EM Coding Alert

Hint: Look for the same patterns CMS is seeing.

The latest focus for recovery audit contractors (RACs) is going to be on physician practices. So believes Frank D. Cohen, director of analytics and business intelligence with Doctors Management, LLC, during the January 24, 2019 webinar “Building a Risk-Based Audit Plan.”

That means your practice needs to be aware of what the RACs are looking for and use the same investigative methodology they use when you perform your own internal audits.

Here’s how to prepare yourself for RAC scrutiny if, or when, that time comes.

Know the Approaches CMS Uses

CMS itself says that it has developed “a variety of approaches over the past several years to audit Medicare and Medicaid claims.” One of those is the Fraud Prevention System (FPS), which CMS introduced in July 2011 as a series of predictive analytical algorithms designed to identify high-risk providers,” said Cohen.

“Beginning at that time, 100 percent of all Medicare fee-for-service claims – including your claims – are passed through these algorithms prior to payment,” he said. CMS reported that during the FPS’ first three years, it was able to prevent nearly $1 billion in inappropriate payments from being sent out and recouped another $2.4 billion in payments that its contractors had already sent to providers, which were later determined to require recoupment.

When reviewers go over your claims, they’re looking for a wide variety of issues. “On the lowest level are just basic mistakes,” Cohen said. “We have a really complex coding system with complex coding guidelines, and there are some 2.6 million edits out there among all payers, so these are simple mistakes like transposed diagnosis or procedure codes. For instance, I’ve seen people bill out $99,213 when they meant to just put in the code 99213 – the issue just involved adding the number in the wrong box.”

Inefficiencies create a lot more financial waste, and include issues like lack of medical necessity, medically unnecessary services, improper diagnosis code linking, and sometimes just bad coding practices by the provider.

The bending of resources often results in accusations of abuse, and that can include improper billing practices such as upcoding, improper referrals, or use of unlicensed or unregistered staff, Cohen said.

There’s also fraud, which involves deception such as billing for services that weren’t provided, or intentionally unbundling services when it’s clear it wasn’t permitted, or even altering medical records. “But remember that fraud only accounts for about three percent of what that total spending dollars are, so it’s a small percentage compared to what we find in the other areas,” Cohen said.

Auditors Seek Patterns

“Auditors have access to all the data of the claims that have been reviewed … they’re looking for patterns,” Cohen said. “If they find patterns, they do an expected value calculation trying to determine their return on investment for these particular audits. They want to know for every dollar spent how much they get back.”

In some cases, reviewers won’t come to your practice and perform an audit – they’ll instead ask you to do a self-audit and report the results to them. In other cases, you’ll be audited based on red flags that reflect what the government is seeking as part of the OIG Work Plan. “Billing for critical care and E/M services, hyperbaric oxygen services, and other items are on it currently, and all of them have the ability to drill down to a more specific area,” Cohen said.

A way to see whether your practice might throw up any red flags is to compare the national frequency of particular pulmonology services to the frequency those services are performed at your own practice, Cohen said. “To do this, you’d look at your top 25 most frequent services and compare that back to the data from the government,” Cohen said. So, if the national average of a code is 3.57 percent of all services and one specific pulmonologist does it twice as often, the higher the priority for performing a self-audit and reviewing that service to ensure you are coding, documenting, and billing it correctly.

Check These Pulmonology-Specific Examples

Consider this list of the most frequently-performed services by pulmonologists based on Medicare utilization data, and compare your practice’s utilization to theirs:

1. 99232 —  Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components …This code represents 12.55 percent of pulmonologists’ claims
2. 99214 — Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity …This service comprised 9.48 percent of pulmonologists’ claims.
3. 99233 — Subsequent hospital care…This code represented 9.09 percent of pulmonologists’ claims
4. 99213 — Office or other outpatient visit ... This comprised 6.15 percent of pulmonologists’ claims.
5. 99291 — Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. This code was reported on 5.30 percent of pulmonologists’ claims.

Pulmonology Coding Alert reviewed the services of select pulmonologists in the US based on their Medicare submission data. In one case, a Florida chest physician reported 99232 as his top-billed code, much like the list above, but it comprised 37 percent of his services. Likewise, 99214 was his second most-reported code, but it represented 27 percent of his services. Because his frequency rates for these services are more than double the national averages, this practice should consider pulling some charts for these codes and evaluating whether the documentation supported the services.

It’s certainly possible that all of his services were reported appropriately, but if not, it’s time to send money back to Medicare and educate the physician on how to appropriately select codes for his services.

A review of another Florida physician’s claims showed that she reported 99213 more than any other E/M code, representing 0.13 percent of her services. Her frequency of billing 99232, 99214, and 99233 was even lower, showing that this physician is significantly below the frequency rates for the top four most-billed codes. Again, you’d want to pull the pulmonologist’s charts and confirm that she is documenting and coding correctly.