Gastroenterology Coding Alert

Check these benchmarks to get the scoop.

Physician practices are increasingly in the spotlight as Medicare auditors increase their rates of Part B reviews, but practices don’t have to be in the dark about whether they’re at risk of getting audited.

That was the advice from Frank  D.  Cohen, director of analytics and business intelligence with Doctors Management, LLC, during the January 24 webinar “Building a Risk-Based Audit Plan,” in which he advised practices how to ensure that they’re prepared for claims scrutiny.

Read on so you can ensure that your GI practice has the tools necessary to be ready.

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, Cohen said.

“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.

A way to see whether your practice might raise any red flags is to compare the national frequency of particular gastroenterology 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 gastroenterologist 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 GI-Specific Examples

Consider this list that shows some of the most frequently-performed services by gastroenterologists based on the latest utilization data from Medicare, and compare your practice’s utilization to theirs:

1. 99213 -- Office or other outpatient visit...  This code comprised 13.42 percent of gastroenterologists’ claims.

2. 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 11.13 percent of gastroenterologists’ claims.

3. 99214  -- Office or other outpatient visit for the evaluation and management of an established patient…This service comprised 9.94 percent of gastroenterologists’ claims.

4. 43239 -- Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple. This code represented 8.47 percent of gastroenterologists’’ claims 45380 -- Colonoscopy, flexible; with biopsy, single or multiple. This code was reported on 4.58 percent of gastroenterologists’ claims.

Gastroenterology Coding Alert reviewed the services of select GI physicians in the US based on their Medicare submission data. In one case, a Connecticut gastroenterologist reported 99213 as his top-billed code, much like the list above, but it comprised 25 percent of his services. Likewise, 99232 was his second most-reported code, and it represented 12 percent of his services. Because his frequency rate for 99213 was nearly double the national average, this practice should consider pulling some charts for this code 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 Connecticut physician’s claims showed that he reported infliximab injections (J1745) more than any other code, representing 28 percent of his services. His frequency of billing 99213, 99232 and 99214 were all below five percent, showing that this physician is significantly below the frequency rates for the top-billed E/M codes. Again, you’d want to pull the physician’s charts and confirm that he is documenting and coding correctly.

Perform Self-Audits Efficiently With These Tips

Your audit plan is the most important part of your compliance program, because without it, your compliance plan is nothing more than a policy and procedural binder stuck on a shelf somewhere, Cohen said.

If you determined that your code utilization is dramatically different from Medicare averages, then you might pull five charts to start your audit, based on the codes you’ve identified as being performed more frequently than average. If you find issues with those five, look at five more, Cohen said. “If six out of the ten are improper, you may want to pull a statistically valid random sample of at least 30.”

If you haven’t evaluated your code utilization and instead you’re performing a random probe audit, you should pull more charts – typically about 200 per physician, he said. Check whether the physicians are coding and documenting correctly, and then calculate the results and determine your audit schedule.

Some practices say if the charts they reviewed were coded correctly 90 percent or more of the time, they audit annually, then they move to quarterly audits if the success rate is between 75 and 90 percent, Cohen said. If the accuracy rate is between 60 and 75 percent, they audit monthly, and if it’s below 60 percent, they’d audit every claim before submitting. You can use a variation on this schedule at your own practice, he said, or you can simply create the schedule that suits you best.

“When you’re done, set up a trend analysis so you can see from period to period and determine how your education and training worked,” he said. “Did the providers do better or worse? Did they respond positively? Are they immune to training? Because you spend lot of time and money on this and you want to know how it’s working.”