complaint 4 facts about present illness Review of at least 10 systems Past personal history Family History Social History ExamExam 1995 – One body area or system related to problem 1995 – 2-4 systems 1995 – 5-7 systems Think 4 or level 4 as we should always include constitutional as one system in every encounter – 8 or more systems Decision Making Decision Making Number of Dx or Trmt Options: One self limited or minor problem (stable). Est. Problem (to examiner) stable,improved. Amount and/or Complexity of Data Reviewed. Risk of Complications: Minimal treatment options (minor problem – eg., cold or insect bite) Minimal or not testing (simple x- rays, EKG, lab via venipuncture, ultrasound) Minimal risk (rest, gargle, bandage, dressings, etc) Number of Dx. Or Trmt Options: Est. Problem (to examiner) worsening. 2 self limited or minor problems stable/worsening. Amount and/or Complexity of Data Reviewed. Risk of Complications: Limited treatment options (stable chronic illness, acute uncomplicated illness) Limited testing (x-rays w/ contrast, lab via arterial puncture, test w/o stress) Low risk ( over-the-counter drugs), physical therapy, minor surg. W/o risk factors) (2 out of 3 parts needed form below to meet level 4 in this section) Risk Part = ( prescription drug management, 1 chronic w/ exacerbation, 1 new w/unknown prognosis, 1 acute and systemic or complicated, 2 chronic stable. Diagnoses & Plan Part= Total of 3 points needed. (Self-limited 1p, 2p max) (Est.-stable 1p)(Est.-not controlled/worsen 2p)(New-No w/u 3p, 1 max)(New w/ w/u 4p) Data Part= Total of 3 points needed. ( Test-lab,x-ray, med 1p)(Disc. Tests w/performing doc. 1p)(Indep. review of 2p)(Obtain records or hx. 1p) (Review/summarize this data 2p) Number of Dx. Or Trmnt Options: New Problem to examiner add. work up planned. Amount and/or Complexity of Data Reviewed. Risk of Complications: Extensive treatment options (life threatening illness, chronic illness w/ severe exacerbation, abrupt change in neurologic status) Extensive testing (Endoscopies or CV testing w/ contrast & high risk factors) High risk (major surgery w/ risk factors, drug therapy w/ monitoring)

18 Legibility Medicare states the “The medical record should be complete and legible” (including your signature and printed name). Illegibility poses serious risks to patient care, jeopardizes optimal reimbursement, and carries potentially disastrous legal ramifications. If it’s not documented or it can not be read, it will not be paid for (wasn’t done?).

19 Counseling or Coordination of Care If 50% or more of the total face-to-face visit was spent counseling and/or coordinating care with the patient and/or family you can select the CPT based on time = 10 Minutes - est = 15 Minutes - est = 25 Minutes - est.

20 Counseling or Coordination of Care Counseling is a discussion with the patient or family (face to face) regarding one or more of the following areas: diagnostic results, impression or recommended diagnostic studies; prognosis; risks and benefits of management options; instructions for management or follow-up; importance of compliance with chosen management options; risk factor reduction; patient and family education. Coordination of care refers to arranging and organizing the patient’s care with other providers and agencies. It must be described. Simply stating “coordination of care” is not acceptable per Medicare.

21 Counseling or Coordination of Care You MUST document total visit time and counseling/co-ordination of care time. Describe your activities. It should be complete enough to substantiate your implied claim regarding time spent with the patient. Documentation must show why it took the time you recorded if you are using time to set the level. The time must also be reasonable and appropriate considering the nature of the presenting problem.

22 99212 CC CC: Cold HPI: HPI: Stuffy nose for 2 daysROS:PFSH: Exam: Exam: ENT MDM: MDM: Viral- Rest, fluids, return if worsens. CC: Cold HPI: Stuffy nose and sinus drainage for 2 days ROS: No Fever PFSH: Exam: Constitutional, ENT MDM: Sinusitis- Rx written, return if not wnl in 5 days

23 CC: CC: Cold with cough and wheezing HPI: HPI: Stuffy nose and sinus drainage. Nausea, cough several days, symptoms began 10 days ago. SOB with cough. ROS: ROS: Some fever and loss of appetitePFSH: Exam: Exam: Constitutional ENT Resp CV GI MDM: MDM: Bronchitis Rx written Return in 3 days if not improved, 7 days if not wnl *Exam +MDM CC: Cold HPI: Stuffy nose and sinus drainage for 2 days ROS: No Fever PFSH: Exam: Constitutional, ENT MDM: Sinusitis- Rx written, return if not wnl in 5 days.

24 99213 CC: CC: Cough/Cold/Wheezing. HPI: HPI: Stuffy nose and sinus drainage, Nausea, Severe cough several days, symptoms began 10 days ago, SOB with Cough. ROS: ROS: Some fever and loss of appetite PFSH: PFSH: Smoker Exam: Exam: Constitutional ENT Resp - Clear CV GI MDM: MDM: Patient diagnosed mild URI. OTC recommended. Return in 3 days for a re-check if not improved, 7 days if not wnl *History + Exam CC: Cold HPI: Stuffy nose and sinus drainage for 2 days ROS: No Fever PFSH: Exam: Constitutional, ENT MDM: Sinusitis- Rx written, return if not wnl in 5 days.

25 99213 CC: CC: Cough/Cold/Wheezing. HPI: HPI: Stuffy nose and sinus drainage, Nausea, Severe cough several days, symptoms began 10 days ago ROS: ROS: Some fever and loss of appetite PFSH: PFSH: Smoker Exam: Exam: Constitutional ENT Resp MDM: MDM: Patient diagnosed with Bronchitis. Rx written. Return in 3 days for a re-check if not improved, 7 days if not wnl *History + MDM CC: Cold HPI: Stuffy nose and sinus drainage for 2 days ROS: No Fever PFSH: Exam: Constitutiona,l ENT MDM: Sinusitis- Rx written, return if not wnl in 5 days.

26 99212 or 99213? Patient Name: John Doe Chief Complaint: “Osteoarthritis” HPI: 75-year-old male with a history of osteoarthritis. ROS: Constitutional symptoms – No fever, no loss of appetite. Cardiovascular – Negative for chest pain. Respiratory – No shortness of breath. Gastrointestinal – No nausea or vomiting. Genitourinary – No difficulty urinating. Musculoskeletal – Pain in joints intermittently. Integumentary – No rash. Neurological – Denies disorientation. Endocrine – No cold intolerance. Allergic/Immunologic – Positive for seasonal hay fever. PFSH: See visit record for date of service 1/1/2010.

27 Exam: Vital signs – T 98.7, P 76, R 20, BP 130/80. Head, Ears, Eyes, Nose, Throat – Oropharynx clear, no mucosal ulcerations and auditory canals clear. PERRLA. Neck – Trachea midline, supple. Lungs – Clear to auscultation bilaterally. Cardiovascular – Regular rhythm and rate. Abdomen – Soft, non-tender. Extremities – Normal. Musculoskeletal – Bilateral knees with normal range of motion, crepitus on motion, pain with ambulation rated 3 out of 10 and tenderness upon palpation. Neurologic – Oriented to time, place and person. Hematologic/Lymphatic/Immunologic – No bruising, no lymphatic swelling. Skin – Normal temperature, turgor and texture. No rash. Psychiatric – Appropriate mood and affect. MDM: Occasional joint pain. Continue same treatment Return to office in three months.

28 HPI The HPI must describe the patient’s symptoms, evolution of his illness and the present status of his condition. The HPI does not includes the following elements (location, quality, severity, duration, timing, context, modifying factors and associated signs and symptoms). This example does NOT describe the patient’s symptoms, the evolution of his illness or the status of his condition in any manner. The absence of the HPI renders this record useless for understanding the patient’s condition and the necessity. EVERY level of an E&M service requires an HPI. The comprehensive ROS and Exam exceeded the level of care needed for the patient’s presenting condition. History qualifies as Problem Focused

29 EXAM Most of the exam documentation is asymptomatic and not related to the presenting problem or affected body area. Medicare will NOT allow one body area for the knee and musculoskeletal system for the other knee. Medicare will allow one-body-part/body-area per system guidelines: Exam is problem focused.

30 MEDICAL DECISION MAKING The patients condition is the key factor in determining medical necessity. You MUST ensure your records describe the patient’s condition and reason for the visit in enough detail for a reasonable observer to understand the patients need. The patient presented with a single, chronic, well-controlled problem (LOW). The explanation of the nature of this problem is vague to even get a sense of whether this service is at all medically necessary. The problem appears to be stable. Is a three month f/u reasonable and necessary for stable osteoarthritis? Those are the questions the information in the record should address for Medicare payment to determine appropriate. Medical Decision Making qualifies as Straightforward

31 THE CPT CODE IS…. Assuming this visit was reasonable and necessary this visit qualifies as a Lack of HPI has rendered this record useless. The service should be coded based on the clinical needs of the patient. Remember the patient’s condition, START AT THE BOTTOM!!!!!!!!

32 EXAMPLES OF INSUFFICIENT DOCUMENTATION Not documenting all diagnostic tests ordered, reviewed and independently visualized. (The record must indicate the reason for ordering the tests). “Continue same treatment” can be problematic. It doesn’t reveal what treatments and for what conditions treatments are being continued. When documenting MDM, listing diagnoses or potential diagnoses without information regarding meaningful and necessary evaluation and management of each problem.

33 Thank You Questions?


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