Cardiology Coding Alert

How do you know if your practice will be flagged for an audit? Dont speculate anxiously; use hard numbers to determine whether your coding variances are higher or lower than normal, says Susan Stradley, CPC, CCS-P, senior consultant for Medical Group of Elliott Davis and Co., LLP, headquartered in Greenville, SC.

Comparing your practices utilization data with national norms will yield invaluable information.

1. Avoid an audit. If your practice is within 10% of the national standard, you probably are not going to be flagged for an audit, she explains. If its 10% to 15% above youre pushing the envelope, but theres still some chance that they wont get around to you.

At 15% to 20% above national norms, youre looking at an audit. Its not a matter of if; its a matter of when, Stradley warns.

2. Determine reimbursement. Similarly, such benchmarking can show you where you are undercoding. If the practice is under the national standard or very high in low-level visits, then you may be losing money, she says.

For example, cardiologists who code too high on new patient visits, but too low on established patient visits, might make an extra $15 the first time they see a patient, but then lose money every time thereafter, she explains. And what do you see more of, established or new patients?

Stradley adds, that national statistics indicate that 35% of new patient visits are overbilled, and 70% of established patient visits are underbilled.

Here are the most common codes that may be undercoded and losing your practice money:

99212 to 99213: established patient, office or other outpatient visit

99201 to 99202: new patient, office or other outpatient visit

99241 to 99242: new or established patient, office or other outpatient consultations

3. Contract negotiations. Information about utilization patterns can be vital when negotiating contracts with payers, adds John Burns, consultant with The Medical Management Institute in Atlanta, GA. Ive seen physicians get excited [when initially skimming a contract] that generously reimbursed for level five visits and consults. Yet, the majority of their patients would not warrant this level of coding. So before you sign you must know the bread-and-butter codes of your practice; otherwise, you might short-change yourself, he cautions.

Dont Stop with the Results

Benchmarking alone doesnt solve anything; it just points out the problems, Stradley cautions.

It also isnt perfect. Remember these are statistics and averages; your utilization pattern may be higher depending on your patient mix and location, she adds.

For example, if your practice is the only one in a small town, you may have a higher percentage of patients in acute care, she says. Or, if you are in a large city with multiple cardiology practices, you may choose not to do certain types of procedures.

Although these circumstances will be reflected in your utilization patterns, they shouldnt be used to justify it, Stradley warns. If youre pushing 15% above national norms, you still need to conduct a self-audit to decide if there is indeed a problem with overcoding.

She recommends pulling a random sample of charts, using the HCFA audit form, and comparing it to the E/M guidelines and other coding regulations. Determine from the actual records if your stats are anything to worry about, she says. (For more details on how to perform an audit, see the November 1998 issue of CCA.)

Own up to Mistakes

Although you are not required to share the results of your self-audit, you do have a legal obligation to pay a refund if you detect overpayment, stresses Stradley.

Repayment forms can be used for a limited number of overpayments. But, if you find your practice has consistently overbilled over a period of time, Stradley suggests trying the following approach:

1. In writing, inform the payer that a self-audit has determined a pattern of inappropriate billing.

2. Explain the national norm you used and how far off the mark you were.

3. Explain your self-audit process and what you discovered (i.e. that you pulled 25 charts and 20% were incorrectly billed).

4. Explain that you do not have enough staff to go back and individually reprocess each claim. Ask if you can use their sampling method to prorate overpayments for a specific period of time.

5. Negotiate a compromise on the repayment amount, if possible.

Although voluntarily writing the government will probably strike fear into the heart of any cardiologist, it shouldnt, Stradley advises.

Medicare will see this as an honest effort to set your billing straight, she adds. Theyre not going to go after the honest physicians. Theyre too busy dealing with the physicians who are truly non-compliant.

Getting Paid for What You Do

What do you do if the benchmarking data points to undercoding and the self-audit provides evidence? And theres a good chance that this may happen in many offices, points out Stradley.

Cardiology practices tend to have a larger percentage of higher-level visits by the very nature of their specialty, yet many practices still tend to undercode rather than risk setting off an audit flag, Stradley says.

But if you discover this is indeed the tendency in your practice, consider carefully whether you want to rebill Medicare. This action can be a double-edged sword, she cautions. How many claims need to be reprocessed? Will the sheer volume raise the hackles of Medicare?

The better alternative, she suggests, is to use the information to educate your cardiologists about appropriate documentation. Often times undercoding suggests your cardiologists may not be confident about their documentation, Stradley notes. And then help your physicians code accurately on future claims.

She offers these documentation tips to help cardiologists code at the appropriate level:

1. Rely on medical necessity, not a template. Templates are a good guide, but they should not be the driving force behind what you do, she says. Only the physician can determine what amount of history, exam, and decision making it will take to appropriately evaluate the patients condition.

Stradley also cautions cardiologists not to pad documentation in order to reach a higher level. Sometimes Im asked Just tell me how much I have to document in order to get a level five, but thats not the correct approach, she warns. Treat the patient in the manner that is appropriate to the patients condition; write down everything you do, and then determine the level of care.

2. Write good notes. Support everything youve done to reach a conclusion, she stresses. If you didnt document it, you didnt do it.

For example, she points out that cardiologists sometimes forget to document the little things that transpired.

They tend to leave these elements out [of the documentation] because they are intrinsically part of their training and experience, she says.

For example, Stradley has seen notes for a patient that presented with chest pain, but there is no mention of when the pain began, how long it lasted, whether it was resolved with rest, or worsened upon exertion, etc.

Of course, the cardiologist asked those questions, he or she just failed to note it in the patients chart, she says.

3. Dont automatically code a certain level. Ive heard some practices attempt to justify an unusually high number of level fives by saying Were specialists, therefore everything we do should be billed at a higher level, she says. But that doesnt mean a thing to an auditor.