The Need for Self-Audits Related to E/M Coding

9/23/2013

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The Need for Self-Audits Related

to E/M Coding

Health Care Compliance Association

Indianapolis Regional Meeting

October 4, 2013

Presented by

Joy Newby, LPN, CPC

Newby Consulting, Inc.

5725 Park Plaza Court

Indianapolis, IN 46220

Voice: 317.573.3960

Fax: 866-631-9310

E-mail: [email protected]

This presentation was current at the time it was published and is intended to

provide useful information in regard to the subject matter covered.

Newby Consulting, Inc. believes the information is as authoritative and accurate as

is reasonably possible and that the sources of information used in preparation of

the presentation are reliable, but no assurance or warranty of completeness or

accuracy is intended or given, and all warranties of any type are disclaimed.

The information contained in this presentation is a general summary that explains

certain aspects of the Medicare Program, but is not a legal document. The official

Medicare Program provisions are contained in the relevant laws, regulations, and

rulings.

Any five-digit numeric Physician's Current Procedural Terminology, Fourth Edition

(CPT) codes, service descriptions, instructions, modifiers, and/or guidelines are

copyright 2012 (or such other date of publication of CPT as defined in the federal

copyright laws) American Medical Association.

For illustrative purposes, Newby Consulting, Inc. has selected certain CPT codes and

service/procedure descriptions to be used in this presentation.

The American Medical Association assumes no responsibility for the consequences

attributable to or related to any use or interpretation of any information or views

contained in or not contained in this publication.

9/23/2013

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Entities that Conduct Audits

• Commercial payers

• Department of Justice (DOJ)

• Office of Inspector General (OIG)

• Zone Program Integrity Contractors (ZPIC)

• Medicare Administrative Contractors (MAC)

• Comprehensive Error Rate Testing Contractor (CERT)

• Medicare and Medicaid Recovery Audit Contractors (RAC)

• Medicaid Integrity Contractors (MIC)

• Medicaid Payment Contractors

– And almost any other entity you can think of!!!

Investigations Result in Net Return

• On February 11, 2013, Attorney General Eric Holder and

Health and Human Services (HHS) Secretary Kathleen

Sebelius released a report showing that for every dollar

spent on health care-related fraud and abuse investigations

in the last three years, the government recovered $7.90.

– This is the highest three-year average return on

investment in the 16-year history of the Health Care

Fraud and Abuse (HCFAC) Program.

5CPT Copyright 2012 American Medical

Association

Compliance Plan – Chart Review

What to review

• Date of service documented

• Date of service matches date billed

• Patient’s name on every page

• Legibility of documentation

• Timeliness of documentation

– Verify services are not billed until the documentation is

complete

• Including the provider’s personal signature

CPT Copyright 2012 American Medical Association

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Chart Review Cont’d

• Claim submitted by the correct provider

• Place of service

• Evaluation and management services

– Code billed matches place of service

• Documentation supports level of care selected


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Chart Review Cont’d

• Documented diagnosis matches diagnosis billed

• Injections

• Procedures

• Diagnostic tests

• Appropriate modifiers appended


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Do the Processes and Procedures in your

Compliance Plan Include

• Who will conduct self audit

• Frequency of self audit

• Number of encounters to audit

• How services will be selected

• Education related to findings

• Process for determining the appropriate timing of re-audits


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Most Important to Remember

If a major problem is discovered, stop the

review and contact your health care

attorney for advice!


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OIG 2013 Work Plan

Evaluation and Management Services—Potentially

Inappropriate Payments in 2010

• The OIG will determine the extent to which CMS made

potentially inappropriate payments for E/M services in 2010

and the consistency of E/M medical review determinations.

• The review will also include multiple E/M services for the

same providers and beneficiaries to identify electronic

health records (EHR) documentation practices associated

with potentially improper payments.


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OIG 2013 Work Plan – E/M Services

– 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 on the basis of the content of the service and

have documentation to support the level of service

reported.


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Why all the attention to E/M codes now?

• OIG Reports Coding Trends of Medicare E/M Services

Published May 2012

– Between 2001 and 2010, Medicare payments for Part B

goods and services increased by 43 percent, from $77

billion to $110 billion.

– Medicare payments for evaluation and management

(E/M) services increased by 48 percent, from $22.7 billion

to $33.5 billion.

– E/M Services represent 30.5 percent of all Medicare Part

B payments.


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OIG Report Cont’d

• From 2001 to 2010, physicians increased their billing of

higher level E/M codes for all types of E/M services.

• The number of E/M services billed also increased by 13

percent, from 346 million to 392 million.

• Average Medicare payment amount per E/M service

increased by 31 percent, from approximately $65 to

$85.


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OIG Report Cont’d

• 99213 was billed most often during the 10-year period,

but there was a shift in billing from the three lower level

E/M codes to the two higher level codes.

– Combined, physicians increased their billing of the

two highest level E/M codes (99214 and 99215) by

17 percent from 2001 to 2010.


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OIG Report Cont’d

• Subsequent Inpatient Hospital Care

– In 10 years, physicians’ billing shifted from lower

level to higher level codes.

• For example, the billing of the lowest level code

(99231) decreased 16 percent, while the billing of

the two higher level codes (99232 and 99233)

increased 6 and 9 percent, respectively.


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OIG Report Cont’d

• Emergency Department Visits

– In 10 years, physicians’ billing of the highest level

code (99285) rose 21 percent, increasing from 27 to

48 percent.

• During the same time, physicians’ billing of all

other codes decreased. Physicians billed the

lowest level code (99281) less than 3 percent of

the time.


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OIG Recommended to CMS

Encourage Contractors To Review Physicians’ Billing for

E/M Services.

• Produce Comparative Billing Reports

– Documented analysis of a physician’s billing pattern

compared to those of his or her peers.

– These reports provide helpful insights into physicians’

billing patterns to avoid improper Medicare payments.

– CMS may also find these reports helpful for identifying

and monitoring physicians who consistently bill higher

level E/M codes.


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9/23/2013

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Self-Disclosed Upcoding Settlement

• Memorial Hospital at North Conway, New Hampshire

(TMH) agreed to pay $20,479 for allegedly violating the

Civil Monetary Penalties Law.

• The OIG alleged that TMH submitted upcoded claims to

Medicare and Medicaid for Evaluation & Management

services provided by one of TMH's physicians.


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Utica Physician Indicted in $12 Million

Health Care Fraud Scheme

The health care fraud counts allege that between 2002 and the end of September 2012, the physician engaged in a scheme to fraudulently obtain payments from health care benefit programs, including Medicare, Medicaid, and numerous private insurers.

• The indictment alleges he did this by submitting claims for

reimbursement representing that he had, on an ongoing and daily

basis, provided a certain number of patients with the medical

services designated by certain medical codes when, pursuant to

the criteria in those codes, it would have been impossible for any

physician to provide the medical treatment to that number of

patients in a single day.


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Utica Physician Indicted in $12 Million

Health Care Fraud Scheme Cont’d• The indictment alleges that certain medical services, which are

described in medical codes, known as CPT codes, have “typical” time

components associated with them, and that during the course of the

fraud scheme, the aggregate of the “typical” time in the codes

submitted for reimbursement by the physician consistently exceeded

24 hours per day.

– The three health care fraud counts are based on the physician billing

for services purportedly provided to patients on November 29, 2007;

February 20, 2008; and June 19, 2008.

• On those three dates, the physician purports to have provided

services to 82, 85, and 92 patients.

• Aggregate “typical” time component associated with the codes

submitted for payment were 30 hours, 35 hours, and 40 hours,

respectively.


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WPS – CERT Findings

• E/M services are the majority of services billed by

physicians and NPPs.

• WPS and the CERT contractor have identified

documentation issues as the number one reason why

Medicare denies a claim, reduces payment, or requests

refunds.


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WPS Recently Published Error Rates

• 99223 Initial hospital care - J8 - 39%

• 99233 Subsequent hospital care – J8 - 43%

• 99310 Subsequent nursing facility care – J8 – 93%

• 99285 Emergency department visit – J5 - 49.94%

– Specialty 93 ED Medicine

• 99214 Establish office – J5 - 18.44%.

– Specialty 06 Family Medicine

• 99214 Establish office – J5 - 28.60%

– Specialty 08 Cardiology

• 99215 Establish office – J5 - 39.76%

– Specialty 11 (Internal Medicine)


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WPS CBRs

WPS Medicare analyzes provider billing patterns for E/M

services.

• This analysis focuses on identifying providers who bill

one E/M code within a category of E/M codes at a very

high rate.

• Identified providers are sent an educational letter and

Comparative Billing Report (CBR) to illustrate WPS

findings.


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WPS CBRs Cont’d

• Providers who fail to modify their billing pattern post-

education, or to provide a valid explanation for this

variance, may be the subject of a probe review or a

referral to another Medicare Contractor.


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WPS Recommendation - Self-Auditing

• If you bill E/M codes to Medicare, WPS recommends

performing a self-audit of your billing and

documentation practices to ascertain if problem areas

exist which may warrant further education or corrective

actions.

• A complete and successful self audit evaluation includes

a coding/documentation review as well as a claim

submission audit.


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WPS Self-Audit Recommendations Cont’d

General Tips to consider when performing a self-audit of E/M Services

• Medical necessity is the overall criterion for payment in addition to the specific technical requirements of a CPT code.

• It is not appropriate to bill a higher level of E/M service when a lower level of service is warranted.

• The volume of documentation should not be used to determine the level of service.

• In order to maintain an accurate record, document during or shortly after rendering the service.


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Documentation Timeliness

• Claims should not be submitted until the

documentation is complete including signature.

• CMS does not have a specific timeframe for chart

completion.

– WPS believes a reasonable time is “a couple of days”

after the encounter.


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WPS Comments on Cloned Documentation

There are several concerns we have heard from the provider

community concerning the use of the EHR to document E/M

services.

• These include the carry forward, copy and paste, and

automated entries.

• A provider completing an E/M service for a patient can use

the automation available with the EHR system; however,

each medical record stands alone.

– This means that when a provider is accessing previous

information, such as the Review of Systems, or the Past,

Family, and Social History, the practitioner must document

what was reviewed of the previous information and

indicate any changes.


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WPS Cloned Documentation – Cont’d

• The same holds true for a copy and paste and automated

entries.

– A practitioner must verify that all elements entered into

the record were performed and the results documented

for that specific date.

• WPS encourages providers to look at their billing trends

through self-audits.


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Correct Use of Checklists and Templates in E/M

Documentation

• Physicians and non-physician practitioners may use

templates, checklists, and/or electronic medical records

to assist in documenting services and saving time.

– WPS considers these formats acceptable documentation.

• Caveat, the documentation submitted must be

specific to the patient and the service in question.

– Appropriate to evaluate the patient’s presenting

problem, problems described in the HPI and ROS

– Exam findings


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WPS Guidelines for the Use of Scribes in

Medical Record Documentation

• "Scribe" situations are those in which the physician utilizes

the services of his, or her, staff to document work performed

by that physician, in either an office or a facility setting.

• For E/M services, surgical, and other encounters, the

"scribe" does not act independently, but simply documents

the physician's dictation and/or activities during the visit.

• The physician who receives the payment for the services is

expected to be the person delivering the services and

creating the record, which is simply "scribed" by another

person.


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Physicians using the services of a "scribe"

must adhere to the following:

• Proper Documentation

– Record entry notes the name of the person

"acting as a scribe for Dr. X."

– Physician co-signs the note indicating the note is

an accurate record of both his/her words and

actions during that visit.


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Auditing E/M Codes and Documentation

• WPS does not use the “scoring system” for

determining medical necessity developed by the

Marshfield Clinic that assigns points to the number

of diagnoses/management options and

amount/complexity of data to be reviewed.


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Recommendations - Levels of Care

Clinical examples included in CPT Appendix C can be used

as analogies when determining the appropriate level of

care.

• 99201

– Initial office visit with a 9-month-old female with diaper

rash.

– Initial office visit for the evaluation and management of a

contusion of a finger.


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CPT Clinical Examples Cont’d

99202

• Initial office visit for a patient with a circumscribed patch of

dermatitis of the leg.

• Initial evaluation and management of recurrent urinary

infection in female.

99203

• Initial office visit for a 53-year-old laborer with degenerative

joint disease of the knee with no prior treatment.

• Initial office visit of an adult who presents with symptoms of

an upper-respiratory infection that has progressed to

unilateral purulent nasal discharge and discomfort in the right

maxillary teeth.CPT Copyright 2012 American Medical

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99204

• Initial office visit for a 60-year-old male with recent change

in bowel habits, weight loss, and abdominal pain.

• Initial office visit for initial evaluation of a 63-year-old male

with chest pain on exertion.

99205

• Initial office evaluation of a 65-year-old female with

exertional chest pain, intermittent claudication, syncope, and

a murmur of aortic stenosis.

• Initial outpatient evaluation of a 69-year-old male with

severe chronic obstructive pulmonary disease, congestive

heart failure, and hypertension.


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99212

• Office visit for a 10-year-old female, established patient, who has been swimming in a lake, now presents with a one-day history of left ear pain with purulent drainage.

• Evaluation of a 50-year-old male, established patient, who has experienced a recurrence of knee pain after he discontinued NSAID.

• Office visit, established patient, 6-year-old with sore throat and headache.

• Office visit for a 27-year-old female, established patient, with complaints of vaginal itching.


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99213

• Office visit for a 68-year-old female, established patient,

with polymyalgia rheumatic, maintained on chronic low-

dose corticosteroid, with no new complaints.

• Office visit for a 45-year-old female, established patient,

with known osteoarthritis and painful swollen knees.

• Office visit for a 56-year-old man, established patient,

with stable exertional angina who complains of new

onset of calf pain while walking.


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CPT Clinical Examples 99213 Cont’d

• Office visit for the quarterly follow-up of a 63-year-old male,

established patient, with chronic myofascial pain syndrome,

effectively managed by doxepin, who presents with new

onset urinary hesitancy.

• Office visit with 55-year-old male, established patient, for

management of hypertension, mild fatigue, on beta

blocker/thiazide regimen.

• Office visit for a 50-year-old female, established patient, with

insulin-dependent diabetes mellitus and stable coronary

artery disease, for monitoring.


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99214

• Office visit for an established patient with frequent

intermittent, moderate to severe headaches requiring beta

blocker or tricyclic antidepressant prophylaxis, as well as four

symptomatic treatments, but who is still experiencing

headaches at a frequency of several times a month that are

unresponsive to treatment.

• Outpatient visit for a 77-year-old male, established patient,

with hypertension, presenting with a three-month history of

episodic substernal chest pain on exertion.


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• Outpatient visit for a 77-year-old male, established patient, with

hypertension, presenting with a three-month history of episodic

substernal chest pain on exertion.

• Office visit with 50-year-old female, established patient, diabetic,

blood sugar controlled by diet. She now complains of frequency of

urination and weight loss, blood sugar of 320 and negative

ketones on dipstick.

• Office visit for a 68-year-old female, established patient, for

routine review and follow-up of non-insulin dependent diabetes,

obesity, hypertension, and congestive heart failure. Complains of

vision difficulties and admits dietary noncompliance. Patient is

counseled concerning diet and current medications adjusted.


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99215

• Office visit for a 36-year-old, established patient, three-month status post-transplant, with new onset of peripheral edema, increased blood pressure, and progressive fatigue.

• Office visit for a 60-year-old, established patient, with diabetic nephropathy with increasing edema and dyspnea.

• Office visit with 30-year-old male, established patient for three-month history of fatigue, weight loss, intermittent fever, and presenting with diffuse adenopathy and splenomegaly.


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99215

• Office visit for evaluation of recent onset syncopal attacks in

a 70-year-old female, established patient.

• Office visit for a 70-year-old female, established patient, with

diabetes mellitus and hypertension, presenting with a two-

month history of increasing confusion, agitation, and short-

term memory loss.


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WPS – Self-Auditing Emergency Department

Codes - FAQ

My question centers on the number of diagnosis or

management options in the MDM of the E/M service. When

coding an Emergency department encounter, would all

presenting problems fall under the "new problem" category

(either with or without additional workup)?

When I place conditions such as cold, otitis media, insect bite,

etc. as new problems without any additional workup and the

physician orders a prescription, the visit often equates to a level

4 visit. When I used the self-limited category, the visit equates

to a level 3, which we believe is more in line with the

physician's work.


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WPS – Self-Auditing Emergency Department

Codes

WPS Response

• The 1995 and the 1997 DGs have a table the provider can use in

determining the level of MDM. There is no specific "new problem"

category.

• The examples you give of cold, otitis media, insect bite would lend

themselves to a minimal level of risk for the present problem.

• The number of possible diagnosis and/or the number of management

options your provider considers is based on the number and types of

problems addressed during the encounter, the complexity of

establishing a diagnosis and the management decisions that are

made by the physician. The highest level of risk in any one category

determines the overall risk.


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CPT Clinical Examples

Emergency Department Codes

• 99281 Emergency department visit for a patient with

several uncomplicated insect bites.

• 99282 Emergency department visit for a patient

presenting with a rash on both legs after exposure

to poison ivy.

• 99283 Emergency department visit for a well-appearing 8-

year-old who has a fever, diarrhea, and abdominal

cramps; is tolerating oral fluids, and is not vomiting.

• 99283 Emergency department visit for a healthy, young

adult patient who sustained a blunt head injury with

local swelling and bruising without subsequent

confusion, loss of consciousness, or memory deficit.


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CPT Clinical Examples

Emergency Department Codes Cont’d

• 99284 Emergency department visit for a 4-year-old who fell off a bike sustaining a head injury with brief loss of consciousness.

• 99284 Emergency department visit for a patient with flank pain and hematuria.

• 99285 Emergency department visit for a patient with a new onset of rapid heart rate requiring IV drugs.

• 99285 Emergency department visit for a patient who presents with a sudden onset of “the worst headache of her life,” and complains of a stiff neck, nausea, and inability to concentrate.


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CERT Finding - 99203

• Service Incorrectly Coded – Physician Billed CPT 99203

– Initial new patient office visit requires these three key components: detailed history, detailed exam and low complexity medical decision making.

– Submitted documentation supports code change to 99202 with detailed history, expanded problem focused exam and low complexity medical decision making.

When you review notes the medical decision making is applicable to the level of care selected by the physician, the reviewer must be very careful when determining if the service was under-documented or over coded.


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WPS CERT Finding - 99211

Physician billed CPT 99211

• Submitted documentation was the INR log with INR and goal

range.

– Submitted documentation supports the only face to face

service provided on the billed date of service was obtaining

of Protime that was billed on same claim.

– No additional evaluation or management services other

than the beneficiary notification to change Coumadin

dosing is documented and unable to determine if

beneficiary was told face to face or via phone about the

results of the INR and dosing.

• Documentation is insufficient for Medicare guidelines.


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WPS CERT 99211 Example #2

• Unbundling – Physician billed CPT 99211. – Visits by the same physician on the same day as a minor surgery or

endoscopy are included in the payment for the procedure.

– Submitted are physician records for billed date of service stating “Here for his first Synvisc injection.”

– Noted use of Modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service); however, submitted documentation does not support modifier code; documentation states “detailed note is in the chart from his last visit.”

– Arthrocentesis and Synvisc injection codes also billed on this claim for this date of service.


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CERT Finding 99214


– Billed code 99214 requires 2 of the following 3

components: detailed history, detailed exam, moderate

complexity medical decision making.

– Submitted documentation supports 99213 with expanded

problem focused history, no exam components and low

complexity medical decision making.

– Visit was not of moderate to high severity.


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– Billed code 99223 requires 3 of the following 3 components: comprehensive history, comprehensive exam, and high complexity medical decision making.

– Documentation submitted supports down code from 99223 to 99221 with a detailed history, detailed exam, and moderate complexity medical decision making.


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CERT Finding – Insufficient Documentation

Coding - 99233

• Insufficient documentation - Physician Billed CPT 99233 X 3 Units

– Missing inpatient progress notes to support E/M services billed for line dates of service 9/09/2008-09/11/2008

– Previously submitted consists of 263 pages of inpatient records that do no include progress notes for the dates of service above

– Of note, physician's orders for the dates were submitted, but no documentation to support face-to-face evaluation of patient


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WPS CERT Finding - 99238

• Physician billed CPT 99238

– Missing documentation to fully support a face-to-face

encounter took place between the beneficiary and

treating physician during the billed hospital discharge day

management service.

– Submitted documentation includes typed discharge

summary that is missing documentation of a face to face

visit between beneficiary and physician and another note

from the same physician that has nothing marked in the

exam section of note.


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– Billed level of service is incorrectly coded.

– Change code from 99239 to 99238.

– Documentation in the discharge note for billed DOS does not support time spent as greater than 30 minutes.

– The content of the documentation could support 30 minutes as well as greater than 30 minutes, but without the time to support the higher level of service was provided would change to 99238, 30 minutes or less.


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CERT Finding – 99307 – Bundled E/M

• Physician billed CPT 99307-25

– Modifier 25 is to be used to report a significant, separately identifiable evaluation and management service by same physician on the day of a procedure.

• The patient’s condition required a significant, separately identifiable evaluation and management service above and beyond the usual preoperative and postoperative care associated with the procedure or service that was performed.

– Submitted documentation does not include significant evaluation and management services above and beyond the usual pre and post op care for debridement on nails, 6 or more, as paid on line 2 of this claim.


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WPS CERT Finding – Teaching Physician #1

• Physician billed CPT 99231-GC

– The attending physician's inpatient progress note for DOS

was not submitted, only the resident's note.

– Since attending physician is billing with GC modifier,

unable to verify that the attending physician performed

the E/M or was present during the key portions of the

service when performed by the resident and participated

in the management of the patient for DOS.


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• Physician billed CPT 99233-24-GC

– MD progress notes state "patient was seen and examined

by me and agree," this is insufficient to support teaching

physician personally saw the patient and participated in

the management of the patient.

– Medicare requires teaching physicians to document at

least the following: a) That they performed the service or

were physically present during the key or critical portions

of the service when performed by the resident; and b)

The participation of the teaching physician in the

management of the patient.


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Physician billed CPT 99284

• Documentation supports the level of service billed.

• Physician should have billed with a GC modifier as the service was

performed by a resident under the direction of a teaching physician.

• For teaching physician services, documentation from both the

resident and teaching physician must be submitted and comply with

the documentation requirements for the service billed.

• In addition, the appropriate modifier must be used to denote

teaching physician services.

– If the service is billed without the appropriate modifier, Medicare

cannot combine the notes for review of level of service.

– By using the modifier the MD is certifying he has complied with

all requirements in §100.1 through 100.1.6" of the regulations.


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Recent OIG Settlements – E/M Coding

After it self-disclosed conduct to the OIG, Sonora Regional

Medical Center (SRMC) California, agreed to pay $597,193 for

allegedly violating the Civil Monetary Penalties Law.

• SRMC contracted with a physician to provide professional

services at SRMC's medical oncology outpatient center.

• The OIG alleged that SRMC submitted claims containing CPT

codes 99204, 99205, 99214, and 99215, that it submitted for

services provided by the physician that were upcoded and

that the physician engaged in a pattern or practice of coding

at a higher level that he knew or should have known would

result in a greater payment than the code applicable to the

services he was actually providing.


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Recovery Audit Contractor To Perform

Statistical Sampling Of E/M Codes

• CMS approved limited review, statistical sampling of

evaluation and management claims to calculate and project

incorrectly paid claims.

– Connelly, Inc. the Region C Recovery Audit Contractor

• RAC Region C includes Alabama, Arkansas, Colorado,

Florida, Georgia, Louisiana, Mississippi, New Mexico,

North Carolina, Oklahoma, South Carolina, Tennessee,

Texas, Virginia, West Virginia, Puerto Rico, and the US

Virgin Islands


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Will these reviews lead to additional

findings?

• Improper billing of services performed by auxiliary personnel

• Teaching physicians improperly billing for services by

residents

• Billing a visit on the same day as a minor surgical procedure

or other service (e.g., osteopathic manipulation) – Modifier -

25

• Improper incident to and shared/split visit billing

• Improper supervision of billed services


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Auxiliary Staff – Improper Use of E/M

Codes

• After it self-disclosed conduct to the OIG, ABQ Health

Partners, LLC (ABQ), New Mexico, agreed to pay $1,096,112

for allegedly violating the Civil Monetary Penalties Law.

• The OIG alleged that ABQ submitted claims to Federal health

care programs for services performed by pharmacy

clinicians during new and established patient visits based on

E/M codes that ABQ knew or should have known were not

reimbursable.


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Settlement for Multiple E/M Billing

Problems

• Physician agrees to pay $17,087 for allegedly violating the

Civil Monetary Penalties Law. The OIG alleged that the

physician and his medical practice, Metabolic Leader,

improperly billed Medicare for:

– new patient E/M office visits for pre-existing patients

– upcoded E/M office visits

– services provided by nurse practitioners that were billed

under the physician's provider number when he was not

in the office


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Visits and Laboratory Tests

• An Evaluation & Management (E/M) service is not

medically necessary when the test is the main reason

for the patient encounter.

– WPS is seeing this situation with many different

types of blood tests, including a prothrombin time

(CPT Code 85610).


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Community Hospital Pays $451,428 To Resolve

Allegation Of Improper Teaching Physician Claims

• Settlement is due to a whistleblower lawsuit brought under the federal

and State of Hawaii False Claims Acts in federal and state court by a

physician who had worked at the Physicians Center at Mililani (“PCM”),

an out-patient clinic operated by Wahiawa General Hospital (WGH).

• The physician alleged that WGH had submitted bills to Medicare and

Medicaid programs for services provided by resident doctors without

the level of supervision required by federal law.

• The government alleged that WGH wrongfully submitted claims to the

Medicare, Medicaid, and TRICARE programs for services provided to

federal beneficiaries from April 1, 2008 through March 31, 2011 by

resident doctors participating in the Family Practice Residency Program

without satisfactory documentation of the required supervision by the

teaching faculty or where the coding of services performed could not be

confirmed by the physicians’ entries in the patients’ medical records.


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Community Hospital Pays $451,428 To Resolve Allegation Of

Improper Teaching Physician Claims Cont’d

• Under the terms of the settlement agreement, WGH shall

pay the federal government a settlement payment of

$451,428.

• WGH also agreed to pay $75,000 in attorney’s fees and costs

to the attorneys who represented the physician.

• The physician who initiated the lawsuits will receive $84,642

of the $451,428 settlement payment.


68

Inpatient Visit and Minor Surgical

Procedure

• Physician billed CPT 99221-25 and 10060 - Initial Hospital

Care Visit and drainage of abscess procedure.

– Notes are missing a valid provider signature. Signature

attestation was submitted upon re-review by Medicare

contractor to allow CPT 10060.

– CPT 99221 was not allowed as it should be included in the

surgery for the same day.


69

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24

Leading Oncology Practice to Pay $4.1 Million

For Billing E/M Services with Chemotherapy• The civil settlement resolves the United States’ investigation into

Georgia Cancer Specialists’ practices relating to billing for

evaluation and management (E/M) services on the same day as a

related procedure.

• Generally, providers are not permitted to bill both E/M services

and a related procedure on the same day under the Medicare

program’s regulations.

– In specific circumstances, providers can avoid this prohibition

by submitting their claims marked with modifier -25, which

tells Medicare to pay both the procedure and the E/M service.

• In this case, the U.S. Attorney’s Office alleged that Georgia Cancer

Specialists applied modifier -25 to claims that did not qualify for

its use, leading to overpayments by Medicare.


70

Physician Pays $379,764 to Settle Allegations of

Improper Billing of E/M Codes with OMT

• A doctor of osteopathic medicine entered into a civil settlement

agreement with the government to resolve allegations that he violated

the False Claims Act due to improper billing to Medicare for E/M services

that were not medically necessary or were not provided.

• Much of the physician’s practice involved treating patients using

osteopathic manipulative treatment (OMT).

– Data analysis indicated that approximately 95 percent of the time

that he billed Medicare for OMT, he also billed Medicare for an E/M

service, using modifier 25, which allowed payment for both the OMT

procedure and the E/M service on the same day.

• The government alleged that the physician improperly submitted claims

with modifier 25 in order to receive payments for both OMT services and

E/M services on the same day for the same Medicare patients.


71

Physician Pays $379,764 to Settle Allegations of

Improper Billing of E/M Codes with OMT Cont’d

• The government further alleged that a review of the

physician’s medical records

– revealed that there was often was no documentation of a

significant, separately identifiable reason for the patient’s

visit (i.e., the patient was there only for regularly

scheduled OMT services).

– there was often no documentation of the medical

necessity for the evaluation and management services.

– there was often no documentation that evaluation and

management services had been performed at all.


72

9/23/2013

25

OIG Report: Fletcher Allen Health Care Did Not Always Bill

Correctly for Evaluation and Management Services Related to

Eye Injection Procedures

• Medicare pays for an E/M service that is significant, separately

identifiable, and above and beyond the usual preoperative work of the

eye injection procedure.

• The OIG reviewed 100 E/M services related to outpatient eye injection

procedures. The Hospital correctly billed for 15 of the 100 E/M services

sampled.

• Based on these sample results, the OIG estimated that the Hospital and

its physicians received overpayments totaling $211,196 for CYs 2008

through 2010.

• The Hospital and its physicians were not eligible for the additional E/M

payments since the services that the physician performed were not

significant, separately identifiable, and above and beyond the usual

preoperative work of the eye injection procedure.


73

OIG Report: Fletcher Allen Health Care Did Not Always Bill

Correctly for Evaluation and Management Services Related to

Eye Injection Procedures Cont’d

• The hospital’s response explained that the billing errors occurred

because the providers believed in good faith that the care they

provided included a separately billable E/M service.

– In all of the sampled claims, the provider not only assessed and

prepared the patient for the eye injection and provided the

injection, he or she also examined the patient's other eye and

assessed the potential effects of the patient's other conditions,

such as diabetes and hypertension, on that eye. The providers

feel that this approach promotes efficient and high quality

medical care, and likely reduces the need for additional visits.

– On further review of these claims by certified coders, however,

Fletcher Allen recognizes that the documentation in 85 claims did

not support a separately billable E/M service.


74

Settlement – Improper Billing for Physician

Services Using Another Physician’s NPI

• Rutherford Hospital, Inc. agreed to pay $706,090 for


• The OIG alleged that Rutherford submitted or caused to be

submitted claims for physicians' services provided by a

doctor to beneficiaries of Federal health care programs using

the provider identification numbers of another doctor, who

did not render the services.

• The OIG contends that Rutherford knowingly misused

provider identification numbers, which resulted in improper

billing of the claims identified and disclosed by Rutherford.


75

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26

Physician to Physician Incident to and/or

Shared/Split Visits Not Allowed

• Bartlett Regional Hospital agreed to pay $1,434,664 for


• The OIG alleged that Bartlett submitted claims using

incorrect physician names and NPI numbers and submitted

claims for non-physician provider services that were billed

under a physician's name and NPI number.


76

Improper Supervision? Florida Doctors, Hospitals and Clinics to

Pay $3.5 Million to Settle Allegations of Improper Medicare,

Medicaid and TRICARE Billing

• The government alleged that between 2007 and 2011, the defendants

regularly billed for radiation oncology services that were not

supervised by a physician, as required by Medicare, Medicaid and

TRICARE, and that, in fact, these services were often performed while

the defendant doctors were on vacation or were working at another

radiation oncology clinic.

• The government also alleged that the defendants billed for other

treatment services even when patients’ medical records provided no

evidence that the services were rendered.

• The defendants also allegedly billed twice for the same services and

misrepresented the level of a service provided to increase their

reimbursement from the federal health care programs.

• As part of the settlement, the whistleblower, who previously worked for

the practice will receive approximately $609,796.


77

OIG 2013 Work Plan Error Rate for Incident-To

Services Performed by Nonphysicians

• The OIG is reviewing physician billing for “incident-to” services to

determine whether payment for such services had a higher error rate

than that for non-incident-to services.

• The OIG will also assess Medicare’s ability to monitor services billed as

“incident-to.” Medicare Part B pays for certain services billed by

physicians that are performed by nonphysicians incident to a physician

office visit.

– A 2009 OIG review found that when Medicare allowed physicians’

billings for more than 24 hours of services in a day, half of the

services were not performed by a physician. The OIG also found that

unqualified nonphysicians performed 21 percent of the services that

physicians did not personally perform.

– Incident-to services are a program vulnerability in that they do not

appear in claims data and can be identified only by reviewing the

medical record. CPT Copyright 2012 American Medical

Association78

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27

Incident to

OIG Settlement January 16, 2013

• After its self-disclosed conduct to the OIG, Bartlett Regional

Hospital (Bartlett), Arkansas, agreed to pay $1,434,664 for


• The OIG alleged that Bartlett submitted claims using

incorrect physician names and NPI numbers and submitted

claims for non-physician provider services that were billed

under a physician's name and NPI number.


79

WPS Incident to Example – NOT!!!

Dr. A is currently treating the patient for diabetes. The patient's evaluation

and management (E/M) encounter in the office today is with a Physician

Assistant (PA) of the same group for an upper respiratory infection. Can the

PA bill the service incident to Dr. A and bill under Dr. A's provider number?

• In the situation described, the upper respiratory infection is not part of

the treatment for diabetes and, therefore, is not an "integral, although

incidental" part of Dr. A's "professional service.“

• The PA should not bill incident to under Dr. A's provider number, but

should bill the appropriate level of new or established E/M service

provided under his or her own provider number.

• The physician must have performed the initial service for the diagnosis

or condition and must remain actively involved in the course of

treatment.


80

WPS Incident To - UPDATE

• Evaluation and Management

– Physician must have diagnosed and established the plan

of care for the problem being assessed.

• Services cannot be billed as incident to for a new patient or a

new problem.

– This guideline is not overridden by physician set

“protocols” in the office.


81

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28

Incident to – WPS Clarification

• When an nonphysician practitioner (NPP, e.g. NP, PA, CNS,

CNW) provides a service outside the physician’s plan of

care, the service no longer meets the guidelines and

therefore cannot be billed under the supervising physician.

– Changes in the plan, including changing a drug or the

dosage of the same drug constitute a new plan, MUST be

billed by NPP.


82

NPP Change in Treatment – WPS Example

The MD/DO orders drug x at x dosage. The NPP sees the

patient in follow up and determines x drug at x dosage is

not working and changes to y drug at y dosage. Can the

service be billed under the MD/DO provider number?

• No, because the NPP is now determining the plan of

care for the patient, the service no longer meets the

incident to requirements.


83

NPP Sees Patient – Physician Available by

Telephone

If the physician is not in the office, but available by phone, can

the NPP bill under the incident to guidelines?

• No. If the physician is not in the office suite, the service does

not qualify under the incident to guidelines. The NPP would

bill for the service under his/her provider number.


84

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29

NPP Independently Performs Service

• Hospital or nursing facility E/M services documented by a Non Physician Practitioner (NPP) for work that is independently performed by that NPP, with the physician later making rounds and reviewing and/or co-signing the notes, is not an example of a "scribe" situation.

– Such a service cannot be billed under the physician's National Provider Identifier (NPI), since it would not qualify as a split/shared visit.

– Neither would it qualify as "incident to," which is not applicable in a facility setting. In this case, the service should be billed under the NPP's name and NPI.


85

WPS Example – NPP – Established Patient

with New Problem

The NPP is seeing a patient for a follow up for diabetes

treatment. The service meets all the incident to requirements

and then the patient says “Oh, by the way – Can you look at this

rash on my elbow?” Is the service still billable under the

incident to guidelines?

• No – the new problem (rash on the elbow) removes the

service from the incident to guidelines and therefore the

NPP must bill under his/her provider number.


86

NPPs and Dermatology – WPS Clarification

We are a dermatology office. The MD/DO saw the patient for

the removal of actinic keratosis (AK) approximately 3 months

ago. The physician assistant is now seeing the patient for a new

area of AK. Since we are performing the same treatment, can

we bill this under the incident to guidelines and receive the

MD/DO reimbursement?

• No, the MD/DO has not seen the patient for the new lesion

and therefore would not have set the plan of care. Submit

these charges under the mid level provider number.


87

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30

NPP and Radiology Supervision – WPS

Clarification

The mid level provider is the only clinician in the office today. She orders a chest x-ray for the patient and this is performed by the technician in our office. Can we bill the technical component of the x-ray under the mid level provider number?

• No. Mid level providers cannot supervise diagnostic tests.

– They can order a diagnostic test, they can perform the technical component acting as the technician, they can provide the professional component by performing the interpretation and report, but they cannot supervise a technician performing the service.

– In the example given, if the supervision requirements are met, the technical portion of the diagnostic test can be billed under the MD/DO.


88

NPP Application of New Cast – WPS

Clarification

The patient had surgery and is returning for a follow up. The NPP sees the patient and determines the patient needs a new cast. Can the NPP submit this under the MD/DO provider number?

• The determination of whether incident to billing applies to the new cast needed by the patient is based on whether the MD/DO indicated a possible need for a new cast as part of his/her plan of care.

– If the service is during the postoperative period, the application of the cast would also need to include Modifier 58 for a staged or related service, or modifier 79 for an unrelated service based on medical record documentation.


89

NPPs and Locum Tenens

We have a mid level provider who is going on maternity

leave. Can we use and bill for a locum tenens mid level

provider while she is gone?

• Locum tenens and reciprocal billing are only available

for MD/DO.

• If you are hiring a temporary replacement for your mid

level provider you will need to enroll the new person

with Medicare.

• You can find more information in the CMS Medicare

Claims Processing Manual, Chapter 12, Section 30.2.11.


90

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31

Incident to – Looking for a New Physician -

WPS Clarification

We are a physician clinic and our physician has left. We

currently have two NPPs providing services. A physician in

another office sponsors and supervises the NPPs. Can we bill

the NPP services as incident to the physician in the other

office?

• No. Services provided in the office must meet the incident to

requirements, one of which is that the billing provider must

be present in the office suite.

• In the situation you describe, bill the services under the NPI

of the NPPs.


91

Incident to – Place of Service Outpatient

Incident to service guidelines do not apply to those items billed in POS 22.

Therefore, a mid-level provider seeing a patient must bill under his/her own

NPI.

• In POS 22, in order to bill under the physician's provider number either

the physician has performed the service or the situation meets the

shared/split guidelines.

– The shared/split guidelines indicate both the MD/DO and the mid-

level provider are in the same group (meaning under the same tax id)

and both are providing a portion of the service to the patient.

• Physicians who have billed for services provided by the mid level

provider in POS 22 when the shared/split guidelines did not apply should

refund Medicare the difference in payment. Physicians are allowed at

100% of the Medicare Fee Schedule and mid level providers are allowed

at 85%.


92

Physician/NPP Shared Visits

• Visit encounter shared between a physician and an NPP from the

same group practice and the physician provides any face-to-face

portion of the E/M encounter with the patient.

• A split/shared E/M visit is defined by Medicare Part B payment

policy as a medically necessary encounter with a patient where

the physician and a qualified NPP each personally perform a

substantive portion of an E/M visit face-to-face with the same

patient on the same date of service.

– A substantive portion of an E/M visit involves all or some

portion of the history, exam or medical decision making key

components of an E/M service.


93

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32

Physician/NPP Shared Visits Cont’d

• Both the physician and the NPP must each personally

perform part of the visit, and both the physician and the NPP

must document the part(s) that he or she personally

performed.

– When the supporting documentation does not

demonstrate that the physician performed a substantive

portion of the E/M visit face-to-face with the same

patient on the same date of service, the service must be

billed by the NPP.


94

Physician/NPP Shared Visits Cont’d

• A visit during which both the MD/DO and the NPP provide a

substantive portion of the E/M service.

– Services provided in an office setting

• Must meet the incident to guidelines in addition to

the split/shared guidelines

– Services provided in a facility setting

• Do not have to meet the incident to guidelines, but do

have to meet the split/shared guidelines


95

Inpatient Shared/Split Visits – Physician/NPP

• Both the physician and the NPP must each personally perform part of the visit, and both the physician and the NPP must document the part(s) that he or she personally performed.

• When the supporting documentation does not demonstrate that the physician "performed a substantive portion of the E/M visit face-to-face with the same patient on the same date of service" as the portion of service performed by the NPP, a service billed under the physician's NPI will be denied. – It is of particular importance to remember that notes documented by

the NPP for E/M services performed independently within a facility, and later reviewed and co-signed by the physician, depict neither a scribe situation nor an appropriate split/shared visit.

– Additionally, "incident to" guidelines do not apply to services in an inpatient setting. In this situation, the service should be billed under the NPP's provider number, and would be reimbursed at the established rate for that provider.


96

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33

Inadequate Physician Documentation for

Shared Visits

• "I have personally seen and examined the patient independently, reviewed the PA's Hx, exam and MDM and agree with the assessment and plan as written" signed by the physician.

• "Patient seen" signed by the physician.

• "Seen and examined" signed by the physician.

• "Seen and examined and agree with above (or agree with plan)" signed by the physician.

• "As above" signed by the physician.

• Documentation by the NPP stating "The patient was seen and examined by myself and Dr. X., who agrees with the plan" with a co-sign of the note by Dr. X.

• No comment at all by the physician, or only a physician signature at the end of the note.


97

Hospital Discharge Services – Shared/Split

Visit

Can a physician and an NPP perform the discharge visit as shared/split? If they can, who bills for the service? If they cannot, who bills for the service?

• A physician and NPP may perform the discharge management services as shared/split.

• Each party must document the work they performed. The documentation must show a face-to-face encounter with the physician.

• If there is no face-to-face encounter with the physician, the NPP must bill the service using his/her National Provider Identifier (NPI).


98

Shared/Split Visit – Physician wants NPP

to Document Entire Service

Both the physician and the NPP performed part of the

Evaluation and Management (E/M) service for the patient.

The doctor left the documentation of the visit to the NPP.

Is this a shared/split visit?

• No. To bill a shared/split visit, both the physician and

the NPP must document the work they performed and

sign their part of the medical record.


99

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34

Common Orthopaedic Scenario – PA

Service

If a PA in orthopedics has the initial encounter with a patient, then the patient meets with the physician the next day and the physician develops a plan of care, can the PA then bill incident to for the encounters after the physician's visit?

• The initial encounter is billed under the NPP number.

• Any subsequent visits after the patient sees the physician may be billed under the physician's provider number only if the situation meets the incident to requirements by developing a new plan of care for the existing problem.


100

Incident to?

Injections, Venipuncture, Minor Visits

We schedule patients for injections, blood draws and other minor visits before the physician comes into the office. Can we bill for these services under the incident to guidelines?

• Medicare pays for services and supplies (including drugs and biologicals) furnished incident to a physician's or other NPP's services, which are commonly included in the physician's bills, and for which payment is not made under a separate benefit category listed in §1861(s) of the Act.

– One of the requirements of incident to billing is that the physician must provide direct supervision - the physician must be in the office suite.

• Laboratory tests have their own benefit category as listed in §1861(s) of the act and as such are not subject to the incident to guidelines.

– Medicare considers a blood draw as part of the Clinical Laboratory services and as such is not subject to the incident to guidelines.

• You can find more information in the Medicare Learning Network (MLN) Matters Special Edition SE0441.


101

Improper Supervision of Diagnostic Test

• MRI Diagnostic Testing Company, Imagimed LLC, and its former owners and chief radiologist to pay $3.57 million to resolve False Claims Act Allegations for magnetic resonance imaging (MRI) services.

– Submitted claims to Medicare, Medicaid and TRICARE for MRI scans performed with a contrast dye without the direct supervision of a qualified physician.

– Also, allegedly, from July 1, 2005, to April 23, 2008 claims were submitted for services referred to Imagimed by physicians with whom Imagimed had improper financial relationships.


102

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35

Improper Supervision of Diagnostic Tests

• Radiology Associates, P.C. (RA) and Oregon Imaging Centers,

LLC (OIC), agreed to pay $189,045 for allegedly violating the

Civil Monetary Penalties Law.

• The OIG alleged that OIC inappropriately billed Medicare for

certain diagnostic tests provided by radiology practitioner

assistants employed by RA that required personal

supervision by a physician, but instead were provided under

direct supervision.


103

OIG 2013 Work Plan - Laboratory Tests—Billing

Characteristics and Questionable Billing in 2010

The OIG will describe billing characteristics for Part B clinical

laboratory tests in 2010. They will also identify questionable

billing for Part B clinical laboratory tests in 2010.

• In 2008, Medicare paid about $7 billion for clinical laboratory

services, which represents a 92-percent increase from 1998.

• Much of the growth in laboratory spending was the result of

increased volume of ordered services.

• Medicare pays only for those laboratory tests that are

ordered by a physician or qualified nonphysician practitioner

who is treating a beneficiary.


104

Questions?

Thanks for inviting me!


105

The Need for Self-Audits Related to E/M Coding

Documents

Transcript of The Need for Self-Audits Related to E/M Coding