Edwin J. Polverino, D.O. Slide 2 Slide 3 Audits Internal audits
Private insurance company audits for quality and accuracy. Private
insurance company audits for fraud and abuse. Government audits for
data collection, quality and accuracy. Government audits for fraud
and abuse. Slide 4 ZPICs The Centers for Medicare & Medicaid
Services (CMS) have added a new contractor to the health care audit
program. This program has replaced two other audit contractors and
consolidated benefit integrity activities. This is called the zone
program integrity contractor (ZPIC). This is a streamlined approach
that is expected to lead increased enforcement activities in to
2011. Slide 5 ZPICs ZPICs will be responsible for ensuring the
integrity of all Medicare- related claims under Parts A & B.
The objective is to identify, stop and prevent Medicare and
Medicaid fraud, waste, and abuse and referring instances to the
appropriate law enforcement. To carry out these objectives, they
are authorized to conduct audits, interview beneficiaries and
providers; initiate administrative sanctions; and refer providers
to law enforcement. Slide 6 ZPICs Audits are never random and a
provider that is selected for a ZPIC audit should understand that
they are under investigation for potential fraud or they are trying
to determine if a fraud investigation should be opened. An audit
could be initiated several ways: use of data analysis to detect
high frequency of certain services as compared to local and
national patterns, trends of billing, any other information
suggesting the provider is an outlier compared to his peers and
audits in response to complaints. Slide 7 ZPICs These audits are
typically un-announced or occur with little notice. Representatives
from ZPIC will sometimes visit providers on-site to conduct audits.
In addition to requesting records, they may conduct interviews with
the providers employees. Slide 8 ZPICs There are three potential
outcomes after an audit: 1. Refer the provider to law enforcement
(OIG) 2. Refer audit results including statistical calculation of
an extrapolated overpayment to provider to MAC (Medicare
Administrative for collection 3. Provider education NOTE THE WORD:
Provider in the above possible outcomes. The law is clear on this
issue, this means you, not your employer. Slide 9 ZPICs Providers
should expect to see a significant increase in audits. To avoid an
audit: Ensure you are following all Medicare policies and
procedures including any applicable coverage decisions. Document
fully and completely all necessary elements before submitting
claims to Medicare. Periodic internal audits. Slide 10 ZPICs To
ensure you have a plan in place if ZPIC shows up: Designate a point
person Establish specific policies Create an intake and tracking
system for the audit Develop and implement a compliance program
Provide training for providers on an ongoing basis Slide 11
Questions on ZPIC? Slide 12 With ZPIC in mind Lets talk about
correct coding.. Slide 13 Undercoding 33% of Primary Care
physicians undercode Possible reasons for undercoding: fear of
violating fraud and abuse laws & misunderstanding the E&M
documentation guidelines By undercoding 30% of established visits
per day, you could lose approximately $340 per day or $90,400 a
year. Slide 14 Established Patient A patient that has received
prior care from the physician or another physician in the practice
of the same specialty in the previous three years. See top right
side of encounter form Slide 15 Documentation Requirements
992129921399214 HistoryProblem FocusedExpanded Problem
FocusedDetailed ExamProblem FocusedExpanded Problem FocusedDetailed
Decision Making StraightforwardLowModerate Slide 16 Problem Focused
(Straightforward) Expanded Problem Focused (Low) Level 3 99213
visit Detailed (Moderate) Level 4 99214 visit Comprehensive (High)
HistoryHistory Chief Complaint 1 fact about present illness Chief
Complaint 1 fact about present illness Review of 1 system Chief
Complaint 4 facts about present illness Review of 2 or more systems
1 note about past, family, social history Chief Complaint 4 facts
about present illness Review of at least 10 systems Past personal
history Family History Social History ExamExam 1995 One body area
or system related to problem 1995 2-4 systems1995 5-7 systems1995 8
or more systems Decision Making Decision Making Number of Dx or
Trmt Options: One self limited or minor problem (stable). Est.
Problem (to examiner) stable,improved. Amount and/or Complexity of
Data Reviewed. Risk of Complications: Minimal treatment options
(minor problem eg., cold or insect bite) Minimal or not testing
(simple x- rays, EKG, lab via venipuncture, ultrasound) Minimal
risk (rest, gargle, bandage, dressings, etc) Number of Dx. Or Trmt
Options: Est. Problem (to examiner) worsening. 2 self limited or
minor problems stable/worsening. Amount and/or Complexity of Data
Reviewed. Risk of Complications: Limited treatment options (stable
chronic illness, acute uncomplicated illness) Limited testing
(x-rays w/ contrast, lab via arterial puncture, test w/o stress)
Low risk ( over-the-counter drugs), physical therapy, minor surg.
W/o risk factors) Number of Dx. Or Trmnt Options: New Problem (to
examiner); no w/u planned. Amount and/or Complexity of Data
Reviewed. Risk of Complications: Moderate treatment options ( 2
stable chronic illnesses, acute illness with systemic symptoms,
chronic w/ exacerbation, new dx w/ uncertain prognosis. Moderate
testing (stress tests, deep biopsy endoscopy or CV tests w/o risk
factors) Moderate risk ( prescription drug management), closed
fracture care, minor surgery w/ risk factors, major surgery w/o
risk factors) Number of Dx. Or Trmnt Options: New Problem to
examiner add. work up planned. Amount and/or Complexity of Data
Reviewed. Risk of Complications: Extensive treatment options (life
threatening illness, chronic illness w/ severe exacerbation, abrupt
change in neurologic status) Extensive testing (Endoscopies or CV
testing w/ contrast & high risk factors) High risk (major
surgery w/ risk factors, drug therapy w/ monitoring) Slide 17
Problem Focused (Straightforward) Expanded Problem Focused (Low)
Level 3 99213 visit Detailed (Moderate) Level 4 99214 visit
Comprehensive (High) HistoryHistory Chief Complaint 1 fact about
present illness Chief Complaint 1 fact about present illness Review
of 1 system Chief Complaint 4 facts about present illness Review of
2 or more systems 1 note about past, family, social history Chief
Complaint 4 facts about present illness Review of at least 10
systems Past personal history Family History Social History
ExamExam 1995 One body area or system related to problem 1995 2-4
systems 1995 5-7 systems Think 4 or level 4 as we should always
include constitutional as one system in every encounter. 1995 8 or
more systems Decision Making Decision Making Number of Dx or Trmt
Options: One self limited or minor problem (stable). Est. Problem
(to examiner) stable,improved. Amount and/or Complexity of Data
Reviewed. Risk of Complications: Minimal treatment options (minor
problem eg., cold or insect bite) Minimal or not testing (simple x-
rays, EKG, lab via venipuncture, ultrasound) Minimal risk (rest,
gargle, bandage, dressings, etc) Number of Dx. Or Trmt Options:
Est. Problem (to examiner) worsening. 2 self limited or minor
problems stable/worsening. Amount and/or Complexity of Data
Reviewed. Risk of Complications: Limited treatment options (stable
chronic illness, acute uncomplicated illness) Limited testing
(x-rays w/ contrast, lab via arterial puncture, test w/o stress)
Low risk ( over-the-counter drugs), physical therapy, minor surg.
W/o risk factors) (2 out of 3 parts needed form below to meet level
4 in this section) Risk Part = ( prescription drug management, 1
chronic w/ exacerbation, 1 new w/unknown prognosis, 1 acute and
systemic or complicated, 2 chronic stable. Diagnoses & Plan
Part= Total of 3 points needed. (Self-limited 1p, 2p max)
(Est.-stable 1p)(Est.-not controlled/worsen 2p)(New-No w/u 3p, 1
max)(New w/ w/u 4p) Data Part= Total of 3 points needed. (
Test-lab,x-ray, med 1p)(Disc. Tests w/performing doc. 1p)(Indep.
review of 2p)(Obtain records or hx. 1p) (Review/summarize this data
2p) Number of Dx. Or Trmnt Options: New Problem to examiner add.
work up planned. Amount and/or Complexity of Data Reviewed. Risk of
Complications: Extensive treatment options (life threatening
illness, chronic illness w/ severe exacerbation, abrupt change in
neurologic status) Extensive testing (Endoscopies or CV testing w/
contrast & high risk factors) High risk (major surgery w/ risk
factors, drug therapy w/ monitoring) Slide 18 Legibility Medicare
states the The medical record should be complete and legible
(including your signature and printed name). Illegibility poses
serious risks to patient care, jeopardizes optimal reimbursement,
and carries potentially disastrous legal ramifications. If its not
documented or it can not be read, it will not be paid for (wasnt
done?). Slide 19 Counseling or Coordination of Care If 50% or more
of the total face-to-face visit was spent counseling and/or
coordinating care with the patient and/or family you can select the
CPT based on time. 99212 = 10 Minutes - est. 99213 = 15 Minutes -
est. 99214 = 25 Minutes - est. Slide 20 Counseling or Coordination
of Care Counseling is a discussion with the patient or family (face
to face) regarding one or more of the following areas: diagnostic
results, impression or recommended diagnostic studies; prognosis;
risks and benefits of management options; instructions for
management or follow-up; importance of compliance with chosen
management options; risk factor reduction; patient and family
education. Coordination of care refers to arranging and organizing
the patients care with other providers and agencies. It must be
described. Simply stating coordination of care is not acceptable
per Medicare. Slide 21 Counseling or Coordination of Care You MUST
document total visit time and counseling/co-ordination of care
time. Describe your activities. It should be complete enough to
substantiate your implied claim regarding time spent with the
patient. Documentation must show why it took the time you recorded
if you are using time to set the level. The time must also be
reasonable and appropriate considering the nature of the presenting
problem. Slide 22 99212 CC CC: Cold HPI: HPI: Stuffy nose for 2
daysROS:PFSH: Exam: Exam: ENT MDM: MDM: Viral- Rest, fluids, return
if worsens. CC: Cold HPI: Stuffy nose and sinus drainage for 2 days
ROS: No Fever PFSH: Exam: Constitutional, ENT MDM: Sinusitis- Rx
written, return if not wnl in 5 days. 99213 Slide 23 CC: CC: Cold
with cough and wheezing HPI: HPI: Stuffy nose and sinus drainage.
Nausea, cough several days, symptoms began 10 days ago. SOB with
cough. ROS: ROS: Some fever and loss of appetitePFSH: Exam: Exam:
Constitutional ENT Resp CV GI MDM: MDM: Bronchitis Rx written
Return in 3 days if not improved, 7 days if not wnl. 99214*Exam
+MDM CC: Cold HPI: Stuffy nose and sinus drainage for 2 days ROS:
No Fever PFSH: Exam: Constitutional, ENT MDM: Sinusitis- Rx
written, return if not wnl in 5 days. Slide 24 99213 CC: CC:
Cough/Cold/Wheezing. HPI: HPI: Stuffy nose and sinus drainage,
Nausea, Severe cough several days, symptoms began 10 days ago, SOB
with Cough. ROS: ROS: Some fever and loss of appetite PFSH: PFSH:
Smoker Exam: Exam: Constitutional ENT Resp - Clear CV GI MDM: MDM:
Patient diagnosed mild URI. OTC recommended. Return in 3 days for a
re-check if not improved, 7 days if not wnl. 99214 *History + Exam
CC: Cold HPI: Stuffy nose and sinus drainage for 2 days ROS: No
Fever PFSH: Exam: Constitutional, ENT MDM: Sinusitis- Rx written,
return if not wnl in 5 days. Slide 25 99213 CC: CC:
Cough/Cold/Wheezing. HPI: HPI: Stuffy nose and sinus drainage,
Nausea, Severe cough several days, symptoms began 10 days ago ROS:
ROS: Some fever and loss of appetite PFSH: PFSH: Smoker Exam: Exam:
Constitutional ENT Resp MDM: MDM: Patient diagnosed with
Bronchitis. Rx written. Return in 3 days for a re-check if not
improved, 7 days if not wnl. 99214 *History + MDM CC: Cold HPI:
Stuffy nose and sinus drainage for 2 days ROS: No Fever PFSH: Exam:
Constitutiona,l ENT MDM: Sinusitis- Rx written, return if not wnl
in 5 days. Slide 26 99212 or 99213? Patient Name: John Doe Chief
Complaint: Osteoarthritis HPI: 75-year-old male with a history of
osteoarthritis. ROS: Constitutional symptoms No fever, no loss of
appetite. Cardiovascular Negative for chest pain. Respiratory No
shortness of breath. Gastrointestinal No nausea or vomiting.
Genitourinary No difficulty urinating. Musculoskeletal Pain in
joints intermittently. Integumentary No rash. Neurological Denies
disorientation. Endocrine No cold intolerance. Allergic/Immunologic
Positive for seasonal hay fever. PFSH: See visit record for date of
service 1/1/2010. Slide 27 Exam: Vital signs T 98.7, P 76, R 20, BP
130/80. Head, Ears, Eyes, Nose, Throat Oropharynx clear, no mucosal
ulcerations and auditory canals clear. PERRLA. Neck Trachea
midline, supple. Lungs Clear to auscultation bilaterally.
Cardiovascular Regular rhythm and rate. Abdomen Soft, non-tender.
Extremities Normal. Musculoskeletal Bilateral knees with normal
range of motion, crepitus on motion, pain with ambulation rated 3
out of 10 and tenderness upon palpation. Neurologic Oriented to
time, place and person. Hematologic/Lymphatic/Immunologic No
bruising, no lymphatic swelling. Skin Normal temperature, turgor
and texture. No rash. Psychiatric Appropriate mood and affect. MDM:
Occasional joint pain. Continue same treatment Return to office in
three months. Slide 28 HPI The HPI must describe the patients
symptoms, evolution of his illness and the present status of his
condition. The HPI does not includes the following elements
(location, quality, severity, duration, timing, context, modifying
factors and associated signs and symptoms). This example does NOT
describe the patients symptoms, the evolution of his illness or the
status of his condition in any manner. The absence of the HPI
renders this record useless for understanding the patients
condition and the necessity. EVERY level of an E&M service
requires an HPI. The comprehensive ROS and Exam exceeded the level
of care needed for the patients presenting condition. History
qualifies as Problem Focused Slide 29 EXAM Most of the exam
documentation is asymptomatic and not related to the presenting
problem or affected body area. Medicare will NOT allow one body
area for the knee and musculoskeletal system for the other knee.
Medicare will allow one-body-part/body-area per system. 1995
guidelines: Exam is problem focused. Slide 30 MEDICAL DECISION
MAKING The patients condition is the key factor in determining
medical necessity. You MUST ensure your records describe the
patients condition and reason for the visit in enough detail for a
reasonable observer to understand the patients need. The patient
presented with a single, chronic, well-controlled problem (LOW).
The explanation of the nature of this problem is vague to even get
a sense of whether this service is at all medically necessary. The
problem appears to be stable. Is a three month f/u reasonable and
necessary for stable osteoarthritis? Those are the questions the
information in the record should address for Medicare payment to
determine appropriate. Medical Decision Making qualifies as
Straightforward Slide 31 THE CPT CODE IS. Assuming this visit was
reasonable and necessary this visit qualifies as a 99212. Lack of
HPI has rendered this record useless. The service should be coded
based on the clinical needs of the patient. Remember the patients
condition, START AT THE BOTTOM!!!!!!!! Slide 32 EXAMPLES OF
INSUFFICIENT DOCUMENTATION Not documenting all diagnostic tests
ordered, reviewed and independently visualized. (The record must
indicate the reason for ordering the tests). Continue same
treatment can be problematic. It doesnt reveal what treatments and
for what conditions treatments are being continued. When
documenting MDM, listing diagnoses or potential diagnoses without
information regarding meaningful and necessary evaluation and
management of each problem. Slide 33 Thank You Questions?
