Medicare Compliance & Reimbursement

Reviewing claims for medical necessity is a critical part of the in-house audit process. But your coders’ and auditors’ interpretation of medical necessity may diverge from that of your clinical staff, which is why solid documentation is vital to both auditing and claims success.

“I’ve always taken the stance that medical necessity is really part of the audit. Medical necessity is not always about the service itself, but the documentation justifies the service,” says Terry Fletcher, BS, CPC, CCC, CEMC, SCP-CA, ACS-CA, CCS-P, CCS, CMSCS, CMCS, CMC, QMGC, QMCRC, owner of Terry Fletcher Consulting Inc. and consultant, auditor, educator, author, and podcaster at Code Cast, in Laguna Niguel, California.

Move Away From Subjectivity

One silver lining of the usefulness of audits is the way they force practices to neutralize any subjectivity surrounding a particular patient or interaction and shift focus only to the hard facts.

For example: If a patient comes in with a request for a mole check and your office performs bloodwork, you’ll need to really demonstrate, via documentation, why the diagnostic testing is necessary. Or maybe you have an established patient coming in and the physician refills their prescription and talks about some minor lifestyle changes — such as the number of miles a patient runs per week — and your office is billing a level of E/M service that may be technically OK but isn’t ethically appropriate.

In scenarios like this, a formal internal audit looking at levels of service reported and medical necessity may bring up valid questions.

It’s not that the provider rendered a service that was medically necessary for the evaluation and management of the patient, but rather that the documentation does not demonstrate the medical necessity for the level of service that’s billed, Fletcher says.

Make it part of your coding and billing audit process to look at the entirety of the document, Fletcher says. Look at the 360-degree view of the record, not just snippets. The Centers for Medicare & Medicaid Services (CMS) is looking at everything that’s included on that date of service — so you should too.

“If something is included that wasn’t warranted or didn’t have medical necessity behind it, that’s also part of the discussion,” Fletcher says.

Assign Level of Service Carefully

Regardless of whether you’re familiar with the idea of a physician ordering tests unsupported by a patient’s clinical record, you can find out exactly how much of a problem this may be in your practice.

Conducting internal and external audits, at least annually, is a good way to achieve peace of mind, Fletcher notes.

When you audit medical records, it’s to see if you can support the level of service. But you look at the “360-view” and ask whether documentation supports the whole record, including the tests ordered, she says.

Don’t Get Lazy With Telehealth

“You can’t bill anything that isn’t medically indicated or within the rules for coverages,” Fletcher cautions. Don’t forget that this applies to telehealth too, where there are very specific requirements.

The public health emergency (PHE) has loosened some of the restrictions on telehealth coding and billing, but the easing of rules really applies only to situations affected — at least tangentially — by COVID-19. The cutting of red tape surrounding telehealth would mostly affect services that were covered if the patient (who doesn’t have to have COVID or be tested for COVID) were to come into the office. This also applies to nonphysician providers (NPPs) whose telehealth services can be reimbursed under certain PHE-specific rules.

Important: Make sure you know and are following the guidelines as specified by CMS. Why? It is critical that your team be thorough in their auditing, because regulatory agencies are looking out for pandemic-related fraud and are now stepping up enforcement.