Edwin J. Polverino, D.O.. Types of Audits Internal audits Private insurance company audits for quality and accuracy. Private insurance company audits

Edwin J. Polverino, D.O.

Edwin J. Polverino, D.O.

Types of 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.

ZPIC’sThe 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.

ZPIC’sZPIC’s 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.

ZPIC’sAudits 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.

ZPIC’sThese 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 provider’s employees.

ZPIC’sThere 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.

ZPIC’sProviders 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.

ZPIC’sTo 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

Questions on ZPIC?

With ZPIC in mind Lets talk about correct coding…………..

Why do we under-code?33% of Primary Care physicians under-code.

Possible reasons for under-coding: 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.

Established PatientA patient that has received prior care from

the physician or another physician in the practice of the same specialty in the previous three years.

99212 99213 99214

History Problem Focused Expanded Problem Focused Detailed

Exam Problem Focused Expanded Problem Focused Detailed

Decision Making

Straightforward Low Moderate

Problem Focused(Straightforward)

Expanded Problem Focused(Low)

Level 3 – 99213 visit

Detailed(Moderate)


Comprehensive (High)

History

Chief Complaint1 fact about present illness

Chief Complaint1 fact about present illnessReview of 1 system

Chief Complaint4 facts about present illnessReview of 2 or more systems1 note about past, family, social history

Chief Complaint4 facts about present illnessReview of at least 10 systemsPast personal historyFamily HistorySocial History

Exam

1995 – One body area or system related to problem

1995 – 2-4 systems 1995 – 5-7 systems 1995 – 8 or more systems

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.


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.


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)




Detailed(Moderate)



History





Exam


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








(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)




Decision Making



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)





Detailed(Moderate)



History





Exam


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










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)





LegibilityMedicare 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 it’s not documented or it can not be read, it will not be paid for (wasn’t done?).

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.

Counseling or Coordination of CareCounseling 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 patient’s care with other providers and agencies. It must be described.

Simply stating “coordination of care” is not acceptable per Medicare.

Counseling or Coordination of CareYou 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.

99212CCCC: ColdHPI:HPI: Stuffy nosefor 2 daysROS:ROS:PFSH:PFSH:Exam: Exam: ENTMDM: MDM: Viral-Rest, fluids,

return if worsens.

CC:CC: Cold Cold

HPI:HPI: Stuffy nose and Stuffy nose and

sinus drainage for 2 dayssinus drainage for 2 days

ROS:ROS: No FeverNo Fever

PFSH:PFSH:

Exam: Exam: ConstitutionalConstitutional, , ENT ENT

MDM:MDM: Sinusitis- Sinusitis-

Rx written, return if Rx written, return if

not wnl in 5 days. not wnl in 5 days.

99213

99213 CC:CC: Cold with cough and wheezingHPI: HPI: Stuffy nose and sinus

drainage. Nausea, cough several days,

symptomsbegan 10 days ago. SOB with

cough.ROS: ROS: Some fever and loss of

appetitePFSH:PFSH: Exam: Exam: ConstitutionalENTRespCVGIMDM:MDM: BronchitisRx writtenReturn in 3 days if not improved, 7 days if not wnl.

99214*Exam +MDMCC:CC: Cold Cold



ROS:ROS: No Fever No Fever

PFSH:PFSH:

Exam: Exam: Constitutional, Constitutional, ENT ENT




99213 CC:CC: Cough/Cold/Wheezing.HPI: HPI: Stuffy nose and sinus drainage, Nausea, Severe cough several days, symptoms began 10 days ago, SOB

withCough.ROS: ROS: Some fever and loss of appetitePFSH:PFSH: SmokerExam: Exam: ConstitutionalENTResp - ClearCVGIMDM: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:CC: Cold Cold




PFSH:PFSH:

Exam: Exam: Constitutional, Constitutional, ENT ENT




99213 CC:CC: Cough/Cold/Wheezing.HPI: HPI: Stuffy nose and sinus

drainage, Nausea, Severe cough several

days, symptoms began 10 days agoROS: ROS: Some fever and loss of

appetitePFSH:PFSH: SmokerExam: Exam: ConstitutionalENTResp 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 + MDMCC:CC: Cold Cold




PFSH:PFSH:

Exam: Exam: Constitutiona,l Constitutiona,l ENT ENT




9921?????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.

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 treatmentReturn to office in three months.

HPI 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 patient’s 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 patient’s 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 patient’s presenting condition.

History qualifies as Problem Focused

EXAMMost 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.

MEDICAL DECISION MAKINGThe patients condition is the key factor in determining

medical necessity. You MUST ensure your records describe the patient’s 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?

Medical Decision Making qualifies as Straightforward

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 patient’s condition, START AT THE BOTTOM!!!!!!!!

EXAMPLES OF INSUFFICIENT DOCUMENTATIONNot 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 doesn’t 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.

Thank YouQuestions?

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Edwin J. Polverino, D.O.. Types of Audits Internal audits Private insurance company audits for quality and accuracy. Private insurance company audits