EM Coding Alert

Take these steps to avoid MAC, RAC, and CERT scrutiny.

Critical care services are currently under a number of different microscopes. Not only are Medicare Administrative Contractors (MACs) targeting the services, but so too are Recovery Audit Contractors (RACs), while Comprehensive Error Rate Testing (CERT) auditors are compiling improper payment rate data.

One way to possibly avoid this kind of examination is by conducting a self-audit. As a bonus, such a survey of your billing rates can help you fix coding issues and improve your bottom line, too. So, we’ve compiled this brief guide to help you conduct your own examination of your practice’s coding and financial health.

Why All the Fuss?

Currently, critical care service claims are under Targeted Probe and Educate (TPE) medical review for Part B MACs, who’ve published their active lists like CGS Medicare, Novitas Solutions, and Palmetto GBA.

In addition, there are three separate issues that RACs are targeting:

1. Excessive units of the initial E/M code 99291(Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes);

2. Critical care services billed on the same day as an emergency department (ED) visit; and

3. The unbundling of critical care.

And as if that’s not enough, critical care services also ranked in the top 20 on last year’s Medicare FFS Supplemental Improper Payment Data Report with a 19.1 percent improper payment rate, accounting for $184 million in improper payments according to CERT auditors’ claims data.

With the heightened scrutiny, it’s vital for you to rein in unnecessary visits or make sure your documentation is bulletproof for those visits that are valid before your claims get pulled for medical review. Your best bet is to pull a random sampling of charts and review them as an auditor would — then educate physicians on any findings that didn’t support the codes they reported.

Ready to Self-Audit Now?

If you are, the first step is to collect a random sampling of critical care claims from your ED practitioners. You’ll review the chart documentation and determine which code you would report for the service, then check what the physician actually billed. Keep a tally of any discrepancies so you know what to discuss with the doctor later, when you can offer the ED physicians tips on how to select the right code.

Once you perform the self-audit, you may want to create a schedule of internal audits going forward, expanding that out to other codes beyond critical care. How frequently you perform internal audits will depend on the size and type of your ED practice. Consider the amount of resources you can devote to the audit while simultaneously conducting day-to-day business.

Pointer: Remember that the more often you can audit, the cleaner your claims will continue. At a minimum, you should conduct an internal audit at least twice a year, experts advise. After you’ve prepared your staff for the auditing process and determined when you’ll perform an audit, you’ll need to define the focus of the audit. Ask: “What do we want to accomplish?” Then focus on the following points:

Determine the audit’s scope.  Which providers, services, date range, and payers will it address?

Determine how to select charts. Will you fix this process for each provider, or will you randomize the chart selection? Pull charts and organize supporting documentation, such as a printout of physician notes, account billing history, CMS forms, and remittance advice.

Final thought: Remember that an audit is much more than coding — it involves documentation, coding, billing and data input, denials management, and office process following policies and procedures.