Practice Management Alert

Experts: Insurers are paying added attention to modifier 25, 59 claims

If you-re not conducting internal chart audits, you may be forfeiting thousands of dollars that your practice is rightfully entitled to.

-Not only will a chart audit uncover documentation and coding errors, but missed revenue is often found--services that should have been reported but were not captured,- says Deborah Grider, CMA, CPC, CPC-H, CPC-P, CCS-P, CCP, EMS, president of Medical Professionals Inc. in Indianapolis and AAPC National Advisory Board president-elect.

Examples: -The billing staff at one [primary-care practice] failed to report any modifiers for office encounters, costing the practice $30,000 in unpaid services that year,- says Curtis Udell, CPAR, CPC, CMPA, senior advisor with Health Care Advisors Inc. in Annandale, Va.

Udell also remembers one audit that uncovered improper modifier assignment, and the practice had no claims correction or appeals processes. -It cost the practice $450,000 in revenue in one year,- he says.

(Note: For more information on internal chart audits, see -How Chart Audits Can Help You Capture Missed Charges- in last month's issue of Medical Office Billing & Collections Alert.)

Audit Your Most-Used Procedure, E/M Codes

When you are conducting your internal audit, focus on the billing issues that are most likely to disrupt the office's cash flow or cause compliance issues.

Internal audits should largely focus on the following, according to Ian S. Easton, PhD, head of Applied Technology at Coastal Georgia Community College in Brunswick, Ga:

- areas the Office of the Inspector General (OIG) plans to target in its Work Plan (http://oig.hhs.gov/authorities/docs/physician.pdf)

- higher-level evaluation and management codes

- high-cost surgeries/procedures that the practice performs often.

Audits should be based on the utilization patterns of the physician and the billing areas the insurance carrier is concerned with, Grider says.

For example: An audit of the reporting practices of Provider B for the last six months indicates that Provider B has reported 20 level-five new patient E/Ms (99205, Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; medical decision-making of high complexity) and only seven  level-three new patient visits  (99203, ... a detailed history; a detailed examination; medical decision-making of low complexity).

The audit shows that Provider B could be a billing outlier. In this instance, make sure that Provider B can justify the E/M levels, or the office might be marked with -billing outlier- status. There is a very good chance that Provider B is overcoding some 99205 services.

Pay Attention to These Hot Spots

When you are considering which types of services and procedures to focus on during the audit, there are certain types of claims that you should audit because payers are paying close attention to them.

During your internal chart audits, experts recommend, you should pay close attention to:

- new and established patient E/M visits. Don't neglect auditing these E/M visits, because practitioners often do not fulfill all of the requirements necessary for the care level they choose.

-Many times, you will find services that the practitioner did not document enough history to reach a higher level, but the complexity for the higher level was evident,- Grider says.

In many of these cases, the practitioner reports the higher level inappropriately, and you-ll want to eliminate this pattern with your audit.

Also, an audit of E/M visits might show that there are opportunities for more reimbursement, says Susan Hvizdash, CPC, CPC-EMS, CPC-EDS, physician educator for the University of Pittsburgh Physicians Department of Surgery and AAPC National Advisory Board Member.

Internal E/M audits often uncover -middle-of-the-road- coding, which occurs when the practitioner chooses level-three codes almost exclusively, eschewing opportunities to report level-four or level-five codes.

For example, Dr. X conducts a comprehensive history and exam on a patient, along with high-complexity medical decision-making. Even though this is a level-five service, a -middle-of-the-road- coder would still report a level-three E/M code for the service.

- use of modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on claims. Many providers do not perform extensive enough E/M services to rightfully report an E/M with modifier 25, Hvizdash says. (For more information on new documentation rules for modifier 25, see this month's Recipe for Billing Success, later in this issue.)

- use of modifier 59 (Distinct procedural service). Modifier 59 use also sticks in payers- crosshairs, because the modifier -essentially has the ability to override all edits in its path,- she says. For this reason, your modifier 59 claims must be supported by substantial documentation.

- consultation coding (CPT codes 99241-99255). Payers always pay close attention to consults because of the service value. -Consults have higher RVUs (relative value units) and are paid about 25 percent higher than the comparable new patient office visit codes (99201-99205), so they are a constant target,- Udell says.