AMERICANAMERICAN OSTEOPATHIC OSTEOPATHIC ASSOCIATIONASSOCIATION

DIVISION OF

SOCIOECONOMIC AFFAIRS Presents:

Medicare Updates, Documentation, Auditing and Incident To” Physician Billing

December 3, 2011

Socioeconomic Affairs StaffSocioeconomic Affairs Staff

• Yolanda Doss, MJ, RHIA,

Director, Division of Socioeconomic Affairs

• Sandra Peters, MHA

Assistant Director, Clinical Practice Outreach

• Michele Campbell, CPC,

Coding & Reimbursement Specialist

• Kavin Williams, CPC, CCP

Health Reimbursement Policy Specialist

Yolanda Doss, MJ, Yolanda Doss, MJ, RHIARHIA

Responsibilities include:– Helping to secure reimbursement for

osteopathic services– Securing the acceptance of osteopathic

credentials– Addressing Medicare issues– HIPAA compliance– Fraud and Abuse

Sandra Peters, MHASandra Peters, MHAResponsibilities include:

– Develop educational material on physician advocacy, manage care, quality and performance measures impacting osteopathic medicine

– Design and manage a set of member services to enhance their manage care interactions and to promote their opportunities to participate in manage care

– Provide update to the AOA leadership on health care trends particularly in the areas of pay for performance and physician profiling

Michele Campbell, Michele Campbell, CPCCPCResponsibilities include:

– Assists AOA members with coding and billing questions

– Assists AOA members with coding disputes with carriers

– Medical record reviews in audit situations.– Coordinates AOA’s responses to AMA CPT coding

requests– Provide physician education on coding and coding

guidelines– Write monthly coding hints and participate in articles

that effect the profession

Kavin T. Williams, Kavin T. Williams, CPC, CCPCPC, CCP

Responsibilities include:– Oversees and assists AOA members with

payment disputes and health payment policies.

– Oversees the AOA Coding and Reimbursement Advisory Panel.

– Represents the AOA at national reimbursement policy meetings.

Contact InformationContact Information

• Yolanda Doss 1-312-202-8187ydoss@osteopathic.org

• Sandra Peters 1-312-202-8088speters@osteopathic.org

• Michele Campbell 1-312-202-8182mcampbell@osteopathic.org

• Kavin T. Williams, -312-202-8194kwilliams@osteopathic.org

The Objective is to Provide The Objective is to Provide InformationInformation

on the Following Topics:on the Following Topics:• Medicare 2012 Updates• Evaluation & Management • Medicare Audits• Recovery Audit Contractors (RAC)• “Incident To” Services

Medicare 2012 UpdatesMedicare 2012 Updates

• Physician Fee Schedule is facing a 30 percent reduction

• Physician Quality Reporting Initiative (PQRI) Bonus Payment 2%

• E-Prescribing Bonus Payment 2%

• OMT Survey

Physician DocumentationPhysician Documentation

• This is critical to your reimbursement• If it was not documented it did not happen• Clear and Legible, words to document by• Chief complaint (this is the driver to most

insurance auditors)• Familiarize yourself with your documentation

style- is it 1995 guidelines that you follow or 1997?

Documentation Guidelines Documentation Guidelines

• The medical record should be complete and legible.

• 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;

– plan for care

Documentation Guidelines Documentation Guidelines [Cont.][Cont.]

• The patient’s progress, response to and changes in treatment, and revisions of diagnosis should be documented.

• The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

• Hospital visits should be included in the patient’s chart

Evaluation & Management Evaluation & Management (E/M) Coding(E/M) Coding

• Coding for office visits

• Modifier usage when billing an E/M with a procedure (OMT)

• Time Based Coding

Chief Complaint (CC)Chief Complaint (CC)

• The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factors that is the reason for the encounter, usually stated in the “patient’s own” words.

• Documentation Guidelines states that the medical record should clearly reflect the chief complaint

Medical NecessityMedical Necessity• This area is not black/white• There are numerous definitions of medical

necessity• Linking the appropriate diagnosis to the

appropriate procedure to support the necessity of the procedure performed is critical.

• Medicare defines medical necessity as services or items reasonable and necessary for the diagnosis or treatment of illness or injury to improve the functioning of a malformed body member.

Coding For TimeCoding For Time

• When is it appropriate to code for time?

• What is the auditor looking for when they review a chart that was billed as time being the controlling factor?

Tips For Verbiage When Tips For Verbiage When Billing For TimeBilling For Time

Example of correct documentation of time:• In your note it should read “ I spent 45 minutes

with the patient and over 50% of that time was spent discussing …

Example of incorrect documentation of time:• “I spent 45 minutes with the patient, discussed

surgical options versus medical management.

What Is An Audit?What Is An Audit?

• An effective tool used by Medicare and other payors to recover monies lost to fraud and erroneous billings.

Why Audits Are Why Audits Are Initiated?Initiated?

• Suspicion (Billing Pattern)• Outlier Physicians• The Senior Patrol• Whistleblowers• Procedure Codes

Who Are The Auditors?Who Are The Auditors?• The Office of the Inspector General (OIG)• Medicare• The Department of Justice (DOJ)• The Federal Bureau of Investigation (FBI)• Carriers

Types of AuditsTypes of Audits

• Prepayment Audits• Post-Payment Audits• Statistical Sampling Method

What Auditors Look For?What Auditors Look For?• Billing for services or supplies that were not

provided.• Billing for non-allowable or non-covered

services.• Altering claim forms to receive a higher

payment amount.• Unbundling claims.

How To Respond To A How To Respond To A Request For Request For

DocumentationDocumentation

• Reply to the audit notice in a timely fashion.• Gather and submit Only the requested

documentation.• Be cooperative.• You may want to conduct an internal audit.

How to Respond to the How to Respond to the Audit FindingsAudit Findings

• If the findings are not favorable:• Attempt to discuss the findings with the

reviewer. • If necessary request redetermination.• If necessary request a level one appeal.

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Medicare Medicare Recovery AuditRecovery Audit

Contractors (RACs) Contractors (RACs)

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RAC LegislationRAC Legislation

• The RAC program was created by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 which pays incentive fees to third-party auditors that identify and correct improper payments paid to healthcare providers in fee-for-service Medicare.

• The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 also requires permanent and nationwide RAC program by no later than 2010

The RAC Demonstration The RAC Demonstration ProjectProject

• The RAC demonstration project took place of New York, Florida, and California.

• By 2010 the RAC covered all 50 states.

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RAC Program MissionRAC Program Mission

• To detect and correct past improper payments,

• To implement actions that will prevent future improper payments.

• Providers can avoid submitting claims that don’t comply with Medicare rules

• CMS can lower its error rate• Taxpayers & future Medicare

beneficiaries are protected

The New RAC’s Are:The New RAC’s Are:• Diversified Collection Services, Inc. of Livermore, California,

in Region A, initially working in Maine, New Hampshire, Vermont, Massachusetts, Rhode Island and New York.

• CGI Technologies and Solutions, Inc. of Fairfax, Virginia, in Region B, initially working in Michigan, Indiana and Minnesota.

• Connolly Consulting Associates, Inc. of Wilton, Connecticut, in Region C, initially working in South Carolina, Florida, Colorado and New Mexico.

• HealthDataInsights, Inc. of Las Vegas, Nevada, in Region D, initially working in Montana, Wyoming, North Dakota, South Dakota, Utah and Arizona.

Additional states will be added to each RAC region in 2009

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Minimize Provider Minimize Provider BurdenBurden

• Limit the RAC “look back period” to three years– Maximum look back date is October 1,

2007 • RACs will accept imaged medical records on

CD/DVD

• Limit the number of medical record requests

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Medical Record Limit Medical Record Limit ExampleExample

• Outpatient Hospital – 360,000 Medicare paid services in 2007 – Divided by 12 = average 30,000

Medicare paid services per month – x .01 = 300– Limit = 200 records/45 days (hit the max)

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Summary of Medical Summary of Medical Record Limits (for FY Record Limits (for FY

2009)2009)

• Inpatient Hospital, IRF, SNF, Hospice

– 10% of the average monthly Medicare claims (max 200) per 45 days per NPI

• Other Part A Billers (HH)– 1% of the average monthly Medicare

episodes of care (max 200) per 45 days per NPI

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Summary of Medical Record Summary of Medical Record Limits (for FY 2009) Limits (for FY 2009)

ContinuedContinued

• Physicians (including podiatrists, chiropractors) • Sole Practitioner: 10 medical records per 45 days per NPI• Partnership 2-5 individuals: 20 medical records per 45 days

per NPI• Group 6-15 individuals: 30 medical records per 45 days per

NPI• Large Group 16+ individuals: 50 medical records per 45 days

per NPI

– Other Part B Billers (DME, Lab, Outpatient hospitals) • 1% of the average monthly Medicare services (max 200) per

NPI per 45 days

RAC Validation Contractor RAC Validation Contractor (RVC)(RVC)

• CMS has contracted with Provider Resources, Inc. of Erie, PA, to work as the Recovery Audit Contractor (RAC) Validation Contractor.

• The RAC Validation Contractor (RVC) will work with CMS and the RAC to approve new issues the RACs want to pursue for improper payments, as well as perform accuracy reviews on a sample of randomly selected claims on which the RACs have already collected overpayment.

• The RVC is another tool CMS will use to provide additional oversight and ensure that the RACs are making accurate claim determinations in the permanent program.

For Additional Information For Additional Information on RACon RAC

• http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6125.pdf

• http://www.cms.hhs.gov/RAC/Downloads/RAC%20Evaluation%20Report.pdf

• http://www.cms.hhs.gov/rac/

Medicare “Incident to” Medicare “Incident to” Physician ServicesPhysician Services

The OIG reviews Medicare services that are “incident to” physicians services to determine the qualifications and appropriateness of the staff who performed them.

Physician DefinedPhysician Defined The “physician” refers to physician or other practitioner (listed below), who are authorized to receive payment for services “incident to” his or her own services.

• physician assistants• nurse practitioners• clinical nurse specialist• nurse midwife, and• clinical psychologist

Professional ServiceProfessional Service

• A direct, personal, professional service which is rendered by the physician

• To meet the “incident to” guidelines, the physician must initiate the course of treatment, and

• Conduct subsequent physician services to show ongoing involvement

Coverage RequirementsCoverage RequirementsTo be covered, service and supplies must

be:

• An integral, though incidental, part of the physician’s or on-physician practitioner’s professional services

• Commonly furnished in a physician’s office or clinic

• Furnished by the practitioner or auxiliary personnel under the physician’s direct supervision

Supervision Supervision RequirementsRequirements

Direct physician supervision of auxiliary personnel is required.

Auxiliary personnel:

• any individual (employee, leased employee, or independent contractor) who is acting under the supervision of a physician

• Auxiliary personnel include nurses, medical assistants, technicians, etc.

Direct Supervision in the Direct Supervision in the OfficeOffice

• Physician must be present in the office suite

• Physician must be immediately available to assist if needed

• Does not require that the physician be in the same room

Direct Supervision in the Direct Supervision in the Office ContinuedOffice Continued

Scenarios that do not meet the direct supervision requirement:

• Availability of a physician by telephone

• Physician presence somewhere in an institution

DocumentationDocumentation To support the use of the incident to provision, the documentation should clearly indicate: • Who performed the “Incident to” service• The physician’s presence in the office suite during the service/procedure

Division WebsiteDivision Website

• Go to www.do-online.org and sign onto DO-Online. – First time users will need their AOA

member number to sign up.• On DO-Online, click on Practice

Management for the division website.• There is also a Division email address:

practicemanagement@osteopathic.org.

What the DO-Online Practice What the DO-Online Practice Management Website has for Management Website has for

YouYou• Billing and Coding• E/M documentation• ICD-9-CM code

updates• OMT information• Legal• Litigation fund• Updates on class action

suits

• CMS/Medicare– Links to local carrier

information

– Information on each CPT code

– Enrollment information

– CMS Medlearn

– CCI link– Fee schedules, new and

prior

What the DO-Online What the DO-Online Practice Management Practice Management Website has for YouWebsite has for You

• Preventive health services

• Demonstration projects

• CERT- fraud and abuse information

• HIPPA

• Managed care

• Osteopathic Advocacy Resources

Division CME SeminarsDivision CME Seminars

• Conducted in conjunction with state associations and specialty colleges.

• Seminars available include Medicare Compliance, HIPAA Privacy Compliance, and Documentation Guidelines and Coding Reimbursement.

• Call Yolanda Doss, MJ, RHIA at 800-621-1773 ext. 8187 or ydoss@osteopathic.org for info.

Contact InformationContact Information

• Yolanda Doss 1-312-202-8187ydoss@osteopathic.org

• Sandra Peters 1-312-202-8088speters@osteopathic.org

• Michele Campbell 1-312-202-8182mcampbell@osteopathic.org

• Kavin T. Williams, -312-202-8194kwilliams@osteopathic.org