Transcript Slide 1

AMERICAN
OSTEOPATHIC ASSOCIATION
DIVISION OF
SOCIOECONOMIC AFFAIRS
Presents:
Medicare Updates,
Documentation, Auditing and
Incident To” Physician Billing
December 3, 2011
Socioeconomic Affairs Staff
• Yolanda Doss, MJ, RHIA,
Director, Division of Socioeconomic Affairs
• Sandra Peters, MHA
Assistant Director, Clinical Practice Outreach
• Michele Campbell, CPC,
Coding & Reimbursement Specialist
• Kavin Williams, CPC, CCP
Health Reimbursement Policy Specialist
Yolanda Doss, MJ, RHIA
Responsibilities include:
– Helping to secure reimbursement for
osteopathic services
– Securing the acceptance of osteopathic
credentials
– Addressing Medicare issues
– HIPAA compliance
– Fraud and Abuse
Sandra Peters, MHA
Responsibilities include:
– Develop educational material on physician
advocacy, manage care, quality and performance
measures impacting osteopathic medicine
– Design and manage a set of member services to
enhance their manage care interactions and to
promote their opportunities to participate in manage
care
– Provide update to the AOA leadership on health
care trends particularly in the areas of pay for
performance and physician profiling
Michele Campbell, CPC
Responsibilities include:
– Assists AOA members with coding and billing
questions
– Assists AOA members with coding disputes with
carriers
– Medical record reviews in audit situations.
– Coordinates AOA’s responses to AMA CPT coding
requests
– Provide physician education on coding and coding
guidelines
– Write monthly coding hints and participate in articles
that effect the profession
Kavin T. Williams, CPC, CCP
Responsibilities include:
– Oversees and assists AOA members with
payment disputes and health payment
policies.
– Oversees the AOA Coding and
Reimbursement Advisory Panel.
– Represents the AOA at national
reimbursement policy meetings.
Contact Information
• Yolanda Doss 1-312-202-8187
[email protected]
• Sandra Peters 1-312-202-8088
[email protected]
• Michele Campbell 1-312-202-8182
[email protected]
• Kavin T. Williams, -312-202-8194
[email protected]
The Objective is to Provide Information
on the Following Topics:
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Medicare 2012 Updates
Evaluation & Management
Medicare Audits
Recovery Audit Contractors (RAC)
“Incident To” Services
Medicare 2012 Updates
• Physician Fee Schedule is facing a 30
percent reduction
• Physician Quality Reporting Initiative
(PQRI) Bonus Payment 2%
• E-Prescribing Bonus Payment 2%
• OMT Survey
Physician Documentation
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This is critical to your reimbursement
If it was not documented it did not happen
Clear and Legible, words to document by
Chief complaint (this is the driver to most
insurance auditors)
• Familiarize yourself with your documentation
style- is it 1995 guidelines that you follow or
1997?
Documentation Guidelines
• The medical record should be complete and
legible.
• The documentation of each patient encounter
should include:
– reason for the encounter and relevant
history, physical examination findings and
prior diagnostic test results;
– assessment, clinical impression or
diagnosis;
– plan for care
Documentation Guidelines [Cont.]
• The patient’s progress, response to and
changes in treatment, and revisions of diagnosis
should be documented.
• The CPT and ICD-9-CM codes reported on the
health insurance claim form or billing statement
should be supported by the documentation in
the medical record.
• Hospital visits should be included in the patient’s
chart
Evaluation & Management (E/M)
Coding
• Coding for office visits
• Modifier usage when billing an E/M with a
procedure (OMT)
• Time Based Coding
Chief Complaint (CC)
• The chief complaint is a concise statement
describing the symptom, problem,
condition, diagnosis, physician
recommended return, or other factors that
is the reason for the encounter, usually
stated in the “patient’s own” words.
• Documentation Guidelines states that the
medical record should clearly reflect the
chief complaint
Medical Necessity
• This area is not black/white
• There are numerous definitions of medical
necessity
• Linking the appropriate diagnosis to the
appropriate procedure to support the necessity
of the procedure performed is critical.
• Medicare defines medical necessity as services
or items reasonable and necessary for the
diagnosis or treatment of illness or injury to
improve the functioning of a malformed body
member.
Coding For Time
• When is it appropriate to code for time?
• What is the auditor looking for when they
review a chart that was billed as time
being the controlling factor?
Tips For Verbiage When Billing For
Time
Example of correct documentation of time:
• In your note it should read “ I spent 45 minutes
with the patient and over 50% of that time was
spent discussing …
Example of incorrect documentation of time:
• “I spent 45 minutes with the patient, discussed
surgical options versus medical management.
What Is An Audit?
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An effective tool used by Medicare and
other payors to recover monies lost to
fraud and erroneous billings.
Why Audits Are Initiated?
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Suspicion (Billing Pattern)
Outlier Physicians
The Senior Patrol
Whistleblowers
Procedure Codes
Who Are The Auditors?
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The Office of the Inspector General (OIG)
Medicare
The Department of Justice (DOJ)
The Federal Bureau of Investigation (FBI)
Carriers
Types of Audits
• Prepayment Audits
• Post-Payment Audits
• Statistical Sampling Method
What Auditors Look For?
• Billing for services or supplies that were not
provided.
• Billing for non-allowable or non-covered
services.
• Altering claim forms to receive a higher
payment amount.
• Unbundling claims.
How To Respond To A Request
For Documentation
• Reply to the audit notice in a timely
fashion.
• Gather and submit Only the requested
documentation.
• Be cooperative.
• You may want to conduct an internal
audit.
How to Respond to the Audit
Findings
• If the findings are not favorable:
• Attempt to discuss the findings with the
reviewer.
• If necessary request redetermination.
• If necessary request a level one appeal.
Medicare
Recovery Audit
Contractors (RACs)
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RAC Legislation
• The RAC program was created by the
Medicare Prescription Drug, Improvement,
and Modernization Act of 2003 which pays
incentive fees to third-party auditors that
identify and correct improper payments paid
to healthcare providers in fee-for-service
Medicare.
• The Medicare Prescription Drug,
Improvement, and Modernization Act of 2003
also requires permanent and nationwide RAC
program by no later than 2010
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The RAC Demonstration Project
• The RAC demonstration project took
place of New York, Florida, and
California.
• By 2010 the RAC covered all 50
states.
RAC Program Mission
• To detect and correct past improper
payments,
• To implement actions that will prevent
future improper payments.
• Providers can avoid submitting
claims that don’t comply with
Medicare rules
• CMS can lower its error rate
• Taxpayers & future Medicare
beneficiaries are protected
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The New RAC’s Are:
• Diversified Collection Services, Inc. of Livermore,
California, in Region A, initially working in Maine, New
Hampshire, Vermont, Massachusetts, Rhode Island and New
York.
• CGI Technologies and Solutions, Inc. of Fairfax, Virginia, in
Region B, initially working in Michigan, Indiana and Minnesota.
• Connolly Consulting Associates, Inc. of Wilton, Connecticut,
in Region C, initially working in South Carolina, Florida,
Colorado and New Mexico.
• HealthDataInsights, Inc. of Las Vegas, Nevada, in Region D,
initially working in Montana, Wyoming, North Dakota, South
Dakota, Utah and Arizona.
Additional states will be added to each RAC region in 2009
Minimize Provider Burden
• Limit the RAC “look back period” to three
years
– Maximum look back date is October 1,
2007
• RACs will accept imaged medical records
on CD/DVD
• Limit the number of medical record
requests
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Medical Record Limit Example
• Outpatient Hospital
– 360,000 Medicare paid services in 2007
– Divided by 12 = average 30,000
Medicare paid services per month
– x .01 = 300
– Limit = 200 records/45 days (hit the
max)
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Summary of Medical Record Limits
(for FY 2009)
• Inpatient Hospital, IRF, SNF, Hospice
– 10% of the average monthly Medicare
claims (max 200) per 45 days per NPI
• Other Part A Billers (HH)
– 1% of the average monthly Medicare
episodes of care (max 200) per 45 days
per NPI
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Summary of Medical Record Limits
(for FY 2009) Continued
• Physicians (including podiatrists, chiropractors)
• Sole Practitioner: 10 medical records per 45 days per NPI
• Partnership 2-5 individuals: 20 medical records per 45 days
per NPI
• Group 6-15 individuals: 30 medical records per 45 days per
NPI
• Large Group 16+ individuals: 50 medical records per 45 days
per NPI
– Other Part B Billers (DME, Lab, Outpatient hospitals)
• 1% of the average monthly Medicare services (max 200) per
NPI per 45 days
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RAC Validation Contractor (RVC)
• CMS has contracted with Provider Resources, Inc. of
Erie, PA, to work as the Recovery Audit Contractor
(RAC) Validation Contractor.
• The RAC Validation Contractor (RVC) will work with
CMS and the RAC to approve new issues the RACs
want to pursue for improper payments, as well as
perform accuracy reviews on a sample of randomly
selected claims on which the RACs have already
collected overpayment.
• The RVC is another tool CMS will use to provide
additional oversight and ensure that the RACs are
making accurate claim determinations in the
permanent program.
For Additional Information on RAC
• http://www.cms.hhs.gov/MLNMattersArti
cles/downloads/MM6125.pdf
• http://www.cms.hhs.gov/RAC/Downloads
/RAC%20Evaluation%20Report.pdf
• http://www.cms.hhs.gov/rac/
Medicare “Incident to” Physician
Services
The OIG reviews Medicare services that
are “incident to” physicians services to
determine the qualifications and
appropriateness of the staff who
performed them.
Physician Defined
The “physician” refers to physician or other
practitioner (listed below), who are
authorized to receive payment for services
“incident to” his or her own services.
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physician assistants
nurse practitioners
clinical nurse specialist
nurse midwife, and
clinical psychologist
Professional Service
• A direct, personal, professional service
which is rendered by the physician
• To meet the “incident to” guidelines, the
physician must initiate the course of
treatment, and
• Conduct subsequent physician services
to show ongoing involvement
Coverage Requirements
To be covered, service and supplies must
be:
• An integral, though incidental, part of the
physician’s or on-physician practitioner’s
professional services
• Commonly furnished in a physician’s office
or clinic
• Furnished by the practitioner or auxiliary
personnel under the physician’s direct
supervision
Supervision Requirements
Direct physician supervision of auxiliary
personnel is required.
Auxiliary personnel:
• any individual (employee, leased employee,
or independent contractor) who is acting
under the supervision of a physician
• Auxiliary personnel include nurses, medical
assistants, technicians, etc.
Direct Supervision in the Office
• Physician must be present in the office
suite
• Physician must be immediately
available to assist if needed
• Does not require that the physician be
in the same room
Direct Supervision in the Office
Continued
Scenarios that do not meet the direct
supervision requirement:
• Availability of a physician by telephone
• Physician presence somewhere in an
institution
Documentation
To support the use of the incident to
provision, the documentation should
clearly indicate:
• Who performed the “Incident to” service
• The physician’s presence in the office suite
during
the service/procedure
Division Website
• Go to www.do-online.org and sign onto
DO-Online.
– First time users will need their AOA
member number to sign up.
• On DO-Online, click on Practice
Management for the division website.
• There is also a Division email address:
[email protected].
What the DO-Online Practice
Management Website has for You
• Billing and Coding
• E/M documentation
• ICD-9-CM code
updates
• OMT information
• Legal
• Litigation fund
• Updates on class action
suits
• CMS/Medicare
– Links to local carrier
information
– Information on each CPT
code
– Enrollment information
– CMS Medlearn
– CCI link
– Fee schedules, new and
prior
What the DO-Online Practice
Management Website has for You
• Preventive health
services
• Demonstration
projects
• CERT- fraud and
abuse information
• HIPPA
• Managed care
• Osteopathic
Advocacy
Resources
Division CME Seminars
• Conducted in conjunction with state
associations and specialty colleges.
• Seminars available include Medicare
Compliance, HIPAA Privacy Compliance,
and Documentation Guidelines and Coding
Reimbursement.
• Call Yolanda Doss, MJ, RHIA at 800-6211773 ext. 8187 or [email protected]
for info.
Contact Information
• Yolanda Doss 1-312-202-8187
[email protected]
• Sandra Peters 1-312-202-8088
[email protected]
• Michele Campbell 1-312-202-8182
[email protected]
• Kavin T. Williams, -312-202-8194
[email protected]