Wednesday, November 2, 2016

How to avoid E/M errors and denials

The Centers for Medicare & Medicaid Services (CMS) says approximately 15 percent of evaluation and management (E/M) services are improperly paid and accounted for 9.3 percent of the overall Medicare fee-for-service improper payment rate in 2014. To help you avoid improper payment of your E/M claims and prevent payment denials, CMS has released a new fact sheet of compliance tips for E/M services.

According to the fact sheet, E/M claims are typically denied for two reasons: incorrect coding, such as the code not matching the documentation, and insufficient documentation, which can include a lack of a physician signature or no record of the extent and amount of time spent in counseling and/or coordination of care when it is used to qualify for a particular level of E/M service.

To prevent your E/M claims being denied, CMS recommends a number of strategies. First, in addition to the individual requirements for billing a selected E/M code, you should also consider whether the service is “reasonable and necessary.” For example, while it is possible to provide and document a level 5 office visit for a patient with a common cold and no comorbidities, it is unlikely that anyone would consider that level of service reasonable and necessary under those circumstances.

Another strategy is to remember the following key variables when selecting codes for E/M services:
•    Patient type (new or established)
•    Setting/place of service
•    The level of service provided based on the extent of the history, the extent of the examination, and the complexity of the medical decision making (i.e., the number and type of the key components performed)

Finally, the fact sheet emphasizes the need to obtain the necessary physician/non-physician provider signatures. You can find links to additional CMS resources and references at the end of the fact sheet.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Monday, October 31, 2016

Comprehensive Primary Care Plus program reopening to practices

Practices that missed the application deadline for the Comprehensive Primary Care Plus (CPC+) program will have another opportunity to apply next year.

The Centers for Medicare & Medicaid Services (CMS) recently announced it was reopening CPC+ applications for both payers and practices. Delays in the initial payer application process this summer shrunk the two-month practice application window by two weeks. Many practices felt this was not sufficient time to evaluate the program and determine if the added payment associated with CPC+ would support the amount of work necessary to comply with the program. 

In addition, at that time only one region in the original Comprehensive Primary Care initiative had achieved shared savings, which led some to believe it was not a successful program. On Oct. 17, CMS announced that four of the seven participating regions experienced net savings for 2015, the program’s second performance year.

The CPC+ program is one of the payment models recognized as an Advanced Alternative Payment Model (APM) in the final rule of the Quality Payment Program (QPP), part of the Medicare Access and CHIP Reauthorization Act. Participation in an Advanced APM offers physicians the opportunity to receive a 5 percent bonus payment.

CMS has not yet provided additional details on next year’s reopening of the CPC+ application process. In the meantime, you can learn more about the CPC+ application requirements by reviewing the original Request for Applications.

Kristen A. Stine, MSOD, Practice Transformation Strategist at the American Academy of Family Physicians

Tuesday, August 18, 2015

Avoid errors when coding pulmonary diagnostic procedures

The latest issue of the Medicare Quarterly Provider Compliance Newsletter includes a useful reminder that billing for evaluation and management (E/M) services and pulmonary diagnostic procedures provided to the same patient on the same date often requires the use of a modifier. Failure to use the appropriate modifier may result in getting paid only for the procedure and not the E/M service. Alternatively, it may result in Medicare identifying it as an overpayment and requesting repayment.

The newsletter notes that at least one Medicare recovery auditor conducted an automated review and identified overpayments associated with limited E/M services (identified by Current Procedural Terminology (CPT) codes 99211-99212) billed without modifier 25 on the same date of service as a pulmonary diagnostic procedure (CPT code range 94010-94799). According to the National Correct Coding Initiative Policy Manual for Medicare Services (especially Chapter 11, Section J.2), when a physician performs a pulmonary function study and obtains a limited history and exam, separately coding for an E/M service is inappropriate. However, if the physician performs a significant, separately identifiable E/M service unrelated to the technical performance of the pulmonary function test, the physician may report an E/M service with modifier 25 appended to the E/M code. (You can find the National Correct Coding Initiative Policy Manual in the “Downloads” section of the National Correct Coding Initiative Edits web page.)

As a reminder, you use modifier 25 to indicate that on the day you performed a procedure or service identified by a CPT code, the patient’s condition required a significant, separately identifiable E/M service above and beyond the procedure that you performed. You must document the separate E/M service consistent with CPT E/M services guidelines. Note that the E/M service may be prompted by the symptom or condition for which you provided the procedure and/or other service. As such, you do not need different diagnoses for reporting the E/M services on the same date.

Pulmonary diagnostic procedures, such as spirometry, are commonly done in family medicine in conjunction with another E/M service. When this happens, first ensure that your documentation of the E/M service supports that it can stand alone from the pulmonary function procedure (i.e., the E/M service was above and beyond the limited history and exam typically associated with the procedure). Then, append modifier 25 to the E/M service on your claim. Doing so will go a long way toward ensuring that you are appropriately paid for both services and that Medicare will not demand an overpayment from you somewhere down the road.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday, June 30, 2015

Place of service matters in Medicare billing

Last December, I reported that the U.S. Department of Health and Human Services Office of Inspector General (OIG) planned to examine place of service (POS) coding by physicians as part of its fiscal year 2015 work plan. Last month, the OIG revealed its findings: Medicare contractors overpaid physicians $33.4 million between January 2010 and September 2012 as a result of incorrect coding related to POS. Specifically, physicians were incorrectly paid for performing these services in non-facility locations, such as physician offices or independent clinics, when they were actually working at facility locations, such as ambulatory surgery centers (ASCs) or hospital outpatient centers.

The difference between a physician’s payment for services performed in the office and services performed in a facility can be significant. Physicians are paid more for professional services performed in their offices than those they perform at hospital outpatient centers and ASCs. When a physician performs in a facility like an ASC, Medicare pays the facility, not the physician, for the facility’s overhead expense. In turn, Medicare pays the physician less under the physician fee schedule because the physician did not have the overhead and much of the other practice expenses of the facility’s location of service.

In the end, it all boils down to the POS reported on the claim. When a physician provides an office-based service, the physician should bill with the correct POS code, generally a POS code 11. When a physician provides a facility-based service, the physician should bill the services with an appropriate POS code reflecting the type of facility, for example, a POS code 22 for hospital outpatient centers or a POS code 24 for ASCs.

So, what can your practice do to avoid such errors? OIG’s report made a number of suggestions, including making sure:

• Billing staff is clear about the definition of “physician’s office” or other non-facility locations and understands the need to code POS appropriately.

• Billing staff is aware that the POS code can affect Medicare payment and that inaccurate use of non-facility POS codes can mean potential Medicare overpayments.

• Billing systems are not designed to submit all physician professional service claims with a non-facility POS code.

• You implement internal controls to identify potential coding errors before claim submission.

As noted, inaccurate use of POS codes can lead to Medicare overpayments, which, in turn, can lead to overpayment recovery efforts on the part of the Centers for Medicare & Medicaid Services (CMS) and its contractors. For instance, based on its findings, OIG recommend that CMS direct its Medicare contractors to initiate, in accordance with CMS policies, the immediate recovery of $7.3 million in potential overpayments from physicians who incorrectly coded physician services performed in ASCs and $19 million in potential overpayments related to the services that may have been performed in hospital outpatient locations. That’s in addition to the $7.1 million in potential overpayments 87 physicians told CMS they intended to pay back for incorrectly coding physician services performed in hospital outpatient locations.

OIG also recommended that CMS and its contractors continue to educate physicians and billing personnel on the importance of internal controls to ensure the correct POS coding for physician services. Finally, OIG recommended stronger and wider efforts to perform coordinated data matches of non-facility-coded physician services and facility claims to identify physician services that are at a high risk for POS miscoding and recover the overpayments that are identified as a result.

All of which means a likely greater focus and scrutiny on POS coding going forward, especially since this is not the OIG’s first inquiry into POS billing.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday, May 19, 2015

More answers to questions about chronic care management

The Centers for Medicare & Medicaid Services (CMS) this month released a set of frequently asked questions (FAQs) about the chronic care management (CCM) service for which Medicare began paying this year.

The FAQs reaffirm some of what was already known about CCM and clarify other areas. For instance, regarding date of service and when to submit claims for CCM, answer No. 4 states, in part, “practitioners may bill . . . at the conclusion of the service period or after completion of at least 20 minutes of qualifying services for the service period. When the 20 minute threshold to bill is met, the practitioner may choose that date as the date of service, and need not hold the claim until the end of the month.”

The CMS FAQs also clarify the prohibition on reporting CCM for “facility” patients. For instance, answer No. 6 notes, in part, “CPT code 99490 cannot be billed . . . for services provided to [skilled nursing facility] inpatients or hospital inpatients, because the facility is being paid for extensive care planning and care coordination services.” The answer goes on to say, however, that if the patient is not an inpatient the entire month, time that is spent furnishing CCM services to the patient while he or she is not an inpatient can be counted towards the minimum 20 minutes of service time that is required to bill for that month. Several other questions and answers address when it is acceptable to report CCM under the Medicare hospital outpatient prospective payment system.

Like the CMS fact sheet on CCM, the CMS FAQs emphasize that CCM must be initiated by the billing practitioner during a comprehensive evaluation and management (E/M) visit, annual wellness visit, or initial preventive physical exam (i.e., Welcome to Medicare visit). During an open door forum call for physicians, nurses, and allied health professionals on May 13, CMS staff clarified that, for purposes of CCM, “a comprehensive E/M visit” could be any face-to-face E/M service with a physician, including 99212-99214.

For more information on Medicare’s CCM service, including links to related content in Family Practice Management, check out the related web page on the American Academy of Family Physician’s web site.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family 

Tuesday, December 2, 2014

OIG to focus on place of service coding by physicians

As part of its Fiscal Year 2015 work plan (which began Oct. 1), the Health and Human Services Office of Inspector General (OIG) says it will examine place of service coding errors by physicians. Specifically, the OIG will review physicians’ coding on Medicare Part B claims for services performed in ambulatory surgical centers (ASCs) and hospital outpatient departments to determine whether they properly coded the places of service. Here’s what you need to know to avoid such errors in your practice:

Prior OIG reviews determined that physicians did not always correctly code places of service on Part B claims submitted to and paid by Medicare contractors. Federal regulations provide for different levels of payments to physicians depending on where services are performed. In particular, Medicare pays a physician more when a service is performed in a non-facility setting, such as a physician’s office, than it does when the service is performed in a hospital outpatient department or, with certain exceptions, in an ASC.

The correct place of service code for a service provided in a physician’s office is “11.” The Centers for Medicare & Medicaid Services (CMS) defines an office as a “location, other than a hospital, skilled nursing facility, military treatment facility, community health center, state or local public health clinic, or intermediate care facility, where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.”

The correct place of service code for a hospital outpatient department is “22.” CMS defines this place of service as “a portion of a hospital (that) provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.”

Finally, the correct place of service code for an ASC is “24.” CMS defines the ASC place of service as “a freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis.”

So be careful and accurate because reporting place of service code 11 when either code 22 or 24 is more appropriate will likely result in a Medicare overpayment.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday, November 25, 2014

Comparative Billing Reports: what do they mean?

Family physicians have recently received Medicare comparative billing reports (CBRs) from Medicare contractor eGlobalTech. These reports measure an individual physician’s use of CPT codes 99211 through 99215 (established patient office visits) and CPT modifier 25 (a significant, separately identifiable evaluation and management service by the same physician on the same day). The reports have raised some questions and concerns, which I’ll try to address.

First, CBRs are nothing new. EGlobalTech has sent out eight other CBRs this year alone in other specialties such as podiatry, neurology, and pathology.

The CBR is very clear that it is for educational purposes only, showing how the recipient compares to his or her peers at both the state and national level in terms of using 99211-99215 and modifier 25. As noted in the frequently asked questions on eGlobalTech's web site, "The goal of these reports is to offer a tool that helps providers better understand applicable Medicare billing rules and improve the level of care they provide to their Medicare patients." It is not to suggest that the physician is necessarily billing incorrectly. To the best of my knowledge, no one in Medicare is using CBRs to deny claims or force physicians to downcode.

As part of the current CBR, eGlobalTech does calculate an "average allowed minutes per visit" using the typical times for 99211-99215 (as printed in CPT) multiplied by the number of times each of those codes was billed and then dividing by the sum of all 99211-99215 billed. It is a proxy that attempts to represent with a single number the physician's place in a bell curve for 99211-99215 use. Neither Medicare nor its contractor know how much time the physician actually spent on a given visit, and there is no suggestion in the CBR that the physician could not have done the number of services billed based on this average time.

For example, a CBR may show the physician billing 99214 and modifier 25 to Medicare at a rate significantly higher than that for his or her state or the country. There may be legitimate reasons for this, including the health status of the Medicare patients that the physician typically sees. As long as the physician's documentation supports the level of evaluation/management (E/M) service billed and the reporting of modifier 25 when used, there is no need for the physician to change what he or she is doing or what is reported to Medicare.

To ensure that their documentation supports what they bill to Medicare, physicians or someone on their practice staff should review their notes for a sample of the practice's Medicare E/M claims (with and without modifier 25). Actually, they may want to do this even if their CBR shows they are billing at a significantly lower rate than other family physicians because that may indicate that they are underreporting their services and depriving themselves of appropriate payment.

Additional information on the current CBR is available on the contractor’s web site, and the contractor will be hosting a related webinar on Dec. 10. A recording of the webinar will be available on Dec. 15 for those who cannot listen to the webinar live.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday, July 22, 2014

Improve the chances of your Medicare claims for obesity counseling

The most recent issue of the Medicare Quarterly Provider Compliance Newsletter said that documentation for obesity counseling has led to numerous instances of overpayment and other errors. Here’s what you need to know to ensure your documentation passes muster in an audit.

First, Medicare covers and pays for behavioral counseling for beneficiaries with obesity, measured as a body mass index (BMI) of 30 kg/m2 or greater. Specifically, obese Medicare beneficiaries are eligible for:

•    One face-to-face visit every week for the first month;
•    One face-to-face visit every other week for months 2-6; and
•    One face-to-face visit every month for months 7-12, if the beneficiary achieves the required weight loss.

Per Medicare, beneficiaries must be competent and alert at the time that they receive counseling, and the counseling must be furnished by a qualified primary care physician or other primary care practitioner in a primary care setting. Additionally, at the six-month visit, the beneficiary should receive a reassessment of obesity and a determination of the amount of weight loss. To be eligible for additional face-to-face visits occurring once a month for during months 7-12, beneficiaries must achieve documented weight loss of at least three kilograms (6.6 lbs.) during the first six months of intensive therapy.

Obesity counseling is reported with Healthcare Common Procedure Coding System (HCPCS) code G0447, “Face-to-face behavioral counseling for obesity, 15 minutes.” Medicare reviewers conducted a special study of HCPCS code G0447. Upon review, they determined that insufficient documentation caused approximately 92 percent of the improper payments. Examples of “insufficient documentation” included:

•    No physician’s signature on the encounter note
•    No documentation of the patient’s clinical condition
•    No documentation that the beneficiary has a BMI greater than or equal to 30kg/m2
•    No documentation that after six months the beneficiary lost 6.6 pounds or 3kg
•    No documentation that obesity counseling and dietary assessment actually occurred

So, to help improve the chances that your claims for obesity counseling will stand up to Medicare scrutiny, you need to document the patient’s clinical condition and qualifying BMI. You also need to document how much weight the patient has lost at the six-month mark and the counseling and dietary assessment that occurred at each visit. Finally, don’t forget to sign the encounter note when you’re done.

Medicare covers intensive behavioral therapy for obesity per National Coverage Determination 210.12. You can learn more about this benefit and the associated rules by reading section 200 of chapter 18 in the Medicare Claims Processing Manual as well as the Medicare Learning Network Matters article on obesity counseling.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday, March 27, 2014

CMS institutes a reprieve in RAC operations

The Centers for Medicare & Medicaid Services (CMS) is in the middle of processing the next round of Recovery Audit Program contracts. To make sure the current Recovery Audit Contractors (RACs) complete their work before the current contracts expire, CMS has announced that it will wind down some of the RACs' operations.

Specifically, CMS says the RACs were to cease sending pre- and post-payment additional documentation requests (ADRs) by the beginning of March and review the ones they already have. RACs have until June 1, 2014, to send improper payment files to Medicare administrative contractors for adjustment.

As a reminder, if you have received an ADR from a RAC, you have 45 days to respond to it. The RACs, in turn, have up to 60 days to make a determination on the claim.

Besides giving the RACs time to complete their work, the CMS said the pause in RAC operations will allow it to continue refining and improving the Medicare Recovery Audit Program. For example, CMS is reviewing the ADR limits, timeframes for review, and communications between RACs and physicians. CMS has already announced a number of changes it plans to make to the RAC program with the next round of contractor awards. CMS invites physicians with additional questions to send them to for answers.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday, February 18, 2014

HHS inspectors to review Medicare coding problems in 2014

It's a few months later than normal, but the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has finally released the list of areas its auditors will target this year.

The OIG usually releases the document in the fall. However, the agency delayed its release until now to better align with priorities that the HHS has set for the year.

Some of the items in the 2014 Work Plan will be of interest to family physicians.

First, OIG will look into reports from Medicare contractors who say they've seen an increase in providers filing medical claims for different evaluation and management (E/M) services but using identical documentation. Medicare requires providers to select the billing code for a service on the basis of the unique content of the particular service and have documentation to support the level of service reported. The agency said it plans to review multiple E/M services associated with the same providers and beneficiaries to determine the extent of documentation vulnerabilities – and potentially inappropriate payments.

The OIG will also review the extent to which physicians and suppliers participated in Medicare and accepted claim assignment during 2012. As part of that review, OIG will assess the effects of participation and claim assignments on the Medicare program, such as noncompliance with assignment rules, and on beneficiaries, such as excessive billing of beneficiaries’ share of charges.

Third, OIG will review physicians’ coding on Medicare Part B claims to make sure they provided the proper place of service codes for services performed in ambulatory surgical centers and hospital outpatient departments. Prior OIG reviews have found a problem with incorrect coding of place of service on Part B claims. Mis-coding can have a big effect on program payments because Medicare pays a physician more when a service is performed in a non-facility setting, such as a physician’s office, than it does for services performed in a hospital outpatient department or, with certain exceptions, an ambulatory surgical center.

For a full list of issues, including others that may be relevant to your particular practice, consult the complete OIG 2014 work plan online.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday, January 16, 2014

Recovery auditors focus on Annual Wellness Visits

Do you provide Annual Wellness Visits (AWV) to your Medicare patients? Are you aware of the different codes to report the visit, depending on whether the patient has had one before? Medicare’s recovery audit contractors (RACs) are apparently finding that some physicians aren't, and that's leading to Medicare overpayments.

The Centers for Medicare and Medicaid Services (CMS) highlights this issue in the January 2014 edition of its Medicare Quarterly Provider Compliance Newsletter. In the newsletter, CMS notes that Medicare pays for an "initial" AWV for each beneficiary once in their lifetime. All successive AWVs must be billed as "subsequent" AWVs. The corresponding billing codes are:

    •    G0438 – Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit
    •    G0439 - Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit

Unfortunately, the RACs have reported finding multiple instances of physicians billing G0438 more than once for the same beneficiary.

For more information on Medicare’s rules related to the AWV, check out section in Chapter 12 of the Medicare Claims Processing Manual as well as Medicare’s quick reference guide and booklet on the AWV. You can also find information on the AAFP’s web site through Family Practice Management's article collection on this topic.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday, November 8, 2013

Billing E/M services with allergy procedures is getting Medicare's attention

If you routinely bill evaluation and management (E/M) services with allergy testing or allergy immunotherapy, expect to receive increased scrutiny from Medicare in the future.

The latest issue of the Medicare Quarterly Provider Compliance Newsletter highlights that recovery auditors have identified this type of coding combination as a potential problem, resulting in what auditors determined were overpayments.

According to the Medicare Claims Processing Manual (Chapter 12, Section 200, subsection C), to receive payment for a visit service provided on the same day that you also provide an allergen immunotherapy service (i.e., any service in the series from 95115 through 95199), you must bill a modifier 25 with the visit code. This indicates that the patient’s condition required a significant, separately identifiable visit service above and beyond the allergen immunotherapy service you provided. The newsletter also notes that obtaining informed consent is included in the immunotherapy service and should not be reported with an E/M code.

Medicare assumes that allergy injections are typically pre-scheduled and that no other services beyond the injection are usually scheduled at the same encounter. Also, Medicare doesn't believe an E/M code is needed to report the minimal amount of work used to determine if the patient is fit to undergo an allergy injection, believing the injection code already includes that work. However, Medicare recognizes that things don’t always go according to schedule, and you may properly bill for these significant, separately identifiable services using modifier 25 for claims processing.

To see if you're potentially running afoul of these rules, Medicare recommends that physicians pull the documentation for a sample of past instances where they billed Medicare for E/M services tied to scheduled services and compare the “visit intent” against the content of the notes.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Wednesday, October 24, 2012

Audit alert: Notable items in the 2013 OIG work plan

Oct. 1, 2012 represents the start of the federal fiscal year. That makes now a good time to look at the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) work plan for the current fiscal year, especially as it relates to physician services under the Medicare program. Knowing what the OIG is examining can sometimes provide a useful “heads up” on issues that Medicare itself may focus on during the coming 12 months.

First, OIG has no fewer than five items on its work plan aimed at diabetes testing supplies:

  • Supplier compliance with payment requirements for blood glucose test strips and lancets,
  • Effectiveness of system edits to prevent inappropriate payments for blood-glucose test strips and lancets to multiple suppliers,
  • Potential questionable billing for test strips in 2011,
  • Improper supplier billing for test strips in competitive bidding areas,
  • Supplier compliance with requirements for nonmail order claims.

Although most of these items are aimed at suppliers, it is reasonable to expect that such attention may prompt those suppliers to be more demanding of physician prescribers. Given the incidence of diabetes among family medicine patients, family physicians are among the most common prescribers of such supplies.

For those practices that have office laboratories, the OIG’s work plan has at least three items of interest:

  • Billing characteristics and questionable billing in 2010,
  • Reasonableness of Medicare payments compared to those by state Medicaid and Federal Employees Health Benefit programs,
  • Part B payments for glycated hemoglobin A1C tests.

Finally, in the particular area of physician services, the following items stand out:

  • Noncompliance with assignment rules and excessive billing of beneficiaries,
  • Error rate for incident-to services performed by nonphysicians,
  • Place-of-service coding errors,
  • Evaluation and management (E/M) services—potentially inappropriate payments in 2010.

Regarding the last item on this list, the OIG work plan states:
We will determine the extent to which the Centers for Medicare & Medicaid (CMS) made potentially inappropriate payments for E/M services in 2010 and the consistency of E/M medical review determinations. We will also review multiple E/M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. Medicare requires providers to select the code for the service on the basis of the content of the service and have documentation to support the level of service reported.

The OIG’s review will focus on 2010 services, but it is reasonable to expect that this will be an area of focus going forward. Since E/M services represent the “bread and butter” of family medicine, and in light of the increasing use of EHRs in family medicine practices, this is one area that probably merits an internal review for most family medicine practices now and in the future.

Of course, the OIG’s work plan is more extensive than just the items listed above, so a scan of the table of contents for that work plan would probably be in order to see if there are other items that may be relevant to your particular practice.  Explanations of all items are included in the OIG work plan.

–Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday, September 27, 2012

Recovery audit contractors get a new fishing license

In a previous blog post, I discussed the Centers for Medicare & Medicaid Services’ (CMS) decision to allow one of its recovery audit contractors (RAC), Conolly, to begin auditing claims for evaluation and management codes, specifically code 99215. Earlier this month, the U. S. Court of Appeals for the 9th Circuit gave RACs and other Medicare contractors even more discretion in this regard. Specifically, in Palomar v. Sebelius, D.C. No. 3:09-cv-00605-BEN-NLS (Sept. 11, 2012), the court upheld that a decision by a RAC to reopen a Medicare claim for complex review was not reviewable.

The Palomar case involved a RAC's determination that services provided to a Medicare beneficiary were not reasonable and necessary. The claim in question was more than one year old and could only be reopened for "good cause" under Medicare regulations. All of the reviewers that examined the case agreed with the RAC's determination regarding medical necessity. However, the administrative law judge who reviewed the RAC determination concluded that there was not good cause to reopen the claim and reversed the RAC decision.

On appeal, the Medicare Appeals Council (MAC) reversed the administrative law judge decision. The council ruled that the Medicare regulation at 42 C.F.R. § 405.980(a)(5) makes a Medicare contractor's decision to reopen a claim unreviewable. Both the U.S. District Court and the U.S. Court of Appeals for the 9th Circuit affirmed this opinion. The courts held that the regulation expressly forecloses jurisdiction to review the reopening decision and that providers may only appeal the substance of a contractor's overpayment determination (e.g. whether or not the services were reasonable and necessary).

The Secretary for the U.S. Department of Health & Human Services argued that the review of contractors' compliance with the regulations is solely a matter for CMS's performance evaluations of the contractors. That leaves physicians at the mercy of CMS’s ability to manage its contractors.

Additionally, because the RACs get a cut of every overpayment that they find, they have incentive to reopen claims whether or not "good cause" exists under the Medicare regulations. This is especially true because most determinations finding an absence of medical necessity are based on a lack of documentation, and because it will be harder to find documentation and testimony to support older claims.

The "good cause" requirement was an important source of protection against contractor fishing expeditions. Unfortunately, the Palomar decision just gave RACs and other Medicare auditors a virtually unlimited fishing license going forward.

–Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday, September 18, 2012

Putting E/M services on the RAC

In July, I posted about a report from the U.S. Department of Health & Human Services Office of the Inspector General (OIG) which found that from 2001 to 2010, physicians increased their billing of higher level evaluation and management (E/M) codes in all types of E/M services. In that post, I encouraged you to make sure that your documentation supports the level of E/M services that you are billing. With the OIG paying attention, the Centers for Medicare & Medicaid Services (CMS) were likely to follow suit, and you needed to be prepared.

Well, it appears that CMS was paying attention, or at least its recovery audit contractors (RACs) were. This week, CMS alerted the American Medical Association (AMA) that it has approved the Medicare Region C RAC. The contractor for Region C,  Connolly, is to begin conducting audits of coding for E/M services in physician offices, specifically CPT code 99215. According to the AMA, in the next several weeks Connolly will begin a complex medical review of code 99215 and will be permitted to extrapolate their findings based on a statistical sample of such claims. Connolly is the Medicare fee-for-service RAC contractor who conducts RAC audits in the following states:

  • Ala.
  • Ark.
  • Colo.
  • Fla.
  • Ga.
  • La.
  • Miss.
  • N.M.
  • N.C.
  • Okla.
  • S.C.
  • Tenn.
  • Texas
  • Va.
  • W.Va.
  • Puerto Rico
  • U.S. Virgin Islands

However, it has not yet been announced if all or only a subset of these states and territories will be under review. As of this writing, Connolly has not posted this information and other details of the review on its website. These reviews are expected to begin imminently in Region C and, according to CMS, are likely to be approved in other Medicare regions in the near future. 

The American Academy of Family Physicians, the AMA, and 100 other state and specialty societies sent a letter to CMS in March 2009 strongly opposing RAC audits of E/M services. However, the OIG report apparently encouraged CMS, through its RAC auditors to do otherwise.

So, what's a family physician to do? I would argue that the advice given in my July post still applies:  make sure that your documentation supports the level of E/M services that you are billing to Medicare. If you are subjected to a RAC audit, take some solace in the fact that, according to CMS' FY 2010 Recovery Auditor Report to Congress, 46 percent of the Medicare RAC determinations that were appealed were decided in the provider's favor. That means you have almost a 50/50 chance of prevailing in the long run. Of course, as John Maynard Keynes once observed, "In the long run, we are all dead." Hopefully, the prospects for physicians in this case are a bit more optimistic.

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