How Compliance Teams Can Deepen Their Physician Partnerships
compliance, auditing, healthcare compliance, compliance training, compliance officer, podcast, physician, Compliance Conversations, Clinical, healthcare auditing
Today’s episode of Compliance Conversations features a conversation between CJ Wolf, MD, and his longtime colleague and medical compliance expert, Jay McVean. Jay has over two decades of experience in medical billing and coding, and he currently serves as the Director of Medical School Billing Compliance at the University of Texas Health Science Center.
Let’s face it – compliance can sometimes feel impersonal when you’re reviewing results, implementing processes, or conducting audits, but Jay and CJ discuss the essential importance of cultivating strong, collaborative relationships between doctors and compliance teams.
Tune in to hear us talk about:
- Common billing and coding pain points from doctors
- How to effectively communicate audit results to physicians and encourage best practices
- Shifting the perception of compliance towards partnership and positivity
By taking the time to understand physician workflows, challenges, and needs, compliance teams can deepen their cross-collaborative efforts and enhance compliance and auditing programs.
CJ: Welcome everybody to another episode of Compliance Conversations. My name is CJ Wolf. I’m with Healthicity, and today’s guest is my good friend and colleague Jay McVean. Welcome, Jay.
Jay: Hey, CJ, thanks for having me. I appreciate it.
CJ: Yeah thanks for joining. It’s always good to talk to Jay, and you’re going to learn a little bit about him, and I’m going to let him even introduce himself a little bit. Jay, tell us a little bit about how long you ended up doing what you’re doing, how long you’ve been doing it, what your current role is and that kind of stuff.
Jay: Sure. It’s an interesting path to where I am today, but I’ll give you the SportsCenter edition. So I went to college thinking that I was going to teach and coach, and really quickly decided once I got into the school system that wasn’t for me. So I started working with some physical therapists who introduced me to a neurologist, started working in a neurologist’s office, had some experience in his office dealing with an infusion suite and infusion billing. I got hired by the infusion company then found my way over to MD Anderson with you, brought me on there. So over the last 20 years I’ve kind of just moved where I was guided and directed and ended up here at the University of Texas Health Science Center in Houston as the director of medical school billing compliance. I have a great staff, an awesome team of auditors that — we spend our days auditing physician medical records and providing education and teaching and training to docs along billing compliance rules and regulations.
CJ: Yeah, and you said 20 years. Don’t tell me it’s been that long. We’re getting old.
Jay: Yeah, it’s been a minute, that’s for sure. Before I started this — I think when I started with you, I had one kid. Now I got one kid who’s graduated college and one who’s about to graduate high school, so it has been that long.
CJ: Oh my goodness. Well, and some things probably haven't changed that much. As we look back on some of these issues, it’s like, ‘Oh my goodness, is this still around?’ But Jay has such great experience working at UT Health Science Center in Houston. Jay, tell us a little bit about the size of the institution. How many doctors? I’m sure you have nurse practitioners and PAs; what’s that audience that you’re responsible for auditing and educating?
Jay: Yeah so that’s always a moving target around here, as you know. Being part of a medical school and residency programs and fellowship programs, the number of billing providers that we have is always fluctuating, but roughly anywhere between 1,800 to 2,000 providers across the entire practice plan. That incorporates not only physicians, but nurse practitioners, PAs. We also have a pretty extensive psychology group, social workers and we have been bringing on dieticians in the last few years to start talking about billing for diabetes management and things like that. We have part of our organization, we run the Harris County psychiatric hospital, so we’ve got a pretty extensive program over there of providers who provide inpatient services for psychiatric patients as well as a big outpatient psychiatric service. We’ve got a school of dentistry. We’ve got a school of nursing. We’ve got a school of public health. So all kinds of different avenues and things that we get into from a compliance standpoint on — you know, medical students as well. So just a wide variety of different topics and subjects that we deal with on a day in, day out basis.
CJ: Yeah, and residents and fellows. You probably have every medical specialty represented. Is there something that you don’t have represented?
Jay: As far as I know, not at the moment. I mean, unless they create something — CJ, we’ve got sub-specialties that I’m like, ‘Oh, OK, that’s now.’<,/p>
Jay: So there’s been branches of, whether it be neurosurgery and sub-specialization there, or whatever. I’m learning new sub-specialties all the time.
CJ: Yeah, cool. Well that is the one cool thing about what we do. We meet people who are doing new things. It’s not always stale, and you get to learn new things. Cool. Well thanks for that background and maybe we could jump in and we could just talk about — I’ll give you a general question: what are some of the most common professional coding, billing, compliance questions you get from doctors, and when I say doctors, I include nurse practitioners and all those other provider types that you mentioned.
Jay: Yeah, unfortunately I’d say the most common question is, ‘Why do I have to follow these rules?’
CJ: OK, so that question has not changed over the last 20 years, because we got it 20 years ago.
Jay: Yeah, no, that still continues to be number one. And really I think the biggest disconnect there is the docs feel like the rules don’t really follow their workflows in their office in the way they see patients clinically, and I do explain to them quite often that, ‘You’re exactly right. These rules don't take into consideration a lot of the workflows and processes and things that you guys do with patients on a day-in and day-out basis, but these are still the rules we have to operate under, and to make our clinics complaint with these rules and whatever we have to do to do that operationally, that’s what we have to do.’ But outside of that, CJ, I think the biggest questions that we get across my groups still are related to, obviously, the one thing that’s never gone away and will never go away, is E&M coding and documentation. Especially with the recent changes that have come in 2021 to the outpatient rules and then what we see coming up probably in 2023 with the inpatient rules, the docs continue to ask questions in regards to that. I think a lot of them felt comfortable with the levels of service they were selecting under the old rules, and now we’ve got these new rules and, ‘Am I in the right ballpark with the levels of service I’m selecting?’ and the documentation and so forth and so on. So that continues to be probably, across our practice plan, one of the biggest questions that we get on a regular basis. And then from there it’s, ‘How do I use my medical students effectively? How do I use my nurse practitioners and PAs effectively? What can I do to make sure that I’m billing at the appropriate levels and maximize my billing but yet continue to have compliant documentation?’ So those are the types of questions that we get most frequently that we help our doctors navigate those waters on this end.
CJ: Yeah. So on E&M, let me ask you a little bit more about that. I can understand that, right, it’s like procedures and the codes, they’re more or less straightforward. Of course there’s going to be some gray areas in some procedure codes. But E&M just seems like this natural place where there’s ambiguity sometimes. Do you think that these changes that we experienced in 2021 and then what we’re going to experience soon, where we’re shifting to medical decision-making as the driving component, that’s going to help. I don’t know if I could ask, ‘Has it helped already?’ because it seems like what you just said is they were used to doing it one way and now it’s changed. Do you think, if we were to look like four, five years down the road, changes are going to help, or do you think we’re just going to be doing more of the same?
Jay: No, actually based on our audit results that we’ve had this year across our practice plan, I think it’s already helped, and I think it’s going to continue to improve as they get more familiar with it. But in the past, where you had a new patient that required three key components and they wanted to bill a level four or five and they missed one exam element or HPI element and it got down-coded, that frustration has gone away. Now what we really are trying to focus on is getting them to understand the correct verbage or making sure they’re giving us enough detail in their medical decision-making portion of their note to support those higher levels that of course every provider wants to be able to bill, or at least levels of service appropriate for that patient. And so I think across the board we’ve found that providers who used to be billing level threes are now feeling more comfortable in billing levels fours because of the way the rules have opened it up for them a little bit more with being able to document, because most of them are doing some sort of medication management. Most of them are doing — we do have a lot, especially in our area, of social determinants of health, and things like that that weren’t really available to them before that are available to them now to help them be able to select a level of service and get it to a little bit higher maybe than what they did previously. So we’ve seen that improvement already. We still go back to our physicians quite a bit on audit and say, ‘Hey,’ especially with, as you probably are well aware of, with these EMRs and the templated medical records and the quick clicks and all of that — a lot of times we’re missing details in that assessment and plan portion of the note that really would make it clear what’s going on with that patient and really drive that level of service even higher, if possible, if they would give us just a little bit more detail.
CJ: Yeah. Do any specific examples come to mind? Like I was presenting at a conference a couple months ago, and the way I presented it — it was a group of coders, and I was trying to teach them examples from how a doctor goes through what’s called a differential diagnosis, right. So patients don’t come into your office with a sign around their neck saying, ‘I have rheumatoid arthritis’ or ‘I have lupus.’ They don’t come in with a sign around their neck. They come in with chief complaints and concerns, and then the doctor has to do his or her detective work, eliminating certain things and narrowing down, so what’s going on in their mind — it’s kind of always been a challenge to get them to put that on paper. Are there any specific things that you can recall that they’re just not putting down, or common things they’re not putting down that’s like, ‘Oh, if they could do these one or two things, that would really help them.’
Jay: Yeah, I guess under the old rules, the ‘95 and ‘97 guidelines, when you talk about ‘Exacerbation: mild, moderate or severe?’ we kind of had those three different levels. Now under the new rules, it’s either ‘exacerbated’ or it’s ‘severely exacerbated,’ and so we’ve gone from three different levels to now we’ve just got two. And so when we’ve met with providers before and we’ve said, ‘Hey, you did say exacerbation, but that’s really getting us to a level four,’ they're like, ‘Well, but if you look at these other things, this is severe exacerbation.’ ‘Well OK, if you could just clearly state, “severe exacerbation,” you eliminate all the guesswork from a coder or from an auditor on the back end, and just by adding that word to your documentation will add a lot of clarity to what’s going on with this patient.’ So I think that’s been one area that we’ve noticed on our end to help not only the providers, but, again, everybody who picks up that note after it leaves that provider’s hands to clearly know what’s going on with that patient.
CJ: Yeah. That’s a good example.Well thanks for that. So the other thing I wanted to ask you, and we did refer to the fact that we’ve been doing this for years, and a lot of good things come with those years of experience. What have you learned over the years as best practice, or maybe things to avoid? So either good things to do or things to make sure you don’t do. When you share coding audit results with physicians and providers, because your team educates, too, right, and I’m sure you’re going out probably meeting with the tough cases. So there’s that communication piece. What have you learned that works and doesn’t work when you share those audit results?
Jay: Yeah so we do a lot of education. I would say we probably do as much education as we do auditing, not only myself but my team. Because, again, we’re trying to make sure that everybody has the information that they need to do it correctly, but you know, CJ, I think one of the things that I’ve really stressed to my team and learned from you as well was simply that you don’t go into a meeting with a provider and just tell them all the things that they're doing wrong. You try to understand their perspective. You try to understand their clinic workflow. You try to understand what challenges they face working through notes and their operational process, and then make suggestions of how they can do it definitely or better to be compliant. You can’t just go in there and regurgitate rules to them and expect them to listen and say, ‘Oh yeah, I’ll fix that.’ You have to walk a mile in their shoes, if you will, and understand, ‘Hey, they’ve got 30 patients coming in in the clinic and they’ve got a nurse practitioner in this room and a medical student in that room and a resident over here and they’re bouncing from room to room, working with different types of folks.’ And then all of the operational challenges that come up with — they get interrupted from this patient because they’re getting a call from the hospital. And so how can you best, as an auditor and educator, understand their perspective and then apply the rules appropriately to their situations or to their scenarios that they have in their clinic? And I think when we’ve done that, we’ve gotten a lot better feedback from physicians and they’ve been more willing to work with us, as opposed to just going in and saying, ‘Hey, you did this wrong, you did this wrong, you did this wrong. Fix it.’ That approach doesn’t work with physicians, because as you know, you’re talking about some of the smartest people on the planet who probably never failed anything in their life, and you go in and sit in front of them and tell them, ‘You just failed an audit.’ Well obviously their defenses go up really quick, and that meeting is probably not going to go your way. So we try not to use the words ‘failed audit.’ We don’t even use the word, ‘audit.’ We tell them we’ve done a review and that we’ve got some feedback for them or we’ve got some results for them. But we don’t tell them that they failed an audit, because automatically you get defensive doctor versus, ‘Hey, I’m willing to listen and understand’ doctor.
CJ: Yeah, absolutely. One of my mentors when I first started doing this kind of work, she helped us go out and shadow doctors. I don’t know if that’s practical nowadays, but 20-some years ago, we would go and shadow them and just watch what half their day was. We might not have time for a full day, or maybe even just do it for a couple hours, and you get a sense of what they're going through. Just like you were talking about: they get interrupted, they have a med student in that room, a resident in that room and they’re trying to keep all this stuff straight. The burdens keep just piling up, and walking through and then just maybe finding one or two things that might help, and then six months later you find one or two more things that might help them. Is shadowing still practical? Is that something that can be done? Do you think that’s helpful?
Jay: You know, post-COVID I would say yes. We did quite a bit of it. We would go to clinics, especially with the docs that were really struggling, providers that maybe we’ve educated a couple times and they’re still not getting it. Just to extend that olive branch and to go show them we’re willing to get in the weeds with them. Yeah, we would go to clinic and round with them. I’ve been to hospitals with some and rounded with them in the hospital setting as well, if that was where their challenge was. But in the last couple of years things have changed so much. We’re now 100% virtual, my team and I. We really don't even have an office any longer except at home. So I guess if we really needed to go to a round with a physician in clinic, we could do so. But in the last couple of years, they’ve wanted, obviously, a limited number of people in clinics and that sort of thing, so we really haven’t been doing a lot of that recently. But like I said, I think that’s a great way to show the physicians that you’re not just picking at them from behind a computer screen, that you’re willing to go out and be there with them, shoulder to shoulder and provide them real feedback in real time and help them. A lot of the times what we find is that the doctors’ biggest hurdle is the EMR, and unfortunately my team and I, we’re not EMR experts, but if we do know that they’re having issues with the EMR, we can reach out to those people who are the experts to get them to come help the providers. And the docs are like, ‘Well, I never even thought to ask for that kind of help.’ We’re like, ‘Yeah, we’ve got people who can help you set up a dot phrase or set up a template or whatever that will help make your life a little bit easier in the clinic’ and things like that. So yeah it helps when we go in and shadow with them or round with them so we can see where their true — because oftentimes we find that their challenges are not necessarily with the documentation. It’s with all the other things that are going on around them.<,/p>
Jay: Yeah, the workflows, the processes and things like that, that’s where their struggle is.
CJ: Yeah, well that’s a great point you make. With that, let’s take a break. We’re going to have a short message, and then we will come back and continue with Jay McVean.
CJ: Welcome back, everybody. We were talking about templates and during the break I was thinking — that’s what I had done when I was sharing that other story about shadowing. I was with a — he was an internist, and specialized basically in diabetics, and like 80% of his patients fit into one of three categories, and so you were talking about dot phrases and those sorts of things, and with this doc, I said, ‘If 80% of your patients are kind of in this grouping,’ and he had then three subcategories, I said, ‘Let’s sit down and help you design a template that works for you.’ And so that’s what we did, and to your point, I was not an expert in the EMR, but we were able to make those connections with the people who were. I could help him with the language and then we had to have somebody that helped us with the EMR. That’s a lot of legwork, but they started to respect us when they saw that we were there to help them solve problems instead of bringing them more problems, or the perception of, ‘Oh, this is going on, that's wrong.’ Rather, they started to see us as partners and colleagues, and so it was a completely different approach, and it’s a battle. It’s a battle of hearts, one person at a time, but with that one doc, fine, that worked well, and then the word spreads, and then before I knew it, people were calling us saying, ‘Hey, I heard Dr. so and so, you helped him do this template.’ And so there’s always going to be some people who just don’t want to get involved, but proving yourself with a couple and having some successes, that can start to create momentum. And so I liked what you were saying about phrases and things in the EMR that can help the docs. Are you seeing that docs are doing a little bit more of that, creating templates and those phrases that they commonly use?
Jay: Oh yeah, for sure. Absolutely. I mean, you know, it’s all about efficiency, right? Being efficient, having efficient documentation, efficient tools so that they can see more patients, so that they can get into OR more, whatever it may be. So yeah, they’re absolutely embracing those efficiencies, but as you mentioned, we’ve got to keep them compliant with those efficiencies. And the other thing, to your point, too, CJ, oftentimes when we are meeting with providers, they hear ‘compliance’ and think of us as the police. We’re out to get them. We’re gonna throw them in jail. And while we do use those examples to show them the real world of what could happen to them if they’re not compliant, we try to make sure that our docs know that we’re not the police. We’re not after them, we’re not trying to get them in trouble with any of their bosses or anything like that. We’re actually doing the complete opposite. We’re here to protect them. We’re here to protect the organization and to provide them with guidance and a resource that they can rely on that says, ‘Hey, these guys are here to help me, not here to go tattle to my boss and tell them that I’ve been doing this wrong for the last three months’ or whatever it may be. So that’s a message that we preach very heavily here amongst my entire team and when we meet with new providers and when we meet with new residents and fellows, the one thing we tell them is, ‘Look, we’re not the police. We’re here to help you guys. We want you to see us as a resource. If you’ve got questions, come ask us. Send us an email. However you need to communicate with us, we’re here to help you guys,’ and on the other end of that spectrum, I make sure that myself and my team is very responsive to providers. We don’t let emails lag for days and days or questions go unanswered. And even if we have to research a question, I still make sure that we respond to the providers and say, ‘Hey, that’s a good question. Thanks for sending it over. I need to do some research, and I’ll get back with you.’ At least they know you received it, at least they know you’re looking into it and they’re expecting your response at some time. So I think those are really vital to any successful compliance group, is making sure your docs know that you’re not there just to say, ‘Ah, I got you!’ that you’re there to really help and be a resource for them.
CJ: Yeah, and it sounds like just good customer service skills as well, prompt responses, those sorts of things. You know, in my experience almost all the docs I worked with wanted to do it right, but I did run across, every now and then, somebody who was just like thumbing their nose at the rules. How do you deal with that? I think those are the expectations, but I think they’re out there. What do you do? Do you have to escalate to their boss? When you know you’ve got an issue and it’s like, ‘This is not going away.’ So those tough ones, what do you do with those?
Jay: Yeah. Like you, I don’t really believe or feel that we have any providers that are just doing things intentionally to defraud the government or anything like that. But we do have some that are set in their ways who want to do it their way versus the right way or versus what the government tells them they need to do or whatever. And so those are the ones where yeah, we’ll do everything within our power to educate, teach, train, show them, provide them with help before we have to elevate it or escalate it to a higher level. But that’s typically my next step up, is to get their department chair involved in the conversation. And again, maybe there’s ways that the department chair, as a physician to physician, can work with them versus a physician to a non-clinician like myself. Oftentimes providers will respond better to physician to physician education. And then if it goes beyond that, we’ve got other avenues, resources, executive compliance committee, chief compliance officer, things like that that could step in and make recommendations or have conversations with the provider. But luckily at our organization we really haven’t had to pull out those big cards too terribly often. Most of the docs realize that we’re there to help them. Every now and then we do have to get the chair involved, and that’s typically where it stops, is once the department chairman is involved. We’ve had an occasion or two where — we had one provider, I’ll be honest with you, we had so many attempted and failed educations, and he was unwilling to change, that the action was that he had to hire, out of his own salary, he had to hire his own coder to code everything for him. That was the only thing we could do to really get the impact across to him that this is important.
CJ: Interesting, yeah. Well with that, you’ve already said this already that you’re there to help them, that you’re trying to protect them from external forces, so my next question is: What are you seeing in those external forces, so maybe enforcement agencies or payers, either locally or nationally, what are some of the higher-risk things that are being emphasized from those enforcement agencies that you’re aware of?
Jay: Yeah, you know I see a lot. I read on the OIG website a lot with their enforcement actions just to make sure that — I think the president of our organization has always told me, ‘Keep us out of the newspaper headlines,’ and so I go in and I read those newspaper headlines to see what’s making the newspaper headlines, and you know I think a lot of what I see right now is things that, thank goodness, haven’t really applied to us. The opioid stuff, the over-medications, the home health and nursing home stuff, all that kind of stuff is really not applicable to us, so I breathe a sigh of relief when I see eight of the 10 most recent things on the OIG website are related to those two items. I’m like, ‘Whoo, OK, that’s not us.’ But you know, CJ, it’s still — the old things keep bubbling up, right.
CJ: They do.
Jay: You and I just did a talk on incident two and shared split things. As we, again, continue to hire more advanced care practitioners across the practice plan, we have to go back and remind and refresh how you use those advanced care practitioners compliantly. What are the rules around the clinic versus in the hospital? We had a big — we even actually had to engage in an outside external audit because we had critical care providers that were using nurse practitioners prior to the change where you couldn’t share-split a critical care visit, and they didn’t really see our interpretation the way we were interpreting the rules and were challenging us. So we went and grabbed an outside audit company to come in and take a look at those critical care cases and see what their results were. So things like that that have always been underlying things with the government. As soon as we feel like we’ve got them squashed out or we’ve got them well-trained or educated on those things, a year or so later they seem to bubble back up and pop up. Recently we’ve implemented a new EMR here at our organization and with that comes growing pains with edits and claim edits and things like that, and so something that we’re dealing with now is the 25-modifier issue procedure, and then an E&M on the same day. And do we stop and look at every one of them? Does the documentation meet 'significantly and separately identifiable?' And oh by the way, CMS, what is 'significantly and separately identifiable?’ Is it one paragraph? Is it one word? Is it a sentence? What are you looking for on your end? And it’s very subjective. So we’ve got folks of different levels of education, experience, background who — a doctor may see it as significantly and separately identifiable from the procedure, but you hand it to a coder and they’re like, ‘No, that doesn’t meet it.’ And you hand it to an auditor, and they say, ‘Well yeah, I think it does meet it.’ And you send it to the payer, and the payer’s like, ‘Well we don’t know. We’re not even going to look at it. We’re just going to deny it off the — just because it’s a 25 modifier.’ So those type of things, again, I haven’t seen a lot from enforcement agencies around those things, but those are the things that seem to continue to — once you get them figured out, or you think you’ve got them figured out, a few weeks later down the road they bubble up again in a different area or different department or whatever. But luckily there really haven’t been any enforcement actions of recent that I’ve felt, ‘Oh my goodness, that’s something we really could get caught behind the eight ball on if we’re not careful’ or whatever, so I think we’ve transitioned a little bit more — well completely away from, we used to do the whole 10 case per provider review every year, make sure every doc has 10 cases, but that’s such a small sample of what they bill. It kind of gives you that false sense of security, so we’ve really transitioned our out of program to more of a risk-based audit program where we’re really looking at specific rules and looking at more cases — 150, 200 cases, and really seeing if we do have a broad problem or if it’s just really not a problem at all, or if we need to do a more focused audit on one or two providers based on those results or if it’s a division or whatever, so we’ve really been able to change our audit profile a little bit more the last few years to address some of those risks, if you will, that the government throws out there or that enforcement agencies are reporting on. And so we’ve been a little bit more nimble, if you will, with our audits. If I see something, then we can go and run a quick audit on it and do a quick spot check, and if it’s not a problem we move on. If it is a problem, ‘OK, what do we got to do? Do we need to look at it at a bigger scope? Do we need to provide education? What’s out there?’
CJ: Yeah, that makes a lot of sense. When you were talking about modifier 25, that’s one of these issues that has been around forever and it seems to still be around as you were talking about it. And I’ve seen a few, not a huge volume of enforcement, but there’s still enforcement there, where I’ve seen — and a lot of the enforcement seems to be coming from scheduled procedures. So like on Monday the doctor scheduled the procedure for them to come back on Thursday in-office and have the procedure done, and when they come back, was there really significant work done above and beyond that procedure that — you’d kind of already made the decision to do it and your procedure day was on Thursdays or something. And one thing I saw recently in the OIG work plan was for dermatology. They're going to look at dermatology because a lot of dermatology is just that. You’ve got these in-office procedures and sometimes you’re evaluating the lesion that day and making the decision and doing that, and then sometimes you’re having them come back, and so the OIG work plan item was specific to dermatology and modifier 25, because they — I can’t remember the exact number, but they had done some sort of analysis of all claims from dermatologists, and it was a large percentage where modifier 25 was used. Now that may be appropriate. Just because there’s a large percentage doesn’t mean it’s inappropriate, but I thought that one was interesting, and then you started talking about modifier 25. The other one that I saw was when it was a urology practice that had some enforcement against them because they had scheduled procedures and then they were just billing E&Ms plus those procedures, and these are probably more obvious examples, right, like I think those gray area ones probably don’t have as much enforcement around, because you know, it’s not a nice bright line. But I think the ones that have that enforced there’s been a pretty bright line where it’s just like, ‘Oh, they’re just coming in. They’re getting the procedure done. They’re going home,’ and there was not a separate E&M. So I don’t know if there are certain specialties that you see that might be at greater risk on some of those modifier issues or not.
Jay: Well you know, always our biggest struggle is related to orthopedics and staged injections or not staged injections. There’s different types of injections where they are going to come in and inject a knee, and they’re going to do it on a regular basis every two to three weeks. And then there’s other injections where they do an injection and then it may work for several months to a year and then the patient shows back up and says, ‘Hey, that injection worked great, but it’s worn off, and I think it’s time for another one because I really don’t want to have surgery.’ And so when you meet the docs on this, they’re like, ‘Look, I have to do an evaluation to determine whether I need to proceed with an injection or whether I need to recommend surgery.’ And when you try to explain to them as a compliance officer, ‘Yeah, I understand that, but you gotta also remember that there’s a component of that evaluation and management that’s already built into the procedure.’ And they’re like, ‘Well, what is that? How much is that?’ And when you go to the government, you go to CMS or your local intermediary and ask for guidance there, you don’t get any clear guidance. It’s very subjective and random as to what is significant or identifiable. So that’s something — another example I could think of would be annual wellness visits and an E&M on the same day. A patient’s coming in for their annual wellness visit but now when they’re there they also report a sickness, or they report something’s going on that the doc has to work up. So the way we’ve explained it in those areas is, ‘OK, let me carve out of your note everything that is encompassed with the annual visit, and then what do I have left to support that E&M?’ And if I’ve got enough to support that E&M, then we can bill it. If not, then we bill the annual wellness visit. Those are things that we’ve been working on in the last few months with those types of issues.
CJ: Yeah. The other thing that I’ve seen quite a bit of enforcement on recently has to do with medical necessity. It has to do with urine drug testing. As you know, there’s a screening urine drug test that you might do, and then there's a definitive. Sometimes that’s called presumptive testing that leads to definitive testing. And I’ve seen three or four cases in the last couple years, and there’s probably more that I just haven’t seen, that enforcement agencies are saying, ‘Look, that’s not medically necessary for you to automatically jump to definitive drug testing or to be doing presumptive drug testing on every person every time they come in just because they are prescribed a pain medication.’ There needs to be some sort of indication as to why you think they might be abusing or something like that, and I know it’s a tough situation, I’m not sure there’s nice, clear-cut answers, but that’s the other thing that I’ve seen quite a bit of enforcement on. And it’s not really coding, it’s more of like a medical necessity issue.
Jay: Right, yeah. Interesting.
CJ: Yeah. So, Jay, this has been great, and I just noticed the time. It’s like the time just flies talking to you. It’s awesome that you’ve got all this stuff in your brain, and we really thank you for taking the time to share it. I want to give you a moment to see if you have any other last-minute thoughts or comments that you think might be helpful for everybody before we close it up.
Jay: No, CJ, I really appreciate you inviting me on and having me as a guest. I, as always, enjoy speaking with you, and I know you and I can probably ramble on about this stuff for hours and hours because we’re both just nerdy coding people like that. You know, your mentorship, your collegial-ness, everything that you’ve done for me over the years — I really appreciate it, and any time I can help pay you back a little bit I’m always willing to do what I can to help you out, and so I appreciate the opportunity to be on your podcast and to talk with you about these sorts of things. And really I guess the only other thing I’d say to those out there listening is if you’re a compliance auditor, compliance officer and you’ve got to meet with those docs, just try to put yourself in their shoes for a little bit and approach it from a different angle if you’re having docs who are combative or who are just really prickly and don’t want to listen to you. Instead of going in with the negative, try to find the positive and see if you can really connect with them on a different level than just the compliance audit, and then use that connection to roll into your compliance audit results and things like that, and I think you’ll probably find that you’ll have better results that way.
CJ: Yeah, that’s great advice. Jay, appreciate your kind words and appreciate your participation, and thank you everybody for listening to another episode of Compliance Conversations. Stay safe, and keep doing the good work.
Questions or Comments?