Put Some Pep In Your Compliance Program With Our New Podcast

Over here at Healthicity, we’ve got some tricks up our sleeves.

You see, it’s our goal to create the best thought-leadership material out there because we want our readers, healthcare professionals like yourselves, to have all of the answers you need at your fingertips. But we don’t want to just create content, we want to create great content that is fun, entertaining, and convenient, so you can fit it into your busy workday. And so, [trumpets] ba, ba, baah, baaaaah!

WE’D LIKE TO ANNOUNCE, NEW, EXCITING CONTENT!

You’ve been reading our thought leadership papers for a year now. Recently, in our ongoing effort to make it easier to stay up-to-date on all things compliance and auditing, we released audio files for you to use in your continuous education efforts or to jam out to during your commute.

Since our audio files have been such a hit, it seems only natural to take it one step further and launch a monthly Healthicity Podcast, Compliance Conversations, hosted by our compliance expert, the one and only, C.J. Wolf, M.D.

On October 18th, 2016, our first Podcast, "How Auditing Best Practices Support Your Compliance," will go live. In this podcast, compliance expert CJ Wolf M.D., and Auditing Mastermind, Lamon Willis, spend twenty-five captivating minutes (perfect length for your lunch break) chatting about the many ways that auditing best practices support your organization’s compliance.

Podcast Episode Details >>

Lamon and CJ will be chatting in depth about common CCI Audit Errors, Modifier 59 Best Practices and much, much more from the perspective of both an expert auditor and a compliance expert. Tune in for your weekly dose of compliance and audit education.

If you’re a healthcare professional who has knowledge to share, we’d love to have you as a guest on our show. Slots are filling up fast, contact CJ Wolf for information, asap.

Don’t want to be a guest but still have knowledge to share? Contribute to the conversation below in the comments section. How can auditing best practices support organizational compliance?

 


 

Episode 1 Transcript

CJ Wolf: Hi, this is CJ Wolf and today we have a great auditing expert with us, Lamon Willis welcome, Lamon.

Lamon Willis: Thank you CJ glad to be here.

CJ Wolf: We talked a little bit today about some of the area that Layman has some expertise in doing in auditing and one of the thing that I hear a lot about Layman is CCI edit so Medicare is Comprehensive correct coding initiatives as well as the modifier 59 that bypasses a lot of those edits and one of the things that I think is interesting is that some people really struggled with this concept even sometimes coders and kind of understanding that. What kind of areas do you see that people are making mistakes in when it comes to the correct coding initiative and/or modifier 59 usage?

Lamon Willis: Well a lot of the issues surrounding it have to do with simply be an uninformed As I have learned when I've been out doing either auditing work itself or teaching, training, speaking engagements whatever it might be I find that a lot of people have never read through the national correct coding initiative manual that’s posted online at CMS publishes, they haven’t downloaded any of the material and read through it all. they usually rely on some type of software to help them whether it's an encoder if they are doing coding or possibly a look tool if they are making some office coding or coding from home maybe or if they are biller they might simply be using the lookup tool, so they relied heavily upon some software that is meant to be helpful but if you don't know the concept and the purpose and design behind the CCI edits themselves then it's still possible for you to misuse modifiers and also misunderstand the edits and try to bypass them later.

CJ Wolf: Yeah, you know that's a really good point. I recall a time when I worked for an organization where a group of about 15 Coding consultants in-house we would every year when the new manual came out we would download them we were assigned chapters because our supervisor felt the same way as you did that some people think that the CCI edit is simply a kind of these numbers and oh, if these two numbers hit and edit then let's put a modifier on it without understanding the real principle behind the manual. Is the manual still published in chapter format? In that chapter more or less mirror the section of the CPT book?

Lamon Willis: Oh yes, that is correct is still published in the main format of the different version 1 for the hospital side of the house the other for the position practices, and so yeah it set up displays like how CPT is broken out by sections, so that you can go through that particular section of the CPT manual essentially with the CCI manual and kind of take a look at those code to code designs and what they are trying to really inform people about the purpose of you know promoting correct coding and trying to use these to reduce error rates when it comes to claims that are paid for Medicare and Medicaid services.

CJ Wolf: Yeah I remember one I think G.I. systems when the gastrointestinal system, I think there is some good narrative in that CCI manual regarding endoscopic procedures right, where if somebody is doing a diagnostic procedure or they are doing a removal of a lesion endoscopically then the biopsy code of that same lesion is typically considered inclusive right and would hit in a CCI edit but a lot of times when they are doing these sort of studies there's multiple lesions and so the code you can tell from a numeric code on the claim right, but the medical records should clarify when it's appropriate to use a 59 and when it's not. Do you have any examples that come to mind of when you know....

Lamon Willis: Yes there are a lot of different examples in that because they have set this up with things like code pair, procedure to proceed edits also unit of service edits, so that's where the medically and likely edits come from as it relates to the service those are set up so that things don't become fragmented or unbundled for example with the MUE's you know it's unlikely that you're going to report more than one unit for a cataract distraction for each eye because you only have two eyes right?

CJ Wolf: Right.

Lamon Willis: So you wouldn't service for any cataract extraction because you only have two eyes and so you know those who are things that you would hope that of course your scrubbing software is going to help you with, if for some reason your online look tool that you're using or your auditing software, your coding software whatever it is. If it’s doing its job of course it would prevent you too but these things right there should be known to us based upon our training or expertise and it just goes back to the reason why you also need to have people who are professionals who are doing the work for you too

CJ Wolf: Right, well you know in my area of compliance the OIG usually carries a lot of weight. Are you familiar with any reports either by OIG or other enforcement agencies to talk about the number of claims that they reviewed and the kind of error rates and if this topic plays into any of that?

Lamon Willis: Yeah for sure so Medicare has some what they call common error rate testing reports that they do on an annual basis and these go through and take a look at codes that are reported by physicians and also Hospitals are part A and part B claims but a lot of times of course you know we’re focusing on some of the physician services themselves, but these error rates reporting issues relate to any and all types of CPT codes that are going to get reported along with the possibility of modifiers and associated modifiers. So back 2015 the Cert reports for both party A and part B claims specifically did a focus on some of the issues around the use of modified 59 which is the modifier that allows you to bypass some of those CCI edits and so on the part A claims that they looked at there were about a little over 20,000 claims they reviewed and they had paid two hundred and 60 billion on those. they projected that about 28 billion of that were paid in error because of the improper use of modifier 59 and then on the part B claims a little over 18,000 claims were reviewed and It was about 90.4 billion in payment that they made on those services and they projected about 11.5 billion in errors for the improper use of modifier 59, and so it again you know it's not something new of course in how we would know how to use this modifier, all of the information related to it you know there's only been minute changes to it in the recent past and so really it just comes down to improper use.

CJ Wolf: Yeah do you see that. I know you mentioned the claim scrubbers and sometimes are the same people that are doing the coding working those claims scrubber reports. I found both to be the case sometimes it is the same person and those people might be more in tuned because they are trained coding to not use the 59 modifier inappropriately where as if you are in a bigger organization and the code did one thing and then it's a different person working those claims scrubber edits they might be misinformed and append the 59 modifier and bypass all those edits. Do you see that happening very much or not?

Lamon Willis: Yes that's definitely the case were obviously the larger the organization the larger the amount of processes that you would have in place.

CJ Wolf: I can think of a single circumstance where that would be appropriate to hardcode modifier 59 to a charge master because the proper use of the modifier is so dependent on those clinical circumstances and there's no way a charge Masters is going to know that in advance.

Lamon Willis: Absolutely, absolutely and even if you thought that you had a scenario where that was the case you know there's always the possibility of your software not working correctly you have a system upgrade of some kind in which something breaks or something fails and so again you know that could be the death mill for you as a compliance person as well because then you have got all these claims that modifier 59 went out on, you got paid probably for some services that you never intended to get paid for and so now you have got to payback possibly hundreds of thousands or maybe millions of dollars for something that you had no intent in doing to begin with.

CJ Wolf: Yeah it reminds me a little of a bit of...there is a lot of talk recently about the 60 day repayment rule you know the affordable care act in kind of this concept of reverse false claims that if you're aware of an overpayment you have 60 days to refund the money but it's not just about one claim you have to go back potentially six years and I'm thinking of a kind of a nightmare scenario of whoop! somebody six years ago hardcoded a modifier 59 maybe had good intentions may be misunderstood some direction they received from their supervisor but now you got six years worth of claims that went out. that you're absolutely right It could run into the millions and could be a nightmare, and then you have this added pressure of once you have identified it you got 60 days to kind of go back. Have you ever done kind of pointed audits regarding modifiers 59 that are you focused on that audit, and if so how do you go about doing that?

Lamon Willis: Yes So I have both on the hospital and physician side one of the things that commonly happened is that you know there would be some type of interview process that takes place with the billing staff and the billing staff would usually be the point of the spear to let you know exactly what's happening with claims and what's going on with services that are being generated from either of the various specialty line you know, if it's a physician organization or in the hospital setting obviously from different departments and so they would commonly be able to tell you, you know we have a lot of claims to kick out for this particular specialty because of such and such and so you find out that there was a need for someone to be looking at the code pair and make a determination of a modifier did in fact need to go on one of the codes and/or if they had just inappropriately reported this other CPT or HCPCS code, and so you knowing going through that type of audit you know it's a time to find out that you know they have some process breakdown obviously, they might have some inappropriate reporting that's going on and you know it goes back to getting those things worked out with, where it originated at in either the specialty line of the department and then also you know providing some training to the staff to allow them to be able to adequately either assign that modifier or have a policy and procedure in place which says well these are the people that are allowed to do that, and you know they know what they're doing when they do it.

CJ Wolf: I was just going to ask you that. Is there a kind of a best practice you know in some organizations the ultimate coding decision resides with the physician they might have a coder who is certified to kind of help with volume of coding that needs to be done but if there's ever a question it can go back to the clinician. Do you see that as a best practice or does it really just varies kind of by organization as to who that decision-maker should be with bypassing those edits?

Lamon Willis: Yeah, I think varies obviously in and practices where you have the capability that your physician staff are doing their own coding it makes sense for them to be people who were queried concerning situations like that, you know along with possibly someone else who May have a little bit of clinical expertise as well but also you know is knowledgeable of coding to be able to ask those questions in a way to get some good answers rather than just needing to know, hey! Can I put this on this code and get this claim out the door kind of thing, that’s not what you obviously want to do. In other authorization though you know you've got a Bigger set of claims that are always going out the door, there is usually going to be some type of front line of people who are going to deal with those issues and then it becomes the onus of the organization to make sure that those staff are trained, they are expert in what they do and that you know there's follow-up of you know looking at their work you know, auditing them to make sure they know what they are doing.

CJ Wolf: Yeah as you were talking it made me think about when I was trying to…I was in an organization where we had physicians that made that ultimate decision sometimes, so the edits would go back sometimes to the physicians on certain issues and I have some docs would be like well, which modifier gets it paid and that was the determination that they were using to decide whether a modifier gets added. So then we had to educate physicians who are busy and they really don't want to know the ins and outs of the CCI modifiers and edits. So I had a supervisor who came up with... Immediately after I tell you this you can if you have any ideas on ways to teach people the complexity and kind of elevator pitch with a short method I would love to hear them. This supervisor called it the happy meal model, because all of us I've gone through a drive thru where you order French fries drink and a burger separately and you would pay more money if you order those items separately as opposed to just ordering the value meal and one day after I was teaching on modifier 59 I actually did go through with the drive thru I had ordered a value meal and then I said I want a root beer and when I got home the receipt... So on paper the receipt showed here is your charge $7.29 for the value meal and then a $1.29 charge for the root beer and so am feeling, and most of us would say oh! you got ripped off and then I used that receipt as an example to teach modifier 59, I said look! That receipt in and of itself doesn't tell you the full story, I will give you two scenarios, the first one I was in the car alone and I ordered a value meal and the root beer was supposed to be a part of what I paid for the value meal so I should not have been charge extra and everyone nods their head and said yea yea that makes sense, and then I said what if the circumstances were slightly different I was going to the drive thru I ordered a value meal and my wife was in the car and said aah, I'm not hungry and she just said get me a root beer. well know the stories totally different and that root beer should be paid separately, because the circumstances around that scenario demonstrate that even though it was a component code, I'm using old language here from the CCI edit, but it is one of these unbundled things but in that second scenario that unbundling was appropriate because there was kind of a second encounter and so I use that analogy a lot to try to help people understand that this is what is meant by unbundling and this is what the CCI edits tried to do is they give you a list of this is a comprehensive code and these are all those components.

Lamon Willis: Absolutely yea that’s a good example. I think that really probably works and its very understandable for practically anyone that would want to listen to things to do with what we are talking about.

CJ Wolf: Exactly

Lamon Willis: You know the fragmenting of services is exactly that, it's a great explanation of that and you know a coder or a biller would get that right away, you know looking through the codebook essentially you know it’s going through a menu list very similar to what you’re talking about and discussing you know and they have got examples of down coding and up coding and fragmenting unbundling, all those type of things in which once you have read through that and you would read through it on a routine basis like we have discussion of doing something annually or maybe even quarterly depending on you know how busy your workload might be because the CCI edits get updated frequently, you know just going through that and refreshing your remembrance about things can be very helpful because you know there are other things in there that deal with increments of time and per session measurements as opposed to you know just surgical procedures because this deals with therapeutic services by you know therapist, you know whether it's speech therapy or its physical therapy or occupational therapy you know there are things for them in there as well. So it's not just about maybe that ENM code that we are all use to or even the surgical component codes but there are things to do with you know per session information as well.

CJ Wolf: Yea that’s a great point I remember one specific example. I was in charge of the interventional radiology reviews for our hospitals and physicians and as I was reading the chapter they actually have the scenario of what I was trying to teach the clinicians about and the scenario had to do with you know when you do like a heart catheterization and these are sometimes called drive by a renal a-orthography where after the physician has done a Heart cast an imaging of the heart they pull the catheter back down the aorta and as they are pulling the catheter out they go by the renal arteries, and the renal arteries you can then engage them by putting the catheter inside the arteries, inject contrast and then take a picture. Well there's a scenario in the CCI manual and it talks about when that’s appropriate and when it isn’t appropriate and it was like the perfect example for me because I was… I found that they were using the modifier 59 to bypass the edit and in many cases it was not appropriate and I showed them that example and it was a real help and I like your point of you know... read that manual over and over again because it's not, it can be all sorts of different scenarios that you sometimes can't even think of.

Lamon Willis: That’s right and let's say maybe you got a new employee so you know they are going to have to do their own boarding, they are training with your organization you've got some different topics that you going to take them through and things and so a part of what you want them to know is exactly what are your other staff members task. so maybe those other staff members they have the luxury of sitting through and enjoying some of that education that you're providing where you went through the manual several times you had question-and-answer sessions, you maybe you even done a little bit of testing or something like that, you know no harm no fowl we are doing a few Q&A's on that. You know having these people do that with you who are new hires is going to be invaluable to them because they probably have never been through that you know so they might still have questions from a previous employer, a previous work they did you know other things where they simply don't know some of those things like for example. One of the things that the CCI ………. [21:12.7] talked about is things that are called intrical services, things that are integral to the service that you're going to perform and provide right, so if you're going to do a surgical service on someone cleansing, shaving, prepping the skin all of that is included you know you don’t get paid separate for that, you don’t try to earn a new biller That is something that they might/would have questions about but see this would help them to automatically right away know the answer, we don’t do that we don't try assign coding for that or try to do billing for that. So there are things in there that will be helpful to all of your employees on a go forward basis is to...

CJ Wolf: Yeah that great point, well any last minute thoughts or things that I might not have asked about that you could think about that is important on this topic?

Lamon Willis: Well I think you know one of the things always keep in mind is we never really stop learning about this, thinking about it you know each time I talk about it and speak about it I learn new things myself because it brings back to my memory possibly something that I haven't talked about in maybe months or months or something but you know there are always things that will come fresh to your mind again that will bring something back home when you talk about it you say those things out loud people hear them rather than just reading them too, it might click something in there Memory too or a question for them to help them provide some answers to them as well so you know just continuation of training and education along these lines I think it's just extremely beneficial for all of us.

CJ Wolf: I agree I think you have told me once before about sometime the medicated administrative contractor or the max will sometimes even have reference material specific to this. We have talked a lot about the CCI manual itself just a national publication right?

Lamon Willis: Yes

CJ Wolf: Then you could get some local variation have you seen any of that?

Lamon Willis: Yeah that's definitely the case. So you can go online to your local either part A or partly B Mack and you can download sometimes they will have a Q&A section, they will have a frequent asked question, they might even have a specific topic on modifiers for example the nuridian jurisdiction E is one that I was using recently to do some training and education where I was teaching that and so they had a property use of the modifier 59 item that they posted on the website from back in March of this year 2016, so it's updated with good information and it goes through some different scenarios it refers you back to Possibly some things to do with the CCI manual but it specifically gets into you know questions and answers you know things you should do things you should not do it kind of breaks that up both for you too so you can give it a quick highlight overview of scanning through it and see you know exactly what you might want to reference from this article; and that’s the way a lot of the Max do is to provide you some education that way that would be very helpful for you.

CJ Wolf: Yeah, that’s a great example I appreciate that and …..I really appreciate your expertise and your knowledge on the topic and i would love to have you back at some point maybe we have some different topics we could talk about or even beat this Horse more dead.

Lamon Willis: Ok that sounds great CJ thank you very much

CJ Wolf: Thanks Lamon.

Questions or Comments?