Transcript Joanne Byron - Click4Corp Design

A CME Program Provided by
Louisiana Regional Physician Hospital Organization
December 7, 2011
Presented by Health Care Consulting Services, Inc.
PO Box 572 Medina, Ohio 44258-0572
Speaker:
Joanne Byron, CEO
About the Speaker
Joanne Byron,
LPN, BSNH, CCA, CHA, CHCO, CIBS, CMC, COBS,CPC, CPC-I, CMCO, PCS
 Joanne has over thirty five years of consulting, auditing and
coding experience with expertise defending clients during
Probes, ZPIC and other government investigations and
audits. She is an experienced instructor in coding and
documentation, developing coding and practice management
training programs for hospital systems and community
colleges.
 Joanne serves on the National Certification Exam Board for
the American Institute of Healthcare Compliance as well as
CEO of Health Care Consulting Services, Inc.
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Disclaimer / Disclosure
Joanne Byron,
LPN, BSNH, CCA, CHA, CHCO, CIBS, CMC, COBS,CPC, CPC-I, CMCO, PCS
 Joanne Byron has declared no relevant financial or
commercial interests to disclose.
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 Improve documentation standards for
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inpatient/outpatient E&M services to
reduce risk of overpayments.
Understanding high-risk E&M areas
targeted by the Office of Inspector
General for fraud and/or abuse.
Coding Inpatient services accurately review 99222, 99223, 99232, & 99233
Avoiding noncompliance when billing
Non-physician providers as “incident to”
Split/Shared Care in the hospital
Observation codes
Critical care codes
Pitfalls of templates
CMS Audit Program
Internet Resource List
12.07.2011 Speaker: Joanne Byron
Program
Objectives
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General principles of E/M
documentation
 Evaluation and Management (E&M) happens to be
highly audited by insurance companies and
government agencies due to proven overpayment
projected conducted by CMS (such as CERT).
 Because there is high usage of E&M codes by primary
care physicians and medical specialties, if an audit
reveals even the slightest upcoding, it can be
extrapolated into enormous overpayment amounts!
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Reduce Overpayment
Risk
 It is vital to understand the complexities of E&M
documentation and coding rules to avoid high
extrapolations.
 Use the information from today’s program to help
implement an internal auditing program in your office.
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Starting with the “basics”
If it isn’t documented. . .
 Professional coders and audits understand – if it isn’t
documented, it didn’t happen.
 If it didn’t happen, it cannot be billed.
 If it is billed before being documented, there are
compliance issues.
 If documentation doesn’t meet medical necessity for
the level of service – higher levels of services will not
be approved by insurance regarding of the amount of
documentation and either downcoded or discovered
on a retrospective audit.
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Lets be clear. . .
 Clear and concise medical record
documentation is critical to providing
patients with quality care and is
required in order for you to receive
accurate and timely payment for
furnished services.
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The physician’s primary focus?
Patient diagnosis and treatment!
 Your documentation is vital for patient’s continuity of
care. There are clearly medical-legal implications
when documentation lacks appropriate information.
 However – another primary purpose of the medical
record is for reimbursement. Without appropriate
reimbursement for services rendered, your office
cannot be financially viable.
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 Health care payers may require reasonable
documentation to ensure that a service is consistent
with the patient’s insurance coverage and to validate:

The site of service;
 The medical necessity and appropriateness of the
diagnostic and/or therapeutic services provided;
and/or
 That services furnished have been accurately
reported.
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 There are general principles of medical record
documentation that are applicable to all types of
medical and surgical services in all settings.
 While E/M services vary in several ways, such as the
nature and amount of physician work required, the
following items are appropriate:
 The medical record should be complete and legible;
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 The documentation of each patient encounter should
include:
 Reason for the encounter and relevant history, physical
examination findings, and prior diagnostic test results;
 Assessment, clinical impression, or diagnosis;
 Medical plan of care; and
 Date and legible identity of the observer.
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• If not documented, the rationale for ordering
diagnostic and other ancillary services should be easily
inferred;
• Past and present diagnoses should be accessible to the
treating and/or consulting physician;
• Appropriate health risk factors should be identified;
• The patient’s progress, response to and changes in
treatment, and revision of diagnosis should be
documented; and
• The diagnosis and treatment codes reported on the
health insurance claim form or billing statement
should be supported by the documentation in the
medical record.
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 In order to maintain an accurate medical record,
services should be documented during the encounter
or as soon as practicable after the encounter.
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What Counts?
Quality – not Quantity
 The provider must ensure that medical record
documentation supports the level of service reported
to a payer.
 The volume of documentation should not be used to
determine which specific level of service is billed.
Unrelated or unnecessary documentation will be
disregarded by the government, CMS or insurance
auditor.
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OIG & EMR (electronic medical records)
 The 2012 Office of Inspector General’s Work Plan
states that Medicare contractors have noted an increased
frequency of medical records with identical
documentation across services.
 Medicare requires providers to select the code for the
service based upon the content of the service and have
documentation to support the level of service reported.
(CMS’s Medicare Claims Processing Manual, Pub. No. 10004, ch. 12, § 30.6.1.)
The OIG has added EMR and identical documentation to
their list of investigations for 2012.
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“Reasonable & Necessary” –
according to payer guidelines
 In addition to the individual
requirements associated with the
billing of a selected E/M code, in order
to receive payment from Medicare for a
service, the service must also be
considered reasonable and necessary.
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Reasonable & Necessary?
The service must be documented to
demonstrate it has was:
❖ Furnished for the diagnosis, direct care (face-to-face),
and treatment of the beneficiary’s medical condition
(i.e., not provided mainly for the convenience of the
beneficiary, provider, or supplier); and
❖ Compliant with the standards of good medical
practice.
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Medicare & Medical Necessity
 Local and National Coverage Determinations (LCDs
and NCDs) are drafted by Medicare.
 These documents provide detailed information
regarding the definition of medical necessity for
various types of services.
 Your office should be using LCDs and NCDs daily prior
to billing Medicare.
 LCDs and NCDs provide information needed for the
Beneficiary Notice Initiative for administration of
ABNs (advanced beneficiary notices)
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Following the Rules
 The two common sets of codes that are currently used
for billing are: Current Procedural Terminology (CPT)
codes and International Classification of Diseases
(ICD) diagnosis and procedure codes.
 There are strict guidelines and rules required when
applying these codes to a claim for reimbursement.
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Following the rules is required for
compliance  The Improper Medicare Fee-For-Service Payments
Report – November 2009, shows that 7.8 percent of the
Medicare dollars paid did not comply with one or more
Medicare coverage, coding, billing, or payment rules.
 This equates to $24.1 billion in
Medicare overpayments and
underpayments annually.
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 The following slides represent information from the
2012 Office of Inspector General’s Work Plan related to
E&M services
 E&M is a long-term target of interest to the Office of
Inspector General.
 Providers are responsible for ensuring that the codes
they submit accurately reflect the services they
provide.
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E&M:
Trends in Coding
OIG 2012 Work Plan
 The OIG will review E/M claims to identify trends in
the coding of E/M services from 2000-2009.
 The OIG will also identify providers that exhibited
questionable billing for E/M services in 2009.
 E/M codes represent the type, setting, and complexity
of services provided and the patient status, such as
new or established.
Joanne Byron, AIHC 11/15/2011
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E&M During Global Surgery Periods
OIG 2012 Work Plan
 The OIG will review industry practices related to the
number of E/M services provided by physicians and
reimbursed as part of the global surgery fee to
determine whether the practices have changed since
the global surgery fee concept was developed in 1992.
 The criteria for global surgery policy are in CMS’s
Medicare Claims Processing Manual, Pub. 100-04, ch.
12, § 40.
Joanne Byron, AIHC 11/15/2011
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E&M: Use of Modifiers
During Global Surgery Period
OIG 2012 Work Plan
 Investigation of certain claims modifier codes during
the global surgery period will be conducted to
determine whether Medicare payments for claims with
modifiers used during the global surgery period were
in accordance with Medicare requirements.
 Guidance for the use of modifiers for global surgeries
is in CMS’s Medicare Claims Processing Manual, Pub.
100-04, ch. 12, § 30.
Joanne Byron, AIHC 11/15/2011
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E&M: Potentially Inappropriate Payments
OIG 2012 Work Plan
 The OIG will assess the extent to which CMS made
potentially inappropriate payments for E/M services
and the consistency of E/M medical review
determinations.
 The OIG will also review multiple E/M services for
the same providers and beneficiaries to identify
electronic health records (EHR) documentation
practices associated with potentially improper
payments.
Joanne Byron, AIHC 11/15/2011
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Other High-Risk Areas related to
E&M Services
 When a CMS contractor audits your E&M records –
other high risk items can easily become the focus –
such as:
 Lack of appropriate documentation to support
injections (B12, chemotherapy, etc);
 Lack of any record to support 36415 (phlebotomy
services when lab specimen is sent to outside referral
lab); and
 Missing orders for diagnostic tests – to name just a few.
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Let’s Review the
3 key elements to E&M
1) History (includes recording chief compliant and/or
reason for each hospital visit – needed very day;
history of present illness; review of systems; and Past,
Family, and/or Social History)
2) Examination (using 1995 or 1997 guidelines)
3) Medical Decision Making (includes dx/management
options; Amt/complexity of data reviewed; and Risk)
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Recording the History Component
under difficult circumstances
 Many times hospitalists treat patients who are on
ventilators or unable to respond.
 When the history cannot be obtained directly from the
patient – history can be obtained from another source –
family member (perhaps upon hospital admission) or
nurses notes (subsequent hospital visits).
 This can apply to the office setting when treating patients
who may not be good historians (dementia, retardation,
etc) – always document the source, person providing the
history, etc.
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Start the note with the “CC”
 A Chief Complaint or “CC” is the first item
an insurance or Medicare Auditor will look
for when reviewing and E&M service.
 Each visit should clearly indicate the reason
for today’s visit – and more specific than just
“follow up”.
 Record conditions which require your
attention and treatment that day!
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Inpatient Considerations
 What new problems are evident from reviewing other
physicians, consultants or nurses notes since your last
visit?
 Have other consulting physicians made record of
conditions requiring your attention today?
 What new conditions are evident from diagnostic lab
results since your last visit? You are likely to have
reviewed the chart prior to stepping into the hospital
room! Record and/or document this information.
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Chief Compliant “CC” Guidelines
 “While documentation of the CC is required
for all levels, the extent of information
gathered for the remaining elements related
to a patient’s history is dependent upon
clinical judgment and the nature of the
presenting problem.”
 This is why recording the reason for the visit or the
“chief complaint” each date of service (including
daily hospital visits) is to very important for
reimbursement compliance!
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History of Present Illness (HPI)
 Documentation of how the patient has progressed (or
not) since your last visit.
 Guidelines state : HPI is a chronological description of
the development of the patient’s present illness from
the first sign and/or symptom or from the previous
encounter to the present.
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HPI and higher levels of service
 For higher levels of service, an extended HPI should be
recorded – this is according to both the 1995 and 1997
guidelines. At least four (4) elements of the HPI
should be documented for the visit. Here is the list of
items within the HPI category:
•Location
•Quality
•Severity
•Duration
•Timing
•Context
•Modifying factors
•Associated sign &
symptoms
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Review of Systems (ROS)
 ROS is an inventory of body systems obtained by
asking a series of questions in order to identify signs
and/or symptoms that the patient may be
experiencing or has experienced.
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Complete ROS
 A complete ROS inquires about the system(s) directly
related to the problem(s) identified in the HPI plus all
additional (minimum of ten) organ systems.
 Those systems with positive or pertinent negative
responses must be individually documented. For the
remaining systems, a notation indicating all other
systems are negative is permissible. In the absence of
such a notation, at least ten systems must be
individually documented.
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Past, Family, and/or Social History
PFSH
 Past history including experiences with illnesses,
operations, injuries, and treatments;
 Family history including a review of medical
events, diseases, and hereditary conditions that
may place the patient at risk; and
 Social history including an age appropriate review
of past and current activities.
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Complete PFSH
 A complete PFSH is a review of two or all
three of the areas, depending on the
category of E/M service.
 A complete PFSH requires a review of all
three history areas for services that, by their
nature, include a comprehensive assessment
or reassessment of the patient.
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Add’l Note on Hx Component
 The CC, ROS, and PFSH may be listed as separate
elements of history or they may be included in the
description of the history of the present illness.
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 A ROS and/or a PFSH obtained during an earlier
encounter does not need to be re-recorded if there
is evidence that the physician reviewed and
updated the previous information. You MUST
make reference to the date of service of that
previous information!
 This may occur when a physician updates his or
her own record or in an institutional setting or
group practice where many physicians use a
common record.
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Reminder about the history
 If the physician is unable to obtain a history from the
patient or other source, the record should describe the
patient’s condition or other circumstance which
precludes obtaining a history.
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Documenting the Examination –
another Key Element
 As stated previously, there are two versions of the
documentation guidelines – the 1995 version and
the 1997 version. The most substantial differences
between the two versions occur in the examination
documentation section.
 Either version of the documentation guidelines,
not a combination of the two, may be used by the
provider for a patient encounter.
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4 levels of examination
Problem Focused
Expanded Problem Focused
Detailed
Comprehensive
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 An examination may involve several organ systems or a
single organ system.
 The type and extent of the examination performed is
based upon clinical judgment, the patient’s history,
and nature of the presenting problem(s).
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1997 exam
 The 1997 documentation guidelines describe two types
of comprehensive examinations that can be performed
during a patient’s visit:
 general multi-system examination and
 single organ examination.
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 Some important points that should be
kept in mind when documenting
general multi-system and single organ
system examinations (in both the 1995
and the 1997 documentation
guidelines) are:
(next slides)
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 Specific abnormal and relevant negative
findings of the examination of the affected
or symptomatic body area(s) or organ
system(s) should be documented.
A notation of “abnormal” without
elaboration is not sufficient.
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 Abnormal or unexpected findings of the
examination of any asymptomatic body
area(s) or organ system(s) should be
described.
A brief statement or notation indicating
“negative” or “normal” is sufficient to
document normal findings related to
unaffected area(s) or asymptomatic organ
system(s).
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“MDM”
Medical Decision Making or
 Medical decision
making refers to the
complexity of
establishing a
diagnosis and/or
selecting a
management option.
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MDM is determined by considering the
following factors:
 The number of possible diagnoses and/or the number
of management options that must be considered;
 The amount and/or complexity of medical records,
diagnostic tests, and/or other information that must
be obtained, reviewed, and analyzed; and
 The risk of significant complications, morbidity,
and/or mortality as well as comorbidities associated
with the patient’s presenting problem(s), the
diagnostic procedure(s), and/or the possible
management options.
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MDM is THE Key Element!
 The complexity of the visit – the risk of significant
complications, morbidity, mortality, comorbidities
associated with the patient’s presenting problems
which you evaluated and treated MUST support the
level of history and examination.
In-other-word – the MDM really drives the level of
service – with supporting history and exam.
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Another element in E&M is
TIME
There are times when you are treating
very ill patients where counseling &
coordination of care constitutes more
than 50% of the visit.
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Time –
can be used to select level of service
 However, there may be times when counseling
and/or coordination of care constitutes more than
half of the visit - it is in these instances TIME is
used to determine the level of service.
 Time is reflected in the CPT code description.
 Total visit time and counseling time must both be
recorded in the progress note.
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Utilizing Non-Physician
Practitioners (NPPs) in the Hospital
 Share visits are permitted by
Medicare in the hospital
setting.
 Incident-to is not.
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 Shared visits require a note
from BOTH the NPP and the
physician – both notes are used
to determine the level of
service and ONE encounter is
billed under the physician’s NPI
number.
 Both providers must have a face-to-face with the
patient.
 Both notes must be appropriately authenticated.
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Utilizing Non-Physician
Practitioners (NPPs) in the Office
 Incident-to is acceptable billing to Medicare in the office
setting.
 The physician must be present in the office suite (the
physician who is reported on the claim form)
 The NPP cannot treat or diagnose new problems or see new
patients.
 The NPP can treat established patients under a physician’s
plan of care and bill the visit.
Shared/Split visits are not appropriate in the office setting.
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Critical Care –
What Hospitalists Should Know
 99291 and 99292 can only be reported when all the
criteria for critical care services are met.
 These critical care codes are NOT used simply
because a patient is in the ICU.
 Documentation must support that the physician
delivered services and intervention to a critically ill
or injured patient – let’s review Medicare’s
wording:
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Critical Care
 Critical care is defined as the direct delivery by a
physician(s) medical care for a critically ill or critically
injured patient.
 A critical illness or injury acutely impairs one or
more vital organ systems such that there is a high
probability of imminent or life threatening
deterioration in the patient’s condition.
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 Critical care involves high complexity
decision making to assess, manipulate,
and support vital system functions(s) to
treat single or multiple vital organ system
failure and/or to prevent further life
threatening deterioration of the patient’s
condition.
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 Although critical care typically requires
interpretation of multiple physiologic
parameters and/or application of advanced
technology(s), critical care may be provided
in life threatening situations when these
elements are not present.
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 Critical care is usually, but not always, given
in a critical care area such as a coronary care
unit, intensive care unit, respiratory care
unit, or the emergency department.
 However, payment may be made for critical
care services provided in any location as
long as the care provided meets the
definition of critical care.
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Chronic Illness and Critical Care:
Examples of patients whose medical condition
may not warrant critical care services:
1) Daily management of a patient on chronic
ventilator therapy does not meet the criteria
for critical care unless the critical care is
separately identifiable from the chronic long
term management of the ventilator
dependence.
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2) Management of dialysis or care related to dialysis
for a patient receiving ESRD hemodialysis does not
meet the criteria for critical care unless the critical
care is separately identifiable from the chronic
long term management of the dialysis dependence
(refer to Chapter 8, §160.4).
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Critical Care Services and Full
Attention of the Physician
 The duration of critical care services to be
reported is the time the physician spent
evaluating, providing care and managing
the critically ill or injured patient's care.
 That time must be spent at the immediate
bedside or elsewhere on the floor or unit
so long as the physician is immediately
available to the patient.
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Critical Care Services and Qualified
Non-Physician Practitioners (NPP)
 Critical care services may be provided by qualified
NPPs and reported for payment under the NPP’s
National Provider Identifier (NPI) when the services
meet the definition and requirements of critical care
services.
 The provision of critical care services must be within
the scope of practice and licensure requirements
for the State in which the qualified NPP practices and
provides the service(s).
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Critical Care Services and
Physician Time
 Critical care is a time- based service, and for each date
and encounter entry, the physician's progress note(s)
shall document the total time that critical care services
were provided.
 The CPT critical care codes 99291 and 99292 are used
to report the total duration of time spent by a
physician providing critical care services to a critically
ill or critically injured patient, even if the time spent
by the physician on that date is not continuous.
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Critical Care Criteria
 Non-continuous time for medically necessary critical
care services may be aggregated.
 Reporting CPT code 99291 is a prerequisite to
reporting CPT code 99292.
 Physicians of the same specialty within the same group
practice bill and are paid as though they were a
single physician (§30.6.5).
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Split/Shared Services Billing is
Prohibited for Critical Care Codes
 A split/shared E/M service performed by a physician
and a qualified NPP of the same group practice (or
employed by the same employer) cannot be reported
as a critical care service.
 Critical care services are reflective of the care and
management of a critically ill or critically injured
patient by an individual physician or qualified nonphysician practitioner for the specified reportable
period of time.
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 Unlike other E/M services where a
split/shared service is allowed the
critical care service reported shall
reflect the evaluation, treatment
and management of a patient by an
individual physician or qualified
non-physician practitioner and
shall not be representative of a
combined service between a
physician and a qualified NPP.
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Report Billing Units
Correctly!
 The CPT code 99291 (critical care, first hour) is used to
report the services of a physician providing full
attention to a critically ill or critically injured patient
from 30-74 minutes on a given date.
 Only one unit of CPT code 99291 may be billed by a
physician for a patient on a given date.
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Total Duration of Critical Care
Codes Less than 30 minutes
99232 or 99233 or other
appropriate E/M code
30 - 74 minutes
99291 x 1
75 - 104 minutes
99291 x 1 and 99292 x 1
105 - 134 minutes
99291 x1 and 99292 x 2
135 - 164 minutes
99291 x 1 and 99292 x 3
165 - 194 minutes
99291 x 1 and 99292 x 4
194 minutes or longer
99291 – 99292 as appropriate (per
the above illustrations)
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Critical Care Services Provided by
Physicians in Group Practice(s)
 Medically necessary critical care services provided on
the same calendar date to the same patient by
physicians representing different medical
specialties that are not duplicative services are
payable.
 The medical specialists may be from the same group
practice or from different group practices.
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Services Bundled into Critical Care
 The interpretation of cardiac output measurements
(CPT 93561, 93562);
 Chest x-rays, professional component (CPT 71010, 71015,
71020);
 Blood draw for specimen (CPT 36415);
 Blood gases, and information data stored in computers
(e.g., ECGs, blood pressures, hematologic data-CPT
99090);
List continued, next slide
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 Gastric intubation (CPT 43752, 91105);
 Pulse oximetry (CPT 94760, 94761, 94762);
 Temporary transcutaneous pacing (CPT 92953);
 Ventilator management (CPT 94002 – 94004,
94660, 94662); and
 Vascular access procedures (CPT 36000, 36410,
36415, 36591, 36600).
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Ventilator Management
 Medicare recognizes the ventilator codes (CPT codes
94002 - 94004, 94660 and 94662) as physician services
payable under the physician fee schedule.
 Medicare Part B under the physician fee schedule does
not pay for ventilator management services in
addition to an evaluation and management
service (e.g., critical care services, CPT codes 99291 99292) on the same day for the patient even when the
evaluation and management service is billed with CPT
modifier -25.
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Observation Services
 The two key identifiers when billing observation
services to Medicare are:
1. The length of stay
2. The number of calendar days
 According to Medicare rules, if an observation stay is
less than eight hours on the same calendar day, you
must bill for the initial observation care only using
Initial Observation Care codes 99218-99220
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 Admit/Discharge codes 99234-99236 are assigned
based on supporting documentation.
 Observation stays that span beyond one calendar day
are coded using the Initial Observation Care codes on
day one and Observation Discharge code 99217 on day
two.
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 When an observation stay is greater than 48 hours,
Subsequent Observation Care codes 99224-99226 are
used for the interim days.
 Medicare has instructed that these codes be reported
by only the admitting physician, although CPT®
guides us to use these for all physicians caring for the
patient during subsequent observation days. Check
with third-party payers for guidance.
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 Remember that all related outpatient E/M services
on a given calendar day are included in the
observation service. CPT® instructs:
“When observation status is initiated in the course of an
encounter in another site of service (e.g., hospital ED,
physician’s office, nursing facility) all evaluations and
management services provided by the supervising
physician in conjunction with initiating observation
status are considered part of the initial observation
care when performed on the same day.”
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 Documentation to secure correct
hospitalist observation billing
includes a dated and timed order, the
reason for observation, and notations
that support personal provision of
services by the physician.
 Document the total time spent to
adhere to the Medicare eight-hour
rule.
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Reporting Observation Hours
 Observation time begins at the clock time
documented in the patient‘s medical record, which
coincides with the time that observation care is
initiated in accordance with a physician‘s order.
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 Hospitals should round to the nearest hour. For
example, a patient who began receiving observation
services at 3:03 p.m. according to the nurses‘ notes and
was discharged to home at 9:45 p.m. when observation
care and other outpatient services were completed,
should have a ―7 placed in the units field of the
reported observation HCPCS code.

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Observation or Inpatient Care Services
(Including Admission and Discharge Services on Same Day)
 To report observation or inpatient hospital care
services provided on a patient that is admitted and
discharged on the same day use codes 99234-99236.
 The physician shall satisfy the E/M documentation
guidelines for furnishing observation care or inpatient
hospital care. In addition to meeting the
documentation requirements for history, examination,
and medical decision making documentation in the
medical record.
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Documentation shall
include:
 Documentation stating the stay for observation care or
inpatient hospital care involves 8 hours, but less than
24 hours;
 Documentation identifying the billing physician was
present and personally performed the services; and
 Documentation identifying the order for observation
services, progress notes, and discharge notes were
written by the billing physician.
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 In the rare circumstance when a patient
receives observation services for more than
2 calendar dates, the physician shall bill a
visit furnished before the discharge date
using the outpatient/office visit codes.
 The physician may not use the subsequent
hospital care codes since the patient is not
an inpatient of the hospital.
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CMS Contractor employed to identify
suspected overpayments
 Carriers and Medicare Administrative Contractors
(MACs) conduct Medical Reviews (MR).
 CMS employs Program Safeguard Contractors (PSCs)
and Zone Program Integrity Contractors (ZPICs),
which are responsible for identifying cases of
suspected fraud and taking appropriate corrective
actions.
 PSCs are being replaced by ZPICs.
The OIG has been investigating the effectiveness of
the ZPIC program and has issued a report of
findings (Click Here)
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CMS also employs . . .
 Recovery Audit Contractors (RACs) to identify and
correct underpayments and overpayments on a post
payment basis, and . . .
 The Comprehensive Error Rate Testing (CERT)
contractor performs reviews on a small sample of
Medicare Fee-For-Service (FFS) claims to produce an
annual error rate.
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Overview of the Medicare Pre and
Post Payment Claim Review Programs
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 The first two programs (NCCI Edits and
MUEs) review claims before they are paid
(called prepayment review).
 The second two programs (CERT and
RAC) review claims after they are paid
(called post payment review).
 The MR program can perform both
prepayment and post payment reviews.
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National Correct Coding Initiatives
(NCCI) Edits
 Performed by: Medicare Claims Processing
Contractors
 CMS developed the NCCI to promote national correct
coding methodologies and to control improper coding
that leads to inappropriate payment in Medicare Part
B claims.
 The NCCI edits are automated prepayment edits. This
means that as the submitted claim is processed by the
Medicare claims processing contractor’s systems, the
submitted procedures are analyzed to determine if
they comply with the NCCI edit policy.
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 Processing systems test every pair of codes
reported for the same date of service for the same
beneficiary by the same provider against the NCCI
edit tables.
 If a pair of codes hits against an NCCI edit, the
column two code of the edit pair is denied unless it
is submitted with an NCCI associated modifier and
the edit allows such modifiers.
 Appropriate modifier usage (such as -25 and -59) is
vital to avoid penalties if audited.
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Medically Unlikely Edits (MUEs)
 Performed by: Medicare Claims Processing
Contractors
 To lower the Medicare FFS paid claims error rate, CMS
established units of service edits for Medicare Part B
benefit claims, referred to as MUEs.
 Just like the NCCI edit, the MUE edit is an automated
prepayment edit that helps prevent inappropriate
payments.
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MUEs = violating units billed on
the claim form
 CMS develops MUEs based on anatomic
considerations, HCPCS/CPT code descriptors, CPT
coding instructions, established CMS policies, nature
of service/procedure, nature of an analyte, nature of
equipment, and clinical judgment.
 Providers should not interpret MUE values as
utilization guidelines. MUE values do not represent
units of service that may be reported without concern
about medical review
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MUEs Process
 Claim lines that pass the MUE edits continue to be
processed.
 Those claim lines that report units of service greater
than the MUE value for the HCPCS code on the claim
line are denied.
 A claim line denial due to an MUE may be appealed.
Providers may request modification of an MUE value
by contacting the NCCI contractor.
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Additional MUE Resources
 CR 6712– Medically Unlikely Edits
(MUEs) Click Here
 CCI Edits: Medically Unlikely Edits
(MUEs) Click Here
 CMS MUEs Page Click Here
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Carrier/FI/MAC MR Program
 Performed by: Medicare Claims Processing
Contractors
 Through error rates produced by the CERT Program,
vulnerabilities identified through the RAC Program,
analysis of claims data, and evaluation of other
information (e.g., complaints), suspected billing
problems are identified by Medicare claims processing
contractors.
 MR activities are targeted at identified problem areas
appropriate for the severity of the problem.
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 If the Medicare claims processing contractor
verifies that an error exists through a
review of a small sample of claims, the
contractor classifies the severity of the
problem as minor, moderate, or
significant and imposes corrective
actions that are appropriate for the severity
of the infraction.
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Corrective Actions Resulting from MR can
be 1 of 3 options:
Provider Notification/
Feedback
Prepayment review
Postpayment review
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Provider Notification/Feedback
 Problems detected at minor, moderate,
or significant levels will require the
contractor to inform the provider of
appropriate billing procedures.
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Prepayment review
 Prepayment review consists of MR of a
claim prior to payment. Providers with
identified problems submitting correct
claims may be placed on prepayment
review, in which a percentage of their
claims are subjected to MR before
payment can be authorized.
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Post-payment review
 Post payment review involves MR of a claim
after payment has been made.
 Post payment review is commonly
performed by using Statistically Valid
Sampling.
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Comprehensive Error Rate Testing
(CERT) Program
 Performed by: CERT Review Contractor (CERT RC)
and CERT Documentation Contractor (CERT DC)
 CMS uses the CERT Program to produce a national
Medicare FFS error rate as required by the Improper
Payments Elimination and Recovery Act.
 CERT randomly selects a small sample of Medicare FFS
claims.
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 CERT then reviews the claims and medical records
from providers/suppliers who submitted them,
and then reviews the claims for compliance with
Medicare coverage, coding, and billing rules.
 In 2009, the CERT contractor randomly sampled
99,500 claims from Medicare claims processing
contractors during a one-year period.
 This process was designed to pull a blind sample of
claims each day from all of the claims providers
submitted that day.
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 CERT contractors follows Medicare
regulations, billing instructions, National
Coverage Determinations (NCDs), coverage
provisions in interpretive manuals, and the
respective Medicare claims processing
contractor’s Local Coverage Determinations
(LCDs).
 The CERT contractor does not develop or
apply its own coverage, payment, or billing
policies.
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Paid Claims Error Rate
 This rate is based on dollars paid after the Medicare
contractor made its payment decision on the claim.
This rate includes fully denied claims for FFS claims.
 The paid claims error rate is the percentage of total
dollars that all Medicare FFS contractors erroneously
paid or denied and is a good indicator of how claim
errors in the Medicare FFS Program impact the trust
fund.
 CMS calculates the gross rate by adding
underpayments to overpayments and dividing that
sum by total dollars paid.
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Provider Compliance Error Rate
 This rate is based on how the claims looked when they
first arrived at the Medicare claims processing
contractor before the contractor applied any edits or
conducted any reviews.
 The provider compliance error rate is a good indicator
of how well the contractor is educating the provider
community since it measures how well providers
prepared claims for submission.
 CMS does not collect covered charge data from
provider facilities that submit claims to FIs or A/B
MACs; therefore, current facility data is insufficient for
calculating a provider compliance error rate.
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Other Error Rates
 The CERT report may also describe other error rates to
provide the most specific information available to
target problem areas.
 Other error rates include error rates by service type
and by provider type.
 CERT has initiated four supplemental measures that
will be reported annually, Power Mobility Devices
(PMDs), Chiropractic Services, Pressure Reducing
Support Surfaces, and Short Hospital Stays.
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CERT Process
 The CERT post-pay medical review process begins at
the Medicare claims processing contractors.
 After the claims have been processed, samples of the
claims are selected for CERT review.
 The CERT then uses information from the claims
processing contractors to request documentation from
the provider/supplier who submitted the sampled
claim.
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 The claim and the supporting documentation are
reviewed by CERT Program clinicians who
determine whether the claim was submitted and
paid appropriately.
 The CERT Program collects additional information
from the contractor for each claim considered to
be in error via a feedback process.
 Due to the sampling methodology, a small
percentage of providers would be subject to CERT
review.
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However . . .
 provider claims that are selected for CERT review are
subject to potential post-pay payment denials,
payment adjustments, or other administrative or legal
actions depending upon the result of the review.
 Claims can be adjusted or denied based on the CERT
review and normal appeals rights and processes do
apply.
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Recovery Audit Contractor (RAC)
 Performed by: Medicare FFS RAC Contractors
 In March 2010, Congress again expanded the role of
recovery audit contracting in the Affordable Care Act.
 The Affordable Care Act expands the RAC Program to
Medicaid and Medicare Parts C and D.
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 This change requires all states to establish
individual Medicaid RAC Programs under
their State plan or waiver.
 In addition, the Affordable Care Act
provision requires these RACs to also serve
in a program integrity capacity, reviewing
each Medicare Advantage and Part D plan’s
anti-fraud plan.
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RAC Process
 RACs apply statutes, regulations, CMS national
coverage, payment, and billing policies, as well as
LCDs that have been developed by the Medicare claim
processing contractors.
 RACs do not develop or apply their own coverage,
payment, or billing policies.
 In general, RACs will not review a claim that has
previously been reviewed by another entity.
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 RACs analyze claims data using their
proprietary software, and identify claims
that contain improper payments and those
that likely contain improper payments.
 If a RAC finds an improper payment, the
RAC sends a file to the claims processing
contractor to adjust the claim and payment
are recouped.
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 In the case of claims that contain likely
improper payments, the RAC requests the
medical record from the provider, reviews
the claim and medical record, and then
makes a determination as to whether the
claim contains an overpayment, an
underpayment, or a correct payment.
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 If a denial or adjustment is indicated by the
review of records, providers will receive
overpayment/ underpayment notification
letters.
 Providers can appeal denials (including no
documentation denials) following the
normal appeal processes by submitting
documentation supporting their claims.
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Best Advice
 Keep in mind reimbursement is one of the primary
purposes of the medical record.
 Maintain records to support coordination of care
while being compliance with medical necessity
and other critical documentation criteria.
 Contact internal audits periodically to review
billing, coding and documentation compliance.
 Stay abreast of coding guidelines and ensure
billing staff are properly submitting claims.
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A Word on Templates
 A word on templates… be careful of
cloning.
 Make sure your documentation
doesn’t sound repetitive from
patient to patient.
 Each medical record must be
individualized for the specific
patient.
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Resources
 Online CMS Internet Only Manuals
Click Here
 1995 and 1997 E&M Documentation
Guidelines Click Here
 Dr. Peter Jenson – E&M University
Click Here
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OIG Internet
Resources
 Advisory Opinions: Click Here
 Fraud Alerts: Click Here
 Compliance Guidance: Click Here
 Open Letters: Click Here
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Thank you for your
time!
Speaker – Joanne Byron
Questions?
Contact Joanne at Health Care Consulting Services, Inc
by Email [email protected]
or call 330-241-5661
Web site: www.hccsincorp.com
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