Cardiology Coding Alert

With the changes in coding for Evaluation and Management (E/M) services, cardiology practices are caught between a rock and a hard place: fear of overcoding and bringing down the wrath of Medicare auditors vs. undercoding, thus forfeiting countless dollars in the squeeze.

A cardiology practice may document enough information for a visit to be considered a level 4, but then they downcode because they are afraid too many high-level visits will open them up to an audit, says Stephanie Servy-Gajic, director of coding management and education at Cardiology of Georgia, a 25-member group in Atlanta.

But even if youre comfortable with the E/M guidelines, beware: physician practices are coming under increasing scrutiny from Health Care Financing Administration (HCFA) auditors looking for Medicare fraud, waste and abuse.

Cardiology practices are especially vulnerable because we have so many Medicare patients, explains Servy-Gajic, who was hired to perform in-house audits as part of her cardiology groups compliance initiative.

Due to the HCFA mandate for prepayment review audits, several of our sources say they have recently seen an increase in the number of auditor requests for medical records, as well as requests for documentation on medical necessity.

Cardiology practices can decrease their chance of an audit and perhaps even ethically increase reimbursement by implementing a compliance program, Servy-Gajic says.

Although such programs are common in larger acute care hospitals, many physicians have been reluctant to implement one in their practice.

Plan Not as Difficult As It Seems

The biggest problem is that they are intimidated by the idea of a compliance plan, particularly if they look at whats on the OIG (Office of Inspector Generals) Web site (http://www.hhs.gov/progorg/oig) as a sample plan, says Susan Stradley, CPC, CCS-P, senior consultant for Medical Group of Elliott Davis and Co., LLP, headquartered in Greenville, SC.

The sample OIG compliance plan does not illustrate what a physicians office needs to do, but rather uses a large laboratory as a model. (Neither OIG nor HCFA mandates the use of compliance plans, but they highly suggest it.)

Its a very long detailed document that doctors cant relate well to, she says. They take one look at it and say Well never be able to accomplish this.

But by sticking to seven basic principles, cardiology practices can satisfy the OIG requirements and not drown in documenting detail. Its fairly easy to give the OIG what they want, offers Stradley. Its not as frightening as you think.

However, both Stradley and Servy-Gajic caution that a compliance program should not be just another exercise in putting policy and procedure on paper.

Auditors want to see more than words, they want to see evidence of a working plan, Stradley cautions. Remember that having a compliance program is more for your benefit than theirs.

Servy-Gajic agrees. A good, working plan will not only keep you from being an audit target, but it will also allow you to pinpoint areas in which your practice is ethically entitled to more reimbursement, she says. It puts a mechanism in place so you can educate your physicians on how to capture that revenue that would otherwise be lost.

Stradley and Servy-Gajic offer the following tips for designing an effective compliance plan:

7-Step Compliance Plan

1. Say what you mean and mean what you say. Have a written statement outlining your commitment to ethical, accurate coding that complies with all regulatory requirements, Servy-Gajic says. The statement should explicitly say that your office has a set of standards and a plan to ensure that everyone -- from physicians to billing clerks -- understands the law must be complied with.

Remember that to prove fraud, the government has to show a willful intent to defraud, which would be extremely difficult if a compliance plan has been implemented and is enforced, Stradley explains.

2. Designate a compliance officer. This sounds like you should hire a new person just to do compliance, but thats not really the case, explains Stradley. In fact, in a small office, the compliance officer should be the physician, she adds.

The idea, she says, is to select a trustworthy person who holds a high level of responsibility in your organization. It needs to be someone who not only can communicate well with all levels of staff, but who also has a strong personality and can make sure compliance issues are enforced. Dont just give it to someone by default, Stradley advises.

The larger the practice, the more difficult it would be for one person to fulfill the role of compliance officer and perform full-time coding or management duties as well, she says.

With a large practice, a compliance officer will be spending most of his or her time educating physicians and other staff members about coding, she says. And to do that you must keep up with regulatory changes, which can be a full-time job in itself.

Stradley says she has seen some large practices that appoint a compliance committee to work along with the officer. Several physicians may sit on this committee, along with billing department staff who represent the inpatient and outpatient sides, as well as the practices health care attorney, she explains. A committee is good because it brings people with different perspectives to the table who can work together to develop a solution. Its structure also helps disseminate information to a large number of people, adds Stradley.

3. Specify lines of communication. Your plan should state how you will communicate changes in coding guidelines and regulatory requirements to the staff. You also need to keep a master notebook of the items that are discussed. Maintain an up-to-date index for this manual so information is easily accessible at all times, Servy-Gajic says.

Communication should include a mechanism for reporting compliance concerns. You need a process for employees to report potential fraud, including any pressure being placed on them to code or bill improperly, Servy-Gajic says.
OIG doesnt specify the exact method by which practices must provide the means to talk freely with the compliance officer, adds Stradley. They just want to see evidence of open lines of communication, Stradley says.

For example, larger practices may set up an anonymous phone line, while smaller ones might put a locked suggestion box in the restrooms.

Keep in mind you dont want to create an intimidating climate that says Someone may report you, but one in which employees feel comfortable in telling the compliance officer that something is of concern or definitely wrong, Stradley says.

4. Perform regular self audits. For example, to audit her own group for E/M services, Servy-Gajic begins by randomly selecting about 14 or 15 charts. I make sure there are some charts with each level of service, as well as ones that represent new and established patients and consults, she explains.

Then using a HCFA audit form, she tries to think like an auditor, reviewing each chart for documentation of the three components of the 97 E/M guidelines: history, examination, and decision making.

Because HCFA says we can use either the 97 or 95 E/M coding guidelines, I also audit charts according to the 95 ones, Servy-Gajic explains.

After analyzing each chart, Servy-Gajic files the completed audit forms in a binder set up with dividers for each cardiologist. Save everything and make sure there are dates on every piece of paper, she advises.

The results are then used for training and also as a paper trail in case of an audit.

5. Educate, educate, educate. Based on the findings of her audit, Servy-Gajic then prepares a list of concerns to be covered in a physician inservice; the list is also filed in the binder.

Next, she takes this material to each cardiologist and offers each an individual consultation to show how he or she can improve their E/M coding.

For some, I do as much reassuring as I do educating, Servy-Gajic says. In some instances, I explain, for example, that they are dictating enough detail for a level four, but then downcoding because they are afraid of becoming audit targets, she adds. I stress that with the proper documentation and their indication of medical necessity, they can bill for the services they perform, and thus they can be justifiably reimbursed at a higher rate.

After the one-on-one inservice, Servy-Gajic has the physician sign and date a statement confirming the training session; the statement is attached to the list of her initial audit concerns and filed in the binder along with the audit results. This piece of paper is necessary because it shows we met one-on-one. Remember, if you dont record the training session, it didnt happen as far as the inspector is concerned, she says.

She also reviews basic coding guidelines that are troublesome, such as a new patient vs. a consult.

In addition to individual sessions, Servy-Gajic plans to offer group classes on coding in which she presents the results of a chart audit and gives recommendations on improving documentation.

Physicians, nurses and non-physician practitioners also receive a booklet on E/M documentation that Servy-Gajic has compiled which includes the following sections:

A. The key components of E/M,

B. HCFA documentation guidelines for E/M,

C. State carriers expectations regarding the quality of medical records.

In addition, she sends memos to all cardiologists when an issue surfaces that needs further explanation. A recent one, for example, examined billing for critical care. The memo opens by describing a clinical scenario, and then presents five coding tips.

6 . Set guidelines for appropriate disciplinary action. You need a statement that makes it clear that blatant manipulation of billing and coding will not be tolerated and will be grounds for termination, says Stradley.

The consequences of violating the law should be outlined for every level of employee, adds Servy-Gajic. If a physician violates the policies, appropriate disciplinary measures, such as suspending billing privileges, should be taken.

7. Respond to detected offenses. Finally -- and this may be the most important point -- auditors will want to see what you did with the information you uncovered in your self-audits.

They want to see if you refiled claims that were not in your favor as well as those that were, says Raymond Jorgensen, MS, CPS, consultant.

Auditors will also check to see whether appropriate disciplinary action was taken, if indicated, adds Stradley.

Your Seven-Point Compliance Checklist 1. A code of conduct 2. Written policies and procedures 3. Effective communication mechanisms 4. Auditing and monitoring systems 5. Educational and training programs for staff and physicians 6. Appropriate disciplinary action consequences 7. Respond to detected offenses

Audit Compliance Tip: Uniform Use of 95/97 E/M Guidelines Can some physicians in a practice document according to the 95 guidelines, while others use the 97 ones? Can one doctor use one set of the guidelines for some charts and the other set for other charts? Yes to the first question, and No to the second. Medicare will continue to use either the 95 or the 97 guidelines when reviewing claims, depending on which is most advantageous for the individual physician, said Robert Berenson, MD, director, HCFAs Center for Health Plans and Providers in a Sept. 22, 1998 press release. A HCFA representative explained to CCA that this statement means that each physician must decide which version of the guidelines he or she would follow. Once the individual physician makes the choice, all subsequent documentation must be consistent with the selected guidelines. However, within each practice, HCFA recognizes that some physicians may follow the 95 guidelines and others may follow the 97 edition, hence inspectors will audit each doctor according to the version he or she has chosen. Physician groups may also set internal policies that require a particular set of guidelines be used by all of their members, the representative said.