Pulmonology Coding Alert

Pass the four-pronged test from CERT reviewers.

You don’t want to be on an auditor’s wrong side. Presenting messy records or illegible documentation may lead to a slap on the wrist, but missing documentation will most certainly prove to be your worst audit sin. Follow our simple preparation tips to steer clear of auditing traps. 

Provide the Auditor with Sufficient Information

This is the heart of a recent Comprehensive Error Rate Testing (CERT) finding, which the Centers for Medicare & Medicaid Services’ (CMS) published in its most recent Medicare Quarterly Provider Compliance Newsletter. Noting that reviewers are “vexed by insufficient documentation,” the agency says that it can be very difficult for reviewers to get documentation, often having to “use investigative measures” to find the source of the records, and even then hitting dead ends. Suffice it to say that if you don’t back up your codes with accurate records, Medicare will want you to give back any money paid to you for those services, which means that missing documentation could cost you a fortune.

CERT reviewers noted that they used a four-pronged approach to seeking documentation from providers, including phone calls and faxes, personal conversations, requests for clinicians to sign attestation statements for medical records that were missing signatures, and searching the internet to find providers. “Even with this intensive follow-up effort,” CMS said, “Documentation frequently was either not obtained or did not contain the information necessary to properly pay the claim.”

Common slip-up: CERT auditors frequently ask a provider for an item that’s missing from the documentation and may just receive a response that comprises the exact same records they already have been sent earlier. “For instance, your pulmonologist billed code 95810 (Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist) to diagnose a patient with narcolepsy. On occasion, a sleep study may be reported more frequently than allowed by the contractor. Most contractors acknowledge this unusual situation, and require an explanation,” explains Carol Pohlig, BSN, RN, CPC, ACS, Senior Coding & Education Specialist at the Hospital of the University of Pennsylvania.

For example, “Novitas instructs that, “Initial polysomnography (PSG) and MSLT occasionally fail to identify narcolepsy.” Novartis further clarifies that “Repeat polysomnography may be indicated and is usually facility based: 

• if the first study is technically inadequate due to equipment failure; 
• if the subject could not sleep or slept for an insufficient amount of time to allow a clinical diagnosis; 
• if initiation of therapy or confirmation of the efficacy of prescribed therapy is needed; or 
• if the results were inconclusive or ambiguous.”

Resource: (http://www.novitas-solutions.com/LCDSearchResults/faces/spaces/search/page/lcd.jspx?Jurisdiction=JL&_afrLoop=1611629463907000&State=Pennsylvania&_afrWindowMode=0&lcdID=L27530&medicareType=Part+B&_adf.ctrl-state=17r2i9u7om_4)

What to do: If the claim comes under scrutiny, and the response to the initial request for document only included the completed PSG, the contractor may request additional documentation, advises Pohlig. The response to the second request should include the missing supportive information such as the initial PSG that identifies the failed study, and the physician visit(s) that established the initial and subsequent need (if applicable) for PSG testing,” she adds.

Remedy: If you find yourself in this situation, don’t try to save time by resubmitting the same documentation again. Instead, take the time to find the missing information and get it to the auditor as soon as possible so you won’t have to repay the MAC.

Treat an Auditor Request With Open Mind

If auditors tell you they want to review your records, don’t panic. Auditors aren’t necessarily on a witch-hunt -- they may find no wrongdoing at all in your documentation. “The term ‘auditor visit’ is itself now a misnomer as the auditors typically do not come to the practice sites as done in the past, but do their enquiries usually via mail or off-site EMR access,” says Pohlig. 

You should pull all encounters that have been selected for audit with all the accompanying documentation, and double-check that everything required is in each file. 

Pulmonology spotlight: For example, if your provider performed an in-office spirometry test, ensure that the physician’s order for it is with the documentation -- otherwise you will have to look for it later.

Important: If you do find any issues while preparing your records for audit, do not alter documentation, change billing records, destroy records, or in any other way compromise the information. You may want to contact your practice’s attorney for advice on how to present the information to the auditor.

Resource: To read the recent Medicare Quarterly Provider Compliance Newsletter, which discusses the auditors’ findings, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN909051.pdf.