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samyjm13

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Calling all experienced ortho coders.....we have a new ortho doc. and he seems to code all most all of his visits with 99205 or 99215 and I disagree with his level of coding. I have followed my ortho audit sheet and feel that most of the time his high level does not meet the required components. We are having quite a problem. I am feeling I am missing something. I have gone to quite a few resources and they are still arguing with myself and my manager. Can someone please help educate me on coding orthopedics at such a high level. Am I missing something. :confused::(

I might be asking a lot but the way I feel right now I could use all the help I can get.

Thanks so much!!!
samy
 
samyjw said:
Calling all experienced ortho coders.....we have a new ortho doc. and he seems to code all most all of his visits with 99205 or 99215 and I disagree with his level of coding. I have followed my ortho audit sheet and feel that most of the time his high level does not meet the required components. We are having quite a problem. I am feeling I am missing something. I have gone to quite a few resources and they are still arguing with myself and my manager. Can someone please help educate me on coding orthopedics at such a high level. Am I missing something. :confused::(

I might be asking a lot but the way I feel right now I could use all the help I can get.

Thanks so much!!!
samy
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You should start by (gently) warning him that he's painting a huge target on his back for an OIG/RAC audit, by billing the highest level of service consistently. The software that's used to pick providers for audits, looks for 'outliers' - doctors whose billing patterns are unusual when compared to their peers. Those who bill a high percentage of 99214's and 99215's are especially vulnerable, because those codes are so expensive - upcoding is considered abusive billing, and is always at the top of the OIG's work plan (see: http://blogs.hcpro.com/medicarefind/2011/11/2012-oig-work-plan-for-professional-services/)

You can figure out how much of an outlier he is, by looking at all of the claims billed out over a given time period, and comparing them to CMS's data (http://www.cms.gov/MedicareFeeforSvcPartsAB/04_MedicareUtilizationforPartB.asp)

Here's the 2010 list for E/M: http://www.cms.gov/MedicareFeeforSvcPartsAB/Downloads/EMSpecialty2010.pdf?agree=yes&next=Accept

You have to do the math yourself, though - for example's sake, I've figured the percentages for orthopaedic surgeons for you, for established patients:

99211 = 57,398 charges = 1%
99212 = 1,569,779 charges = 19%
99213 = 4,797,461 charges = 59%
99214 = 1,559,479 charges = 19%
99215 = 146,545 charges = 2%
(Math refresher, for those who forgot how to figure percentages: add them all together, and then divide each amount by the total ...the total for these charges is 8,130,662, so to get the percentage of 99213's billed, I divided 4797461/8130662...then move the decimal place two places to the right on the answer, and round it to the nearest whole #)

You'd do the same for your provider's raw data to get their percentages, and compare the 2 - (it's a lot easier if you have Excel - you can make a chart with them side by side, and really see where they differ). If your provider is billing 99215's more than 20% of the time, they are far more likely to be audited than someone who bills mostly 99213's, even if the level of service is warranted every time. But, they still get to decide if it's worth the risk, so to persuade them that it's probably not, you can reference this stuff (although, if Trailblazer's not your MAC, you may want to get similar publications from your MAC's website - otherwise, he might dismiss it as 'irrelevant' to him):

http://www.trailblazerhealth.com/Publications/Job Aid/medical necessity.pdf

http://www.trailblazerhealth.com/Publications/Job Aid/DocumentingComponentsEOV.pdf

http://www.trailblazerhealth.com/Pu... preventing most common e-m coding errors.pdf

Hope that helps! ;)
 
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Thanks, I forgot to mention that this doc. at his office doesn't take medicaid or medicare patients, when he comes to our clinic he agreed to take them, and I think that is where the disagreement comes from. Again, thanks so much for the info. it will help.
 
Although it may reduce the risk of being audited, lack of Medicare and Medicaid participation doesn't make a provider invincible to the law. Private payers conduct audits with the same parameters as government payers, and they can cause a provider to lose their contract with the payer. Additionally, some healthcare fraud laws are applicable to all forms of health care, whether provided to a Federal program beneficiary, or not. If the provider sees VA or Tricare patients, or patients who are covered by Federal employee health plans, they can still be held liable under several Federal laws, for submitting claims to government-funded programs, which are not supported by documentation, or are not medical necessary.

You should do what you can to inform them of your concerns, document your efforts, and if the behavior continues, it may be advisable to seek other employment. Never allow yourself to get caught up in someone else's shady dealings. But, on the flip side of that, you should also do your homework to be certain that what you're seeing is incorrect, if you have any suspicions about a provider's motives in their code choices. Keep in mind that many aspects of coding are subjective, and may be interpreted in more than one way. If the physician can reasonably justify their code selection, and they are able to support it with documentation, you should trust their discretion as a practitioner.

See: http://www.supercoder.com/articles/...if-doctor-cheats-can-billers-be-charged-8495/
 
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