This two-part series focuses on the recent report by the Center for Public Integrity which revealed a growing trend in billing for higher level Medicare patient visits among doctors. Many are blaming the increased use of EHRs. In Part 1, we examined the problem and some of the causes. In this second of two parts, we discuss actions planned by CMS in response to these studies, as well as what physicians can do to avoid the ire of the federal government.
As a result of the May OIG report about the rising levels of service being billed for Medicare patients, Marilyn Tavenner, acting administrator of the Centers of Medicare and Medicaid Services (CMS), planned to develop and issue a Comparative Billing Report to 5,000 physicians across the country who were identified as outliers for their high levels of billed Evaluation and Management (E&M) codes. Additionally, Tavenner planned to direct Medicare Administrative Contractors (MACs) to focus on the top 10 high billers in each jurisdiction for review. With the average E&M error at around $43, and the cost to audit each claim at anywhere from $30 to $55, though, CMS said it is weighing the costs of more extensive audits.
Several medical provider organizations were notified by CMS in early September, however, that one Recovery Audit Contractor, Connolly, was approved to begin complex medical reviews of E&M codes, particularly level five established patient office visits.
The AMA sent a letter to CMS vehemently opposing such audits, saying that they will “lead to erroneous recoupments and lengthy, expensive appeals for both physicians and CMS,” will “result in erroneous RAC outlier determinations and waste CMS resources,” and will undermine CMS’s stated goal to “strengthen and support high quality, patient-centered care.”
With these recent trends in E&M billing and healthcare’s critical mass of EHRs, physicians must be certain that their documentation of patient visits and procedures supports the level of service being billed. According to CIPROMS, Inc., Coding Liaison Cara Geary, educating physicians and coders on appropriate documentation, and keeping track of instances when visits were actually downcoded for being poorly documented, keeps everyone on the same page about what is required.
“Now more than ever, it is imperative that patient charts reflect physician decision-making,” Martin Merritt wrote in “Medical Records: Detail Physician Decisions in Every Chart” for Physicians Practice. “Proper assignment of CPT and ICD-9 codes is only half the battle. The chart should reflect why the code was assigned.”
Also, an auditing program that includes both internal and external audits for entire practices and for each coder is an important part of avoiding the attention of government contractors, Geary said. Comparing group averages of E&M use to national averages, and individual physician averages to group averages, maintains accountability and ensures accurately documented and coded charts.
Additionally, E&M coding should be monitored before and after transitioning to an EHR, says Karen Zupko, in “Upcoding: Is Your EHR Putting You at Risk?” (free log-in required). She also recommends periodic audits of documentation within the EHR to look for possible cloning.
Lucien Roberts says it best, however, in an article for Physician’s Practice, “Avoid Medicare Fraud Claims by Coding Correctly”: “What the feds consider ‘fraud’ is much broader than your definition . . . . Don’t let your practice be caught up in Medicare’s recovery program. It’s a simple matter to examine your own coding patterns and compare them to national utilization data collected by Medicare.”
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