Important Auditing Topics in 2016

Annually, the Centers for Medicare and Medicaid Services (CMS) publishes its Fee-For-Service (FFS) Improper Payment Report, a result of the accumulated totals of the Comprehensive Error Rate Testing (CERT) audits.

There are several trends from 2015 which have continued into 2016 and are listed as findings by the Medicare Recovery Audit Contractors (RACs). It’s important to keep an eye on these hot-topics and trends so that we can do our best to stay one step ahead at all times. Keeping the dialogue going in all aspects of auditing is the best way educate ourselves, or remind ourselves, of important tidbits of information that we might forget otherwise.

Evaluation and Management (E/M) Services

Insufficient Documentation

The improper payment rate for E/M services was 14.6%, which accounted for 10.2% of the overall Medicare FFS improper payment rate, projected to be $4.6 billion during the 2015 reporting period.

Incorrect coding and insufficient documentation caused most of the improper payments for E/M services during the 2015 report period. Often, the physician submitted medical documentation that supposed a different E/M code than the one billed. Many other claims were found to have insufficient documentation because the submitted records lacked a physician signature. For other claims, physicians provided services in settings other than their own offices and did not submit records maintained by hospitals or other facilities.

Non-Physician Practitioners (NPPs)

The CERT program identified many improper payments billed for E/M services using physicians’ National Provider Identifiers (NPIs) but provided solely by NPPs. For certain E/M visits and settings, if a physician and a qualified NPP each perform and document a substantive part of an E/M visit face-to-face with the same beneficiary on the same date of service, then the physician can bill this visit under his or her NPI.

If an NPP provides an E/M service (in person) for a physician’s patient in a hospital, they must bill under their own NPIs if the physician doesn’t also perform and document a substantive part of an E/M visit face-to-face, with the same beneficiary, on the same date of service.

E/M Hospital Visit – Initial

The improper payment rate for initial hospital visits was 30.2%, accounting for 2.0% of the overall Medicare FFS improper payment rate. The projected improper payment amount during the 2015 report period was $888.9 million.

The majority of improper payments for initial hospital visits were due to incorrect coding. In addition, CERT identified improper payments due to insufficient documentation. The servicing provider specialties of Internal Medicine and Cardiology comprise 41.6% of improper payments for initial hospital visits.

Example:

A provider billed HCPCS 99223 (initial hospital care, per day, which requires three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity). The submitted documentation included an unsigned visit note for a date of service other than the billed date of service. The auditor requested documentation for the billed date of service and received an attestation statement for the previously submitted visit note (i.e., not for the billed date of service). The CERT program scored this claim as an improper payment due to insufficient documentation.

E/M Hospital Visit – Subsequent

The improper payment rate for subsequent hospital visits was 19.1%, accounting for 2.3% of the overall Medicare FFS improper payment rate. The projected improper payment amount during the 2015 report period was $1.0 billion.

The majority of improper payments for subsequent hospital visits were due to incorrect coding. The servicing provider specialty Internal Medicine comprises 36.4% of improper payments for subsequent hospital visits.

Example:

A provider billed HCPCS 99233 (subsequent hospital care, per day, which requires at least two of these three key components: a detailed interval history; a detailed examination; medical decision making of high complexity). The submitted documentation did not meet the requirements for 99233 but did meet the requirements for 99232. HCPCS 99232 requires two of three key components: an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity.

The beneficiary was stable; the provider ordered laboratory tests and made no changes in treatment. The CERT program downcoded the claim and scored it as an improper payment due to an “incorrect coding error.”

E/M Office Visits - Established

The improper payment rate for office visits with established patients was 7.7%, accounting for 2.6% of the overall Medicare FFS improper payment rate. The projected improper payment amount during the 2015 report period was $1.1 billion.

The majority of improper payments for office visits with established patients were due to incorrect coding.

The servicing provider specialties of Internal Medicine, Family Practice, and Cardiology comprise 40.1% of improper payments for office visits with established patients.

Example:

A provider billed for HCPCS 99215 (office or other outpatient visit requiring two of three key components: comprehensive history, comprehensive examination, and medical decision making of high complexity). The submitted documentation did not meet the requirements for 99215 but met the requirements for 99214. HCPCS 99214 requires two of three key components: detailed history; detailed examination; medical decision making of moderate complexity.

The CERT program downcoded the claim and scored it as an improper payment due to an “incorrect coding error.”

Audit Tip:

A continued need for E/M training and education exists within multiple specialty physician organizations nationwide. An enhanced auditing and monitoring program with focused audits for E/M services can help provide greater compliance and financial stability to an organization.

Minor Procedures

This is a very broad category of Part B services, which includes HCPCS codes for specific therapy services, minor excisions, procedures, diagnostic studies, and treatments.

The improper payment rate for minor procedures was 20.1%, accounting for 1.3 percent of the overall Medicare FFS improper payment rate which was projected to be $593.6 million for 2015.

The majority of improper payments for minor procedures were due to insufficient documentation. For Medicare coverage, the beneficiary’s medical record must contain documentation of the service provided, including: Relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

The ordering and referring provider specialties of General Surgery, Family Practice, and Internal Medicine comprise 69.9% of improper payments for minor procedures.

Example:

A provider billed for a vitamin B-12 injection. The submitted documentation included a screen print supporting the administration of the billed medication to the beneficiary in the left deltoid.

The auditor requested additional documentation such as the physician’s order for the medication, clinical documentation supporting the plan/intent for the billed medication, and documentation supporting the medical necessity of the vitamin B12 injection. Following the request for additional documentation, the provider sent duplicate documentation and records from 2005. The CERT program scored this claim as an improper payment due to insufficient documentation.

Audit Tip:

Notice that there were three things requested by the auditor to confirm the service:

1. Physician’s order for the medication
2. Clinical documentation supporting the plan/intent for the billed medication
3. Documentation supporting the medical necessity of the vitamin B12 injection

Example:

A provider billed for HCPCS 97112 (therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes), with GP modifier (Services Delivered Under an Outpatient Physical Therapy Plan of Care); 2 units of service. The submitted documentation included the therapy daily progress note supporting 28 minutes of massage therapy (which does not support a bill for HCPCS 97112) and the physician’s order to evaluate and treat. The auditor requested additional documentation. However, the provider failed to send a therapy plan of care or support for the billed service. An order to evaluate and treat does not meet the requirements of a therapy plan of care. The CERT program scored this claim as an improper payment due to insufficient documentation.

Audit Tip:

The Outpatient Therapy Plan of Care is the crucial element of documentation which is necessary for all therapy services and should be provided when documentation requests are made. Failure to do so will cause claim rejections, denials, and request for repayment of reimbursement.

RAC Audits for Region A: Performant

This Medicare RAC listed as a top issue the following item from collections from January 1, 2016 through March 31, 2016: “Global Surgery: Pre- and Post-Operative Visits.”

This involved the identification of overpayments associated to minor and major surgical services through an automated review or data analytics, ala data mining. The following three areas:

1. E/M services billed the day prior to a major (90-day) surgical service without modifiers 57 or 25.
2. E/M services billed the day of a major (90-day) or minor (0-or 10-day) surgical service billed without modifier 25 or 57.
3. E/M services billed 10 days following a 10-day minor surgical service or 90 days following a 90-day major surgical service and billed without modifier 24 (unrelated visit in post op period) or when modifiers 53, 54, 76, 78, Q0, and/or Q1 are appended to the surgical procedure.

In light of these findings, there’s clearly a problem related to coded and billed services with modifiers.

Audit Tip:

Provide education to providers, coders, and billers related to pertinent modifiers. Follow-up with internal auditing and monitoring of services to confirm education goals are met.