Anesthesia Coding Alert

Auditing is a necessity in the health care and coding world, whether you’re a provider or coder. And while going through the process of mock internal audits might seem like drudgery, the more often you check records to spot clean-up areas, the better you’ll fare when professional auditors come to call.

Focus on these key areas to boost your chances of being prepared.

1. Frequency:  Many auditors such as ZPICs like to focus on frequency of improperly paid claims because they can generate, under the False Claims Act, penalties of up to $11,000 per claim — so for them to meet high-dollar recoupments, they need to have a high number of those claims, says Frank D. Cohen, director of analytics and business intelligence with Doctors Management, LLC.

2. Procedure Code Utilization by RVU: The relative value units (RVUs) are looked at more by recovery audit contractors (RACs) and private payers, Cohen says. “They’re looking at the magnitude of RVUs being reported. RVUs can easily be converted to cost, such as the Comparative Billing Reports that come out.” If reviewers discover that your costs for providing services are higher than your peers’, they may investigate further, he adds.

3. Modifier Utilization: “We’ve always seen modifier utilization, particularly with modifiers 25 and 59, but in 2018 we saw a lot more modifier audits that were impacting the 24 and 78 modifiers as well, and I expect that will expand into the near future,” Cohen notes.

4. Time: The Harvard RUC time study assigned a certain number of minutes to every procedure code that has a work RVU. As Cohen explains, “The analysis is used to determine whether the number of assessed hours a provider reports is reasonable and believable. The government has something called the ‘medically impossible day,’ which is when the physician’s assessed hours exceed 5,000 hours per year — the government says, ‘we don’t think that is possible,’ and the OIG considers this a big issue that they look at.”

5. E/M Codes: If you only code for anesthesia services, E/M codes don’t come into play with your claims. But they certainly do if you report services for a pain management specialist. Although E/M codes make up 1 percent of all procedure codes, they comprise about 18 to 20 percent of all volume and about 26 percent of the total paid claim amount. “I’ve done 400 to 500 post audit extrapolation cases throughout my career, and I can tell you that E/M codes make up a very small percentage of what the actual overpayment damage estimates are,” Cohen says. “It’s my opinion that we spend way too much time focused just on E/M codes and not enough time on other codes looking at things like frequency.”

Risk accumulates, Cohen adds. “If you have RVU issues and E/M issues and frequency issues and time issues, it significantly increases your profile across the board.”