Deeper Than the Headlines: Clinical Practice Compliance Conference

I just returned from San Diego where I spoke at the HCCA’s 2018 Clinical Practice Compliance Conference. It was three days of compliance information focused on physician practice issues. If you missed it, don’t forget the HCCA posts all the handouts on their website.

Here are a few of the areas that caught my attention:

1. Audit the use of certain modifiers

Some presenters advised practices to audit the use of certain modifiers. Most of us probably know that certain CPT coding modifiers will bypass some payor edits, often resulting in additional reimbursement. However, sometimes the use of those modifiers are appropriate and sometimes they are not.

When modifier -25 is appended to an E/M code it will typically get two services reimbursed: the E/M code as well as a procedure performed on the same day. This is appropriate if the E/M code reported represents a significant, separately identifiable E/M, above and beyond the normal pre-op or post-op care associated with the procedure. The documentation should support this as well.

The other modifier that often warrants auditing is modifier -59. This modifier frequently bypasses many of the NCCI edits. Again, there are times when this is appropriate and times when it would not be appropriate. Some examples of when it might be appropriate include a separate session, separate location, or an unrelated condition or procedure.

Many enforcement agencies, including the OIG, have performed audits in these areas in the past. Additionally, there have been financial settlements resulting from whistleblower lawsuits regarding alleged misuse of these modifiers.


Anyone involved in the healthcare compliance field has seen the uptick in HIPAA enforcement actions. Included in these actions are both financial settlements as well as corrective action plans.

Presenters at the conference spoke about the importance of being proactive in HIPAA. This includes regularly performing a HIPAA Privacy Assessment and a HIPAA Security Assessment. Such assessments take a “snapshot” in time of where a practice’s current HIPAA privacy and security compliance programs and efforts stand.

The results of these assessments should lead to identified areas for improvement and a documented mitigation or work plan. Properly prioritizing those work plan items is essential to make efforts at mitigating the highest risks first.

3. Teaching physician rules

Yours truly and a colleague, Jay McVean, from the Univ. of Texas Health Science Center Houston (UTHSCH) spoke to those working with physicians who involve medical residents, fellows and/or medical students in caring for patients.

Our session was called “Compliance for Teaching Physicians: What Have We Learned?”

We discussed the now famous PATH (Physicians at Teaching Hospitals) audits which were among the first major compliance enforcement initiatives in healthcare. We also explained why this is still a significant compliance issue.

This was followed by providing attendees with answers to the question of how compliance professionals at UTHSCH provide training, audits, and tools for teaching physicians. This included key attestation statements and documentation processes to follow to stay compliant.

Other sessions included:

  • Compliance Risks in the EMR
  • OIG Update: Key Priorities in Compliance
  • Measuring Compliance Program Effectiveness
  • Monetizing Quality: How to Align Quality with Compensation Models and Payer Contracts
  • Opioid Crisis: How to Monitor for Compliance
  • Managing Conflicts of Interests at Your Organization

The conference was wonderful for those working in compliance with physician practices. Take a moment to review some of the handouts and if you have any questions, don’t be shy…share a post!

Questions or Comments?