9/15/2015. Learning objectives. Coding and compliance. Coding Compliance for the IDS Environment. Could Your Coding be Costing You Money?

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Coding Compliance for the IDS Environment

Could Your Coding be Costing You Money?

Nancy Enos, FACMPE, CPC-I, CPMA, CEMC MGMA 2015 Annual Conference

Learning objectives

1. Discover how administrators of physician practices can work with hospital administration to create a culture of compliance for the physician practices

2. Outline the importance of individual physician coding benchmarking to assess risk

3. Analyze physician compensation plans that are incentive based and how to avoid coding fraud and abuse

Coding and compliance

• The relationship between a hospital and physician practice can often lead to important coding and compliance risks falling through the cracks.

• Day to day operational issues in hospital based clinics can have a negative impact on charge capture and documentation completion, leaving the system open to penalties in the event of a compliance investigation.

• Many hospitals fail to provide auditing, monitoring, and education to providers.

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Auditing and monitoring

• Auditing and monitoring is the first element of a compliance program.

• The OIG defines an effectivecompliance program as one that is designed to detect and prevent fraud.

• Does your compliance program have an audit protocol that will expose hidden problems?

Benchmarking

You have to measure before you can manage. Benchmark each division/specialty

• Benchmark individual providers • Compare to MGMA or CMS data

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Beyond the benchmark

Trouble may be hidden outside the “highly utilized codes” –Office notes and hospital notes should be reviewed –Coding should be scrutinized for “missing codes”

Ex: 99291 and 99292, or 99238 and 99239 –Audit selection based on benchmark data

CPT Code Units % Audit Sample 99212 117 17% 3 99213 42 6% 1 99395 68 10% 1 99396 392 57% 9 99397 42 6% 1 15

Documentation variables

• When providers see patients outside the clinic or office, and use alternate methods of documentation

–Lack of training or appropriate templates –Multiple EMR’s in use

• Nursing home visits • Bedside procedures • Wound care centers • Home visits

• Satellite offices that do not have access to EHR

“Extra” services

Office procedures that are not specifically documented, but only mentioned in the physical exam (pap smear) or worse, in the assessment and plan (debridement was done..) and a CPT code assigned

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“Routine services”

Pre-op consultations

–Many providers are required by the hospital to dictate a history and physical prior to admission for surgery –Included in the global period for the surgeon if done the

day before or the day of surgery

–How it is medically necessary two days before surgery? –Once the surgery is scheduled, use caution when billing

for routine services

“Routine services”

Pre-op consultations

–When a surgeon refers a patient to their PCP for a pre-op consultation, Medicare will cover the consultation if it is medically necessary.

– HPI should document the medical issuesthat require clearance

• Review of systems • Physical exam • Medical decision making

Office procedures

Wound care

–Debridement codes are based on the size of the area of the debridement

–Nurse notes cannot be referenced when the performing provider does not document the area of the wound –Procedure notes should be complete:

Indication, method, supplies used, condition of the patient at the end of the procedure, instructions

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Office procedures

Debridement example:

• 11042:Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less

• The physician surgically removes foreign matter and contaminated or devitalized subcutaneous tissue (including epidermis and dermis, if performed) caused by injury, infection, wounds (excluding burn wounds), or chronic ulcers. Using a scalpel or dermatome, the physician excises the affected subcutaneous tissue until viable, bleeding tissue is encountered. A topical antibiotic is placed on the wound. A gauze dressing or an occlusive dressing may be placed over the surgical site.

• Report 11042for the first 20 sq. cm. or less and11045for each additional 20 sq. cm. or part thereof.

Modifier -25

• A complete SOAP note supporting the E/M procedure

–If related to the procedure, may be bundled • A complete procedure note supporting the office

procedure

–Indication, approach, instruments, method, extent, size, patient condition at the end of the procedure, instructions

Non-physician practitioners

• Most undercoding occurs with NPPs • Selection of the “level of service”

–Medical necessity as described by HPI –Extent of exam as noted in Objective –Risk as noted in Assessment and Plan • There is no rule that guides an NPP to

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Authenticity of notes

• Copy and paste • Cloned notes

• Conflicts between HPI (bruising) and ROS (hem/lymph - no bruising)

• Conflicts between HPI and family history –Pt here for full skin check, worried because mother

has malignant melanoma –No family history of skin cancer

Medical necessity

According to the OIG, if a physician does a detailed exam during a sick visit, and some of the elements do not appear to be related to the chief complaint… –This is not a problem if the code selection is not higher

based on the extra elements

–If the code selection is higher based on history and physical exam, the code may be too high if not supported by the medical decision making

Case studies

• A hospital group performs compliance audits quarterly as part of their compliance program and the results impact the physicians compensation.

• 1 of the 4 audits focus on “out of office” ancillary/secondary services.

• The results of the “out of office” audits revealed problems with notes that were not created in the primary EMR system.

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Group A Podiatry

Group A’s audit results for Q1, Q2 and Q3 were above the benchmark, but Q4for alternate site

were poor

Group A Podiatry

Reasons

–Paper forms were used in the hospital wound care center and notes were not entered into the practice’s EMR –Paper forms were used by the NPP at nursing home –Forms were completed by nurse and signed by the

physician without a SOAP note being created

–Encounters were billed with E/M codes (modifier 25) and wound care codes together, with no documentation of the E/M service

Group A Podiatry

Resolution

• Physicians met with auditor to go over audit results • Education was provided on documentation

requirements

• Nurse notes can only be included when verified/referred to by physician • Dictation of SOAP note was initiated

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Group B General Surgery

• Office notes were audited Q1, Q2 and Q4 • Clinic notes were audited Q3

Group B General Surgery

Reasons

• After Q1 audits, an educational session was provided and Q2 audits showed improvement • Q3 audits focused on clinic notes, not charted in

the EMR

–Dictated notes were brief and did not include ROS and PFSH, brief exams, although MDM was moderate in many cases (ex: new hernia) • Q4 audit of clinic notes after education

Group B General Surgery

Resolution

–Re-education using the clinic notes, going over documentation deficiencies for each visit that was under documented

–Surgeons agreed to dictate notes in the clinic as they cannot access the EMR

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Group C OB/Gyn

Initial audit showed billing compliance to be poor for all 15 providers in the group.

Group C OB/Gyn

Reasons

• OB/Gyn practice was acquired by the hospital system with no change in office management

• Behavior in the office continued based on prior policies • Coding increased as the new provider compensation model

was RVU based –Examples

•Billing a new OB visit as a 99204

•Billing prenatal visits and hospital (surgery) rounds •Contraception visits billed as sick (E&M) visits

Group C OB/Gyn

Additional findings

High error rate in audit of office notes due to incorrect •Documentation of time based services •Billing of counseling and contraception •Calculations of medical decision making

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Group C OB/Gyn

Resolution

• New policies were put in place to track provider’s productivity, allowing for “billing” for hospital rounds and PN visits with 0 RVUs and $0

• First OB visits were tracked in the flow sheet • EMR templates modified to capture time • Contraceptive visits and other counseling were

changed to be documented with time and reported with 99401-99404

Group D Urgent Care

• Medical director of urgent care was enrolled with insurance carriers but NPPs and “moonlighters” were not all credentialed (high turnover) • “Incident to” rules were used in billing cases

under the name of the medical director • Medical director did not sign notes

Medicare requires the physician or non-physician practitioner to review the progress and co-sign charts. The physician or non-physician practitioner accepts responsibility and liability for “incident to” services.

“Incident to” rule

Performing provider must be an employee of the practice.

Auxiliary personnel is defined as any individual who is acting under the supervision of a physician, regardless of whether the individual is an employee, leased employee, or independent contractor of the physician, or of the legal entity that employs or contracts with the physician.

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“Incident to” rule

• The physician or non-physician practitioner (NPP) must perform the initial service, diagnose the patient’s medical condition, develop a treatment plan, and remain actively involved in the management of the care of the patient. • Such a service could be considered to be “incident

to” when furnished during a course of treatment where the physician performs an initial service and subsequent services of a frequency which reflects his/her active participation in and management of the course of treatment.

“Incident to” rule

• Furnished by the physician or by auxiliary personnel under the physician’s direct supervision

• Direct supervision: The physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the auxiliary personnel is performing services.

Group D Urgent Care

Benchmarking and chart audit results –NPPs were undercoding

–MDs were overcoding

–Forms were often completed (paper) with a line drawn down the entire ROS or exam

–Nurse notes incomplete

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Group E Hospitalist Group

Reasons

• The hospitalist group depends on a clerk to coordinate charge entry of “hospital cards” • Clerk is not a certified coder

• Overlapping charges (same patient, same day) are often entered

• Critical care time is often incorrectly calculated when more than one provider participates on same date

Group E Hospitalist Group

Hospital EMR templates may not be set up to capture the elements required for

–Comprehensive history –Comprehensive exam

Hospital Admission 3/3 HISTORY EXAM MDM Time 99221 Initial Admission, Low Detailed 5-7 Straightforward 30 99222 Initial Admission, Moderate Comprehensive 8+ Moderate 50 99223 Initial Admission, High Comprehensive 8+ High 70

Inpatient Consultation 3/3 Rule of R's

99251 Initial inpt consult straightforward Prob. Focused 1 Straightforward 20 min 99252 Initial inpt consult Expanded Exp. Problem Focused 2-4 Straightforward 40 min 99253 Initial inpt consult Detailed Detailed 5-7 Low 55 min 99254 Initial inpt consult Moderate Comprehensive 8+ Moderate 80 min 99255 Initial inpt consult High Comprehensive 8+ High 110 min Only one per hospitalization

Group E

Hospitalist Group

Resolutions

Provider education on documentation elements of Evaluation and Management services

•History (Initial H&P) to include complete ROS, PFSH

–Avoid “family history noncontributory”

–Refer to ancillary notes (medication list, past illnesses)

•Exam - comprehensive exam requires 8 elements •When and how to document time

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It’s all about the documentation

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The detail in ICD-10 depends on the information in the note

• Coders and billers are trained not to use “unspecified” codes and

• Are always directed to query the provider for more detailed information

Clinical documentation improvement goals

• Identify areas in ICD-10-CM that include new

terminology for clinical documentation

• Define areas that enable improved data capture if more specific conditions are documented • Identify how documentation affects quality

measure reporting and reimbursement

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Why is clinical documentation important?

Documentation is critical for patient care

• Serves as a legal document

• Reviews quality

• Validates the patient care provided

• Complies with CMS, Tricare and other payers regulations and guidelines

• Impacts coding, billing and reimbursement Good medical records reduce the re-work of claims processing.

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Documentation do’s

Complete Legible Timely Concise Detailed Patient Centered Accurate 40

Documentation

• Improves quality of care • Complies with CMS regulations • Drives revenue

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Coding drives revenue

New ICD-10 codes will create a demand for more details in the documentation to support ICD-10 codes.

• Charge entry • Payments • Denials

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Closing thoughts

• Does your hospital administration work closely with the physician practices?

• Is the physician practice administrator included on the hospital compliance committee?

• Are compensation plans strictly RVU based or are other incentives, such as compliance performance, a component?

Nancy M Enos, FACMPE, CPC-I, CEMC is an independent consultant with the MGMA Health Care Consulting Group. Nancy was a practice manager for 18 years before she joined LighthouseMD in 1995 as the Director of Physician Services and Compliance Officer. In July 2008 Nancy established an independent consulting practice.

As an Approved PMCC Instructor by the American Academy of Professional Coders, Nancy provides coding certification courses and consultative services. Nancy frequently speaks on coding, compliance and reimbursement issues.

Nancy is a Fellow of the American College of Medical Practice Executives. She serves as co-chair of the IT Advisory Panel of the Information Management Society for MGMA. She is a Past President of MA/RI MGMA.

www.enosmedicalcoding.com [email protected] About the speaker