2. The Pre-Payment audit of 99285 applies to Florida First Coast Providers. Audits are usually picked up by other payers. Georgia Update

3.  “In response to continued CERT errors and risk of improper payments First Coast will implement a prepayment audit for CPT 99285. This will apply to claims submitted on or after 6/13/2016. This applies to all providers”  http://medicare.fcso.com/Medical_review/03358 75.asp http://medicare.fcso.com/Medical_review/03358 75.asp  Above also includes physician billing guidelines

4.  ER E/M Level  Highest level other than Critical Care  Errors include inappropriate use of 99285 in comparison to other E/M levels and insufficient documentation to support the level of care

5.  No national guidelines  “We will hold each facility accountable for following its own system for assigning the different levels of HCPCS codes. As long as the services furnished are documented and medically necessary and the facility is following its own system, which reasonably relates the intensity of hospital resources to the different levels of HCPCS codes” ◦ CMS, -65 FR 18451, April 7, 2000

6.  2008 OPPS Final Rule gave 11 standards for E/M assignment for hospitals ◦ Follow CPT description and intent and relate or to the intensity of hospital services ◦ Based on hospital not physician resources ◦ Must be clear for compliance purposes and audits ◦ Meet HIPAA requirements ◦ Require clinically necessary documentation ◦ Don’t facilitate up-coding

7.  Standards continued: ◦ Must be written or recorded, well documented and provide the basis for code selection ◦ Applied consistently ◦ Should not change frequently ◦ Readily available for MAC/FI review ◦ Result in coding decisions that can be verified by hospital staff and outside resources

8.  First Coast is also doing pre-payment audits for the following E/M codes: ◦ 99232 ◦ 99233 ◦ 99222 ◦ 99223 ◦ 99291 ◦ 99204 ◦ 99205 ◦ 99215 ◦ http://medicare.fcso.com/Publications_B/0336180. pdf http://medicare.fcso.com/Publications_B/0336180. pdf

9.  Current Pre-payment reviews for GA ◦ 83880 B-type Natriuretic Peptide (BNP) (IP, OBS) ◦ This service is considered reasonable and necessary for establishing the diagnosis of CHF in acutely ill patients. ◦ Should be ordered in ER or MD Office ◦ Not to be used for monitoring the efficiency of treatment for CHF or tailoring therapy for CHF

10.  Looking at and finding errors with physician E/M billing.  Both in the hospital and in the office  They are comparing physician billing with the inpatient progress notes and finding that the bills don’t match the documentation  They are also down coding office visits due to documentation  1995 E/M guidelines, CPT 2015, and PUB 100-04, Chapter 12§ 30.6.1(Selection of Level of Evaluation and Management Service).

11.  They are reviewing drug screens for documentation of illicit drug use or non-compliance  They are finding missing orders and missing documentation  Make sure to review the information being sent in response to ADRs ◦ Signed order ◦ Documentation of medical necessity ◦ Documentation of MD intent to do testing (Progress notes)

12. Final rule has not been published Are you getting ready?  Create a written discharge planning policy with the help of all departments and physicians  Start with making sure the D/C plan is started within 24 hours of admission.  Develop community resources and contacts