Cardiology Coding Alert

Presented by Kristine Eckis

The following supplement to Cardiology Coding Alert is the transcript of a teleconference presented by The Coding Institute. To obtain the slides for the conference, please log on to our Online Subscription System at http://codinginstitute.com/login and download the current issue, and the slides will be contained therein. If you're not sure how to use the Online Subscription System or need help downloading the issue, please contact our customer service department at 1-800-508-2582 or service@medville.com, and one of our representatives will be able to assist you.

The speaker for the teleconference, Kristine Eckis is President of The Bottom Line Medical Administrative Consultants, Inc. "Bottom Line" celebrates its 10-year anniversary in 2005. With 26 years of combined medical and legal experience, Kristine consults with medical practices nationwide providing evaluations and recommendations for operational improvements and accounts receivable management. She also assists with practice start-ups and provides coding education and chart audits, both on and off-site. She is a Board Member of the American Association of Healthcare Consultants and a member of the National Association of Healthcare Consultants and AHIMA. Kristine has been accredited by the American Academy of Professional Coders as a Certified Professional Coder since 1996.

Thank you Mandy.  It is a pleasure to be with all of you this morning.  Welcome to the seminar.  I hope that you will be able to take something back to your practices and improve with what we are going to go over today. 

Before we look at the actual targets for 2005, I would like to provide you with a little glimpse of past activities by the OIG and CMS.  To give you a little background will help you understand where it is going and how successful it has been and why we need not to stick our heads in the sand and think we do not need to pay attention to this or it is not going to affect us.  This is just not something we have to worry about because it absolutely is, and it is not going to go away and you will hear me say that probably two or three more times today.

First of all back in 1996, CMS was known as HCFA, which was Health care Finance Administration and they implemented a plan to audit approximately 20% of all physician practices over the following five years.  They hired 350 FBI agents, which a lot of people do not know.  They also hired private contractors to help them conduct the audits and to assist with the endeavor and their initial results were staggering.  They collected $23 for every dollar they invested into this effort.  So it was very, very lucrative for them. 

Well then HIPAA came along a couple of years later and redefined fraud and abuse.  And just for your information, I have given you on slide 3 the new definitions.  "Fraud is intentional deception or misrepresentation that an individual knows to be false," whereas abuse is "incidents or practices of providers that are inconsistent with accepted sound medical practices," and that is pretty straightforward.
 
The program continued and it began to expand and it is not just the OIG now, and of course OIG is Office of Inspector General.  And the reason I say that is Medicare encouraged its beneficiaries through notices, even on TV commercials for a while, I do not know if some of you recall, but they encouraged Medicare beneficiaries to report any suspicions that they had, and they told them that if they were in fact true and they did recover revenue that they would share it with them.  And so as a result of this encouragement these retirees received over $530 million as whistleblowers by August 2001.  And then another $80 million within the next five months was paid out for a total of $610 million paid to whistle blowers by January 2002 and that is phenomenal.  And that is just the whistle blowers, their portion.  Then our managed care plans came along, and they saw how lucrative it was for the OIG, so they wanted to jump on the bandwagon and recoup some of these revenues off those.  So they figured if it is happening with Medicare it is happening with our plans and we are paying too much as well.  Many of our plans added amendments to their contracts and they sent them out in the mail.  Sometimes they were even disguised as junk mail.  They would be yellow or hot pink and they would just be a tri-fold flyer that would come.  We are so busy as office managers and physicians and sometimes, if it looks like junk mail, we just kind of throw it in the trash, but I would encourage you to look at anything you receive, especially if it is from a managed care plan.  Because what they have done, they send out amendments to their contracts, which allows them if they have not already incorporated it, it allows them to come in and audit for over payment.  It used to be that they would just come in to your office and they would audit through NCQA guidelines and that is National Committee for Quality Assurance. They would look and make sure that the physician had signed off on his dictation, that the patient's name was on each sheet of paper in the file, that there were identifiers and they have specific guidelines.  And they will give you a little report and say that they need improvement or not, or you did wonderful.  But now they are coming in and they are doing exactly what the auditors are doing for Medicare and they reserve the right to demand the overpayment back within 30 days and sometimes with fines and patentees, which can actually if it is substantial, shut a practice down. 

Another thing with regards to this, before we go along, is that it is important that you check your contracts and the ones that have these clauses in them, make sure that you add an amendment yourself or get them to add to these clauses that you reserve the right for a third party arbitrator.  I would prefer to see you use a CPC (Certified Professional Coder) to intervene, so if they come in and audit your charts and you know they are coming in because they want money back and sometimes they do not send qualified coders in.  So you might get somebody in there auditing that really does not know what they are doing.  Coding is not always black and white, so you need to make sure that you can have a CPC intervene and that the managed care plan and you agree to take the decision of the CPC as the final result instead of allowing them to have the say so and you do not even have a say in this situation at all, you are just at their mercy.  I strongly advise that.

So the latest report was just released for the first half of the Year 2004.  I am on slide 5.  And these are the results of investigations that were finalized during the first six months of 2004.  So what did they do, well they said they saved American tax payers over $16.8 billion and that was an increase of $4 billion for the same time period from the previous year, so again they are increasing their findings.  They excluded 1,544 individuals or entities for fraud or abuse of Federal health care programs or beneficiaries. They convicted 234 individuals or entities that engaged in crimes against department programs.  They also had 107 civil actions including the False Claims Act.  And of course, the False Claims Act is submitting claims for services that were not actually provided.  And it is hard to believe there are people out there doing this but a few bad apples spoil the barrel as they say, and we are all paying for it, but this is going on and this is why they are out there.

Also in the report they stated that they will continue to be an aggressive source with an HHS which is Health and Human Services, not only to improve the efficiency of the department but to punish those who defrauded the program.  "This office is dedicated to maintaining public credibility of our viable programs," and that is a quote from the actual report.  So you can see the success of their efforts and the intensity of the program and again, it is not going away, so it is time to stop, to learn about it, see what is going on, conduct an assessment of our own practices and correct any deficiencies we have so that we are not subject to any of these actions.  And also, that we do not have to worry about it because we know what we are dealing with and we know we corrected anything that needed to be corrected.

Now before we get into the actual targets, I want you to know that not all targets will apply to all of your practices and some of these are primary care, some of this are specialists, but we are going to go over.  The first few should apply to almost everybody and I want to especially elaborate on some of them.  Anytime we go through the slides and you see at the top 2002 or 2004, this means that this particular target for this year was a former target in the year listed at the beginning, so for evaluation and management codes, we have this was a target for 2002, 2003 and 2004 and again this year.  At one point, I think it was 2002, they singled out 99214, which is level 4 of an established patient visit, and 99233, which was level 3 of the hospital subsequent visit specifically, because they found that both of those codes were almost always overcoded by two levels.  So they concentrated only on those two codes that year, but what they found is that all of the codes were similar, so they have been looking at all the evaluation and management codes, not just those two and they have been looking at them each year and they are getting really good at it.  You are also going to see that many of these targets are directly related to coding, billing and documentation.  So you want to keep those three things in mind: coding, billing and documentation as we go through here.

So our first target and these are actual quotes from the OIG.  "OIG will examine patterns of physician coding of evaluation and management services and determine whether these services were coded accurately."  In 2003 Medicare pair over $29 billion for evaluation and management services.  This was an increase from $23 billion that they paid in 2001.  So in two years they increased their payments by $6 billion.  "Prior work revealed that a significant portion of certain categories of these services is billed with incorrect codes resulting in large overpayments."  I want you to notice the words 'certain categories of these services.'  We are going to discuss this in just a minute when we get to consultations.  The OIG will assess the adequacy of controls to identify physicians with aberrant coding patterns.  So how do they identify these physicians?  Well, they do it with bell curves and they have established bell curves for every specialty and all types of physicians, they have a profile on every physician.  So they can take your established levels 99211 to 99215 for any specialty and they have a bell curve on it, as to what is the norm for this type of specialty, and they will compare your bell curve to the norm and if it is really out of line, that is what is going to flag you.

So let us take a look at some of the bell curves on slide #9.  I have given you a typical bell curve for a family physician, new patient office visit 99201 to 99205.  And if you look at that it is pretty stable and the 99203s are the most visits, and the second most visits that a family physician usually has according to the standard and the norm for the nation is 99202 with 99204 close behind.  So it kind of looks like a hill.

Now, if you advance to the next slide, we have Dr. Overcode, and most of his visits are 99204s and the second highest level of visits for Dr. Over code is 99205.  So clearly his bell curve is standing out when you look at the typical bell curve for the averages for the family physician.

On the next slide, we have Dr. Undercode and he has mostly 99202s and secondly 99203s.  What I want to caution Dr. Undercode about, if you are out there, is that Dr. Undercode always thinks that if I code a little less, even though I am losing revenue that I am entitled to, they are not going to come and bother me.  They would not flag me because I am under coding. That is not true.  Undercoding can get you flagged as easily as overcoding simply because they are going to look at this and they are going to say hey! Dr. Undercode does not know what is going on here.  I bet if we go visit him, we will find some more problems.  So it will not keep you from being flagged for an audit. 

Another way that the OIG and CMS is monitoring or trying to determine what they are going to go after and what they are going to look into is simply the payment increases that they have, and I am giving you several today, as how much they pay out.  How many billions of dollars they pay out and how it increases dramatically and when there are large deviations this is another way that they flag what they are going to look at.

On slide #12, I am talking about consultations and what I found interesting is that consultations were not singled out and not targeted for 2005.  If you see they were a prior target in 2000, they dropped it in 2001 and found that they did not have any improvement whatsoever, so they brought back the target in 2002, 2003 and 2004.  What I want to caution you here is that just because it is not a target this year, does not mean there is not ongoing efforts involving consultation and that is with anything.  Anything that has been a target in the past, they are probably still looking at it and they are probably still investigating it.  It is just that it is not a new target for this year.  And I refer you back to the wording in our target for E/M coding, where it said a 'significant portion of certain categories,' and in this instance we are talking 99241 to 99245, consultations.  In 2004 this was their wording:  "The OIG will determine appropriateness of billing for physician consultation services and the financial impact of any inappropriate billings on the Medicare program."  They paid out $2 billion for consultations in the Year 2000.

So just as a review on slide 13, I remind you of what a consultation is.  Most of us do have consultations, even primary care physicians have consultations.  A lot of them are unaware that they are preop visits when a specialist asks the primary care to clear a patient for a surgical procedure, that is a consultation for the primary care physician, so he should be billing with one of those codes from 99241 to 99245 when he clears patients for surgeries.

A consultation must be at the request of another physician.  It is not a referral of a patient to another physician for care and treatment.  When you refer the patient, you are transferring care.  A consultation must always include a written report sent back to the requesting physician and the report is going to include the physician's advice, opinion or recommendations only.  Then at the conclusion of the consultation, the patient is returning to the physician that requested the consultation and the continued treatment will be provided by the physician that requested the consultation.  So it is really important: you have got to have a request, you have got to examine the patient and provide your opinion, advice or recommendation, and you are sending the patient back to the physician for continued care.  Those are the requirements for a consultation.  And there has been a lot of confusion, there has been a lot of animosity and there has been a lot of physicians that have been upset because they feel like anytime a patient is sent to them by another physician that it is a consult, but a lot of times it is a referral and referrals are new patient visits, not consults.

So we will move along to our second target which was also a target in 2004 and that is the use of modifier 25.  And they stated, the OIG will determine whether providers used modifier 25 appropriately.  In general a provider should not bill evaluation and management codes on the same day of the procedure or other service unless the evaluation and management service is a significant separately identifiable service from such procedure or service.  Of the $23 billion allowed for evaluation and management services in 2001, approximately $1.7 billion was paid out for E/M services billed with modifier 25.  So they are going to determine whether these claims were billed and reimbursed appropriately.

The definition of modifier 25 is included on slide 15.  Significant, separately identifiable evaluation and managements by the same physician on the same day of a procedure or other service.  You use this when the patient's condition requires a significantly, separately identifiable evaluation and management service above and beyond the other service provided.  The E/M service may be prompted by the symptom or condition for which the service or procedure was provided, therefore, different diagnoses are not required.  There are a lot of practices out there that think you have to have a different diagnosis and that is not true.  And that is Medicare guidelines that it is not true.  So you do not have to have two separate diagnosis.

So we have got some examples on slide 16 of what I am talking about.  If you have a patient who presents for a routine physical or a well woman exam, and during the course of that examination, the physician discovers and treats a separately identifiable problem, then you may bill for your well exam with your V code for your annual exam and your preventive service CPT code like 99385.  You may also bill for treating the problem which in my example, I use a 99212 with modifier 25, which tells the payer that you have treated the patient for something separately identifiable from the routine physical and then you just link your diagnosis for the problem to the problem CPT code 99212, and you should get paid for both services. 

The next three samples that I give you are just where a patient has come in for a problem.  Say they come in with a problem with their knee, the injection trigger point 20550.  And you have not determined that they need an injection yet, you have to evaluate this patient to come to the determination that they need the injection so you are entitled to be paid for your evaluation and management service, as well as the injection of the trigger point.  And again the proper coding is outlined; therefore, your modifier 25 always goes on the CPT code, the evaluation and management code.

Now the fourth sample, destruction of the lesion of the vulva.  If you see a patient today and you examine them and you schedule them for a procedure but they do not want to have the procedure done today, say they want to come back tomorrow or they want to come back in two days to have the procedure done.  To day you would only bill for the evaluation and management; when they come back, if no separate evaluation and management was necessary because we already did it earlier, then you would only bill for the procedure.  But a lot of offices are still billing for another evaluation and management plus the procedure and so they are abusing modifier 25 and this has been the problem with that one.

Now we will move along to our third target.  And that is the use of modifiers to bypass the National Correct Coding Initiative edits.  And what we are talking about here is bundling and unbundling and again this was the target last year and it is continuing to be investigated this year.  The OIG is going to determine whether claims were paid appropriately when modifiers were used to bypass these edits.  The initiative is one of CMS's tools for detecting and correcting improper billing and it is designed to provide Medicare Part B carriers with code pair edits when they are reviewing the claims for payment.  At times, a provider may include a modifier to allow payment for both services within the code pair under certain circumstances.  And there are edits that no modifier would ever apply.  You can never use a modifier.  And then there are those where you can bypass them in these certain circumstances and I am going to show you one in a second.  But in 2001, Medicare paid $565 million to providers who included the modifier with code pair edits within the National Correct Coding Initiative to bypass the edits.  So their thinking, obviously, is that there is some abuse going on here.  So they are going to determine whether the modifiers were used appropriately.

On slide 19, I give you an example of what we are talking about, it is rather simple one.  First of all, certain codes may not be used together if one of the procedures coded is a component of the other procedure or, if one of the procedures coded is a less comprehensive version of the other procedure.  So what we have here is we have a simple repair of a wound.  Code 12001, and then we have code 11400, which is an excision of a benign lesion.  One would expect that if you open the skin to excise a lesion that you will close the skin; and yet there are practices out there that are billing for the removal of the benign lesion with 11400.  And then they are saying that they repaired the wound with 12001.  You cannot do that.  These codes are bundled.  Again one would expect that if you open, you are going to close.  So this would fall into a bundled pair.
 
Now there are certain circumstances where it may be that you did both of these services and deserve to be paid.  What if you excised benign lesion on the arm and the same patient had a gash on their leg and you did a simple repair of the wound on the leg.  Well yes, certainly you should be compensated for both of those procedures, so to do that you have to bypass the edit by using modifier 59, which says to the payer, I did this and it was on a different site, so I deserve to be paid.  It was a second procedure, it was not involved with the 11400, and you will get paid.  But I guess there has been a lot of abuse in several areas but that is just to give you an idea of what we are talking about when we are talking about bypassing the edits.

Our fourth target is a new one for this year.  It is wound care services.  The OIG will determine whether claims for wound care services were medically necessary and billed in accordance with Medicare requirements.  Medicare-allowed amounts for certain wound care services billed by physicians increased from approximately $98 million in 1998 to $147 million in 2002.  That is almost a $50 million increase for four years.  So you can see how large this deviation is and why it would cause them concern.  Anyway the OIG will also examine adequacy of control to prevent inappropriate payments.

Our fifth target is carried over from last year and long distance physician claims and it really kind of puzzles me.  I cannot even believe that it is carry-over.  I could not believe it was a target last year but we will go ahead and investigate it here.  The OIG will review Medicare claims for face-to-face physician encounters where the practice setting and the beneficiary's location were separated by a significant distance.  All beneficiaries may seek professional services for specialized consultation during leisure travel, those with an ongoing illness requiring skilled care would be less likely to travel long distances from the home and that makes sense to me.  But in the case of Florida, we have snow birds, they come down for the winter and they spend the winter months here sometimes four to six months.  And so they may have an illness and yes they are far away from home but they have a different provider while they are down in Florida.  And then there are those people that live in areas where they do not trust the health care in the area they reside in and so they travel to larger urban areas for their health care.  So this kind of surprises me, there must be something going on here, it is not making sense to them.  They will examine claims to confirm that the services were provided and accurately reported.

Our sixth target is care plan oversight and this is one that I kind of, I think it may not be justified and I will explain why.  The OIG will evaluate the efficiency of controls over Medicare payments for care plan oversight claims submitted by physicians.  Under Medicare home health and hospice benefits, care plan oversight is physician supervision of beneficiaries who need complex or multidisciplinary care requiring ongoing physician involvement.  The OIG reimbursed for care plan oversight $26 million in just one year from $15 million in 2000 to $41 million in 2001.  That $26 million increase may have been justified and the reason I say that, is back in 2000 our primary care doctors and the doctors that were providing the care plan oversight really did not have a clue of how to track these services.  They did not have good policies and procedures in place and they were missing them, they were not tracking them correctly and they were missing out on a lot of revenue that they were entitled to.  And I think over the years what they did is they discovered ways to track these services and they came up with their own method and therefore they are capturing that revenue now.  So I quite doubt that they are finding a lot but that is just my personal opinion.

Our seventh target-ordering physicians excluded from Medicare and this is ongoing from last year.  Under Federal regulations, physicians who are excluded from Federal health programs are precluded from ordering, as well as performing services for Medicare beneficiaries.  And yet the OIG has identified a significant number of services that have been ordered by excluded physicians.  Now you can avoid this in your practice simply by conducting a background check on any new physicians that you are considering bringing into the practice.  But it is amazing to me that they would take the chance - to be excluded from the program and take a chance of getting caught.  I think that might mean jail time.

Our eighth target, physical and occupational therapy services.  The OIG will review Medicare claims to determine whether the services were reasonable and medically necessary, adequately documented and certified by physician certification statements.  I think a lot of these certifications are missing.  Physical and occupational therapies are medically prescribed treatments concerned with improving or restoring functions, preventing further disability and relieving symptoms.  So they are actually going to go in and make sure that these services were indeed ordered, documented and certified by the physicians.

Our ninth target is a new one.  Cardiography and echocardiography services; and this is pretty straightforward, but apparently there has been a lot of confusion with the entities, hospitals, physician offices and leasing agreements as to who should be billing for what portion of these services.  The OIG will review Medicare payments to determine whether physicians billed appropriately for the professional and technical components of these services.  When the physician performs the interpretation separately, the modifier 26 should be used with the CPT code to show that the physician rendered professional services only, your modifier 26 designates professional services only.  Now your modifier TC is for the technical component, and the person that owns the equipment or the entity that owns the equipment bills for the technical component, so they would use the same CPT code, but they would append modifier TC to show that they deserve to be paid for the technical component, and so in stead of each of them getting paid in full for the whole code, they are each getting paid for their portion of services.  In cardiography especially, they have come out with several codes they designated different codes to specify that the physician did the interpretation and report only, so that will alleviate some of the confusion.  But there still are enough of those codes left out there that we need to be very careful to bill only for what we do.  If you own the equipment and you also provide the interpretation and report, then you would bill with the CPT code without any modifier at all and you will get paid for what they call the global.  You get paid for both portions because you deserve to be, it is the global fee.

Our tenth target it is a new one also, they are looking at billing service companies.  And again, I said not all of these will affect all of us, and here is definitely one, a lot of us do not use billing service companies.  But the OIG will identify and review the relationships among billing companies and physicians and other Medicare providers who use their services.  They are going to identify various types of arrangements that physicians and other Medicare providers have with the billing services and they are going to determine the impact of these arrangements on the physicians' billing.  And here I think what they are looking at is inducement.  If there is some kind of an arrangement there, where it would encourage the billing service company to do something unethical.

Our eleventh target is a very interesting one.  Medicare payments to VA physicians.  The OIG will asses the validity of Medicare reimbursement for services billed by physicians who receive remuneration from the VA for the time the physicians reported as being on duty at a VA hospital.  Physicians employed by the VA may not bill Medicare for services rendered at other hospitals during the times they are on duty at the VA.  Preliminary work of the OIG has identified a number of VA physicians who received Medicare reimbursements totalling $105 million for services rendered between January 1, 2001 and June 2004.  By using time reporting and payroll documentation from the VA - so they will actually go to the VA site and review these records - they are going to identify services rendered by physicians who were reported on duty at VA hospitals and yet remunerated from other facilities on the same day.  This is going to be quite an investigation.  I am sure there are some nervous people out there.

Out twelfth target is physician services at skilled nursing facilities and I am now on slide 31.  The OIG will examine Part A and Part B claims with overlapping services for SNF and that is skilled nursing facility patients, and determine whether duplicate payments were made to either the physicians or the nursing homes for the same patient services.  Physicians may bill Medicare only for the professional component of the service on behalf of SNF patients.  The technical component of physicians' services is covered under the patient's Medicare Part B stay in the SNF and should not be billed separately by the nursing home.  There has been a tremendous amount of confusion with this and then they come through and they say there is an exception to the rule that nursing homes may receive Part B payments for both components, if both parties have an agreement under which only the nursing home may bill and receive these Part B payments.  As I said, this is quite confusing, but if this applies to you, Medicare just released a wonderful detailed article concerning the SNFs and consolidated billing rules, and they call it Medlearn it is their new educational handout.  Medlearn #MM3683.  It was dated January 21st.  You can go to their website and download it, if this affects you, I would certainly download it and make sure you are in compliance with the new rules because they are changing constantly.

Our thirteenth target, Part B mental health services.  And I know a lot of us have had problems in our offices.  I have had physicians call me and ask me, 'how can I bill for anxiety because the payers would not pay for anxiety or they cut my payment in half.'  And I do not know what to tell you, but they come out with these rules and we have got to abide by them, so we will just review this as they have written it.  The OIG will determine whether Part B mental health services provided in physicians' offices were medically necessary and billed in accordance with Medicare requirements.  Payments for mental health services provided in the physician's office accounted for approximately 55 percent of the $1.3 billion in payments for Medicare Part B mental health services in 2002.  In a prior report, the OIG found that Medicare allowed $185 million for inappropriate mental health services in the outpatient setting.  That is huge and they need to fix this for sure.  They are also going to determine the financial impact of claims that do not meet the Medicare requirements.

And the final physician target that the OIG has listed for this year concerns provider-based entities.  The OIG will determine the extent to which health care entities that have been designated as "provider-based" are in compliance with requirements for receiving this designation.  In prior work, the OIG found that hospital ownership of physician practices is widespread and that fiscal intermediaries are frequently unaware whether these hospitals are being treated as provider-based or freestanding and of course that affects reimbursement.  Medicare and its beneficiaries may be paying excessive amounts of services inappropriately billed as provider-based.  So the OIG will determine the impact on Medicare reimbursement of entities billing as provider-based instead of as freestanding.
 
That concludes the 2005 targets, designating which ones are new and which ones are carry-overs, but I would also like to take this a little step further.  In that initial semi-annual report that we looked at in the beginning of the series here, I wanted to point out some statements made by CMS.  In the past, the OIG has always urged practices to develop a voluntary compliance program.  If you have been audited there is no choice, it is mandatory, they will make you put in a program and there are plenty of mandatory programs out there.  But they concluded in their semiannual report with another endorsement for compliance plans and this is what they said: "OIG will continue to issue compliance program guidance to assist the health care industry in establishing voluntary corporate compliance programs and in developing effective internal controls that promote adherence to applicable Federal statutes, regulations, and the program requirements of Federal health care plans."
 
"The adoption and implementation of voluntary compliance programs significantly advances the prevention of fraud, abuse and waste in Federal health care programs while furthering the health care industry's fundamental mission to provide quality patient care."

So briefly, I would like to look at a voluntary compliance plans and just familiarize you with it if you are not familiar with it.  It is not as intricate as it sounds, it is not scary, it is actually quite simple and it is a wonderful thing to do voluntarily right now with everything that is going on.  It has seven components on slide 39.  The seven components are;

Conducting Internal Chart Auditing.  When they first released the seven components, internal chart auditing was #5 on the list, they list them in order of importance.  And a couple of years ago they removed it from #5 and placed it at #1 and they said if you do not do anything else voluntarily, do your internal chart auditing.

The second component: implement compliance and practice standards.  Basically what you are going to do is state what your practice does, what your practice believes that we endorse what is right, that we are not going to participate in fraud and abuse, that we are going to do everything the right way according to the rules. 
Designate a compliance officer, that is easy enough, you get your office manager or a fellow physician but someone in the office to be the compliance officer.  Then you conduct appropriate training and education.  Once you have got your whole plan in place what you are going to do is educate your staff.  We have implemented a compliance plan: so and so is our compliance officer, this is what we stand for, these are the rules that we are going to abide by.  And then after that, after they have been introduced to the plan and know all about it, you will also continue to have ongoing training pertinent to each staff member's area of responsibility.  A coder might get coding training.

Respond to detected offenses and develop corrective action.  That is what your compliance officer will do.  Develop lines of communication:  this can be done by just having a locked box somewhere where employees, staff members can put anything in that locked box and report it to the compliance officer.  And also of course in your compliance plan you would say that you can report something to the compliance officer and remain immune from any type of action, as far as personnel wise.  And then enforce disciplinary standards if the compliance officer gets communication, looks into it and finds that there was a problem, then of course he is going to fix it and make sure it does not happen in the future.  That is all this program is.  Then what you can do is you can further expand it to have a voluntary billing and reimbursement compliance plan.  As I have stated on slide 40, you had the same seven factors, the difference is when you implement compliance and practice standards, you are going to specify your billing and your coding rules for your office.
 
For instance, we will not waive deductibles, we will not waive copayments.  Because of course that is looked on as an inducement.  Basically, we will not bundle and un-bundle and we will use our modifiers appropriately.  So that is all that it is saying, and then of course you would again educate your staff.

In closing I would like to encourage you to consider assessing your practice and developing a voluntary billing and reimbursement compliance plan.  It is going to be absolutely your best defense against any potential fraud and abuse allegations if you ever do get audited.  And I would like to remind you too that OIG is not so bad.  They are out there trying to eliminate fraud and abuse.  They are after the bad apples.  They look at intent.  And if you are trying to do the best you can and you make a mistake they are not going to slap you - or they are not going to slap you hard.  It is when it is flagrant. 

There was a practice in North Carolina and they had been audited and much to their surprise, they got in trouble, they were told that the OIG would be back shortly and they were going to be testifying and they were very upset.  But they followed what they were told and they went ahead at that point and put in the compliance plan.  Each month, I think a period of three months passed before they came back to fine them.  Each month, they did their internal chart auditing they had educated their staff, they reviewed the auditing with the physicians to alert them of their overcoding and their undercoding and how they could correct it.  When OIG came back and they saw the effort this practice had made to do the right thing, even though they have already gotten in trouble, they reduced the $70,000 fine to $30,000.  So by putting in a compliance program and showing good intent, it could make a huge difference in a fine if you were ever to be fined.
 
And then I would like to encourage you also to be proactive and strive for continual operations improvement.  This way you can practice without worrying and without intimidation, without under coding, thinking that if you under code, you will not get in trouble.  And the physicians cannot afford to under code anymore.  They need to get and collect everything they are entitled to  legitimately of course.  So start practicing without worrying and without intimidation and take a look at these targets, see which one apply to you.  You might want to go to the National Coverage Determination on billing and coding issues to help you and see if you can not just bring a little piece of mind to your practice.  I would like to thank you so much for attending today.  I hope it was helpful in someway.  Operator we are ready to open the lines for questions.

Thank you Ms. Eckis.

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