Practice Management Alert

Question: Our Medicare carrier is doing a lot of prospective audits of regional billing offices, and the rumor is that Medicare is requesting nursing-home notes. How can we respond in the most compliant way possible when the carrier comes for us? How can we also learn from the auditing process?

Massachusetts Subscriber

Answer: When Medicare's bell tolls for your office, you want to keep good records of its audit so you can learn from it. Keep a log of Medicare's requests, the date you received them, the providers, patients'names, what codes you reported, and what responses you sent to Medicare. Make sure the responses aren't sent out by just anyone. The manager in your office should review all of the information before you respond to Medicare's request. Ensure that what you send them is legible. If you fax the notes to Medicare, the reviewers may not be able to read the copy.

Every month, go back through the log and see what Medicare has paid you and what it denied of your requests and then learn from the audit. The only way you'll find out what Medicare will end up paying you after the audit is to look out for what it sends you. The audited claim won't be highlighted; Medicare will just pay it out, lower the code, or deny it, depending on how they assess your documentation. Medicare's request is the only measurement that tells you Medicare's "opinion" of your documentation. If Medicare downcodes your claim, figure out why, and audit the claim yourself to see if you agree.

Teach providers what you've learned from the Medicare providers. Show them Medicare's changed claim, saying, "This is the one that we billed as a 99312, and Medicare audited it as 99311. We agree with Medicare because of these components. So, from now on, if this is the level of service you provide and document, use code 99311 for appropriate billing." Or, "This is a claim that was coded as a 99312, and it's paid as a 99312. So, we're on the right track."

You Be the Expert and Reader Questions contributed by A. Clinton MacKinney, MD, MS, the AAFP representative on the AMA CPTAdvisory Committee and medical director at HealthPartners Central Minnesota Clinics in St. Cloud, Minn.; Betsy Nicoletti, CPC, a consultant with Helms in Concord, N.H; Sandra Soerries, CPC, CPCH, director of healthcare compliance services with Tait Advisory Services, a consulting firm in Kansas City, Mo.; reviewed by Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc., in Spring Lake, N.J.