Why is the government ramping up RAC audits? Health care fraud costs US Taxpayers $60 Billion a year. Federal Agents charged close to 1,500 people last year alone.
Ever wonder why the government is spending more and more money on RAC audits and other fraud detection and deterrence initiatives? Each year it seems the Department of Justice and Office of Inspector General uncover more and more shocking examples of fraud and abuse. In the last year alone the feds have arrested con artists who steal Medicare numbers from the elderly in order to submit false claims, doctors that prescribe excessive amounts of controlled substances so they can sell them on the streets, even some who steal federal grant money intended for cancer or autism research. Not only are these acts deplorable and morally reprehensible because they steal money that is intended for the disadvantaged, the poor, and the sick - these criminals cost US Taxpayers $60 Billion (with a B) a year. Tom Costello contributed this report this morning on the Today Show. Be sure to assess your practice for any compliance risks, implement a strong compliance policy, and maintain it. If you uncover any concerns about fraud or abuse, be sure to contact a compliance expert and consider self-disclosure. With the amount of federal dollars being recouped each year (last year alone the federal government recouped $4.5 Billion in fines, penalties, and restitution) you can rest assured that the government will be ramping up its efforts.
Mike Enos, CPC, CPMA, CEMC and Nancy Enos FACMPE CPMA, CEMC, CPC-I, CPC have authored a series of articles published in MGMA's Connexion Magazine. The September issue featured the first part in the Code of Conduct Section, and Part 2 has now been published in the October edition.
In the September article EMR Risk- If it wasn't done, don't document it: Tackling E&M coding errors in the age of EHR's we explored the growing trend of overdocumentation made easier by EMR's. We discussed the causes and risks associated with overdocumentation, as well as proper ways of documenting lengthy visits to make sure you are reimbursed appropriately. In this article, we investigate the pitfalls and risks related to overdocumentation and cloned notes specifically.
Cloned notes (using the exact same verbage from patient to patient), copied notes, and automatically generated notes should be examined closely, and physicians should be trained on how to delete, correct, and authenticate the contents of their notes to ensure that the notes actually reflect the services provided, and nothing more. Often times in copy-and-paste notes, or other EMR notes where information from previous services are "pulled forward" into the note, we find information that is erroneous, superfluous, and sometimes directly contradictory with what is described in the history of present illness or the examination.
EHR's that have a "coding tool" can be especially risky, when the level is calculated based on data elements, and not medical necessity.
CMS has approved complex audits of high level E/M services, following their May 2012 Report on improper billing and coding of high level Evaluation and Management Services.
Connolly has today posted on their web site their new audit scope related to E&M audits:
Impacts: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia.
Last week the OIG released a report: http://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf. on the utilization of codes for Evaluation and Management Coding.
The data shows a sharp increase in level 4 and level 5 E/M utilization over the last decade. The study’s authors don’t point to any evidence of improper billing, but they do send the names of the 1,700 highest-billing physicians to CMS and recommend that CMS send those names to the MACs for review and possible recoupment of any overpayments.Coders, have you come across any practices that might fall into that high-billing territory and if so, do you see any habitual billing errors at those practices? Also, should those practices that have always played it safe see this report as a sign that they should continue to do so?
The increased adoption of EMR's may be leading primary care and internal medicine practitioners to code at a higher level, with the assurance that they have a structured, complete note. This may justify an increase in their coding and they are no longer undercoding and losing the practice money by playing it safe.
The other side of the coin is that use of EMR templates may lead to cloned notes, creating a higher level of documentation that is not always supported by medical necessity. Remember, these tools can help in creating text, but each note should be authentic. Every element of History of Present Illness (HPI) must be documented personally by the provider, and every element of Review of Systems (ROS) and Physical Exam should be justified (for medical necessity) in the HPI. Risk based coding puts the emphasis on the type of medical decision making, which should always agree with the level selected.
The best way to prevent fraud is to have an annual chart audit performed by a qualified, independent auditor. The American Academy of Professional Coders has a certification program and exam for Certified Professional Medical Auditor (CPMA) to ensure understanding of the criteria for chart auditing and provider feedback. To learn more, contact Nancy Enos at firstname.lastname@example.org
OIG 2012 Work Plan Summary of Physician billing errors under scrutiny
The 2012 OIG Work Plan has been published (http://oig.hhs.gov/reports-and-publications/archives/workplan/2012/Work-Plan-2012.pdf). Practices should review the issues under review and ensure that these risk areas are included in their Compliance Program, continuing education and audit projects in order to detect and prevent fraud and correct any potential risks. The following list is excerpted from the work plan:
Place of service
OIG will review physicians’ coding on Medicare Part B claims for services performed in ambulatory surgical centers and hospital outpatient departments to determine whether they properly coded the places of service. Federal regulations provide for different levels of payments to physicians depending on where services are performed. (42 CFR § 414.32.) Medicare pays a physician a higher amount when a service is performed in a nonfacility 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 ambulatory surgical center.
OIG will review physician billing for “incident-to” services to determine whether payment for such services had a higher error rate than that for non-incident-to services. OIG will also assess CMS’s ability to monitor services billed as “incident-to.” Medicare Part B pays for certain services billed by physicians that are performed by nonphysicians incident to a physician office visit. A 2009 OIG review found that when Medicare allowed physicians’ billings for more than 24 hours of services in a day, half of the services were not performed by a physician. OIG also found that unqualified nonphysicians performed 21 percent of the services that physicians did not perform personally.
Incident-to services represent a program vulnerability in that they do not appear in claims data and can be identified only by reviewing the medical record. They may also be vulnerable to overutilization and expose Medicare beneficiaries to care that does not meet professional standards of quality. Medicare’s Part B coverage of services and supplies that are performed incident to the professional services of a physician is in the Social Security Act, § 1861(s)(2)(A). Medicare requires providers to furnish such information as may be necessary to determine the amounts due to receive payment. (Social Security Act, § 1833(e).) (OEI; 00-00-00000; expected issue date: FY 2013; new start)
E/M trends in coding of claims
OIG will review evaluation and management (E/M) claims to identify trends in the coding of E/M services from 2000-2009. OIG will also identify providers that exhibited questionable billing for E/M services in 2009. Medicare paid $32 billion for E/M services in 2009, representing 19 percent of all Medicare Part B payments. Providers are responsible for ensuring that the codes they submit accurately reflect the services they provide. (CMS’s Medicare Claims Processing Manual, Pub. No. 100-04, ch. 12, § 30.6.1.) E/M codes represent the type, setting, and complexity of services provided and the patient status, such as new or established. (OEI; 04-10-00180; expected issue date: FY 2012; work in progress)
E/M during global period (Modifier 24)
OIG will review industry practices related to the number of E/M services provided by physicians and reimbursed as part of the global surgery fee to determine whether the practices have changed since the global surgery fee concept was developed in 1992. Under the global surgery fee concept, physicians bill a single fee for all of their services that are usually associated with a surgical procedure and related E/M services provided during the global surgery period. The criteria for global surgery policy are in CMS’s Medicare Claims Processing Manual, Pub. 100-04, ch. 12, § 40. (OAS; W-00-09-35207; various reviews; expected issue date: FY 2012; work in progress)
E/M improper documentation due to cloned notes, identical documentation
OIG will assess the extent to which CMS made potentially inappropriate payments for E/M services and the consistency of E/M medical review determinations. OIG 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 based upon the content of the service and have documentation to support the level of service reported. (CMS’s Medicare Claims Processing Manual, Pub. No. 100-04, ch. 12, § 30.6.1.) (OEI; 04-10-00181; 04-10-00182; expected issue date: FY 2013; work in progress)
Providers are responsible for auditing and monitoring their documentation and billing activity and should have an annual audit as a baseline. For more information, contact Nancy Enos Medical Coding at www.nancyenoscoding.com