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  • AMERICAN OSTEOPATHIC ASSOCIATIONDIVISION OF SOCIOECONOMIC AFFAIRS Presents: Medicare Updates, Documentation, Auditing and Incident To Physician BillingDecember 3, 2011

  • Socioeconomic Affairs StaffYolanda Doss, MJ, RHIA, Director, Division of Socioeconomic Affairs Sandra Peters, MHAAssistant Director, Clinical Practice OutreachMichele Campbell, CPC,Coding & Reimbursement SpecialistKavin Williams, CPC, CCPHealth Reimbursement Policy Specialist

  • Yolanda Doss, MJ, RHIAResponsibilities include:Helping to secure reimbursement for osteopathic servicesSecuring the acceptance of osteopathic credentialsAddressing Medicare issuesHIPAA complianceFraud and Abuse

  • Sandra Peters, MHAResponsibilities include:Develop educational material on physician advocacy, manage care, quality and performance measures impacting osteopathic medicineDesign and manage a set of member services to enhance their manage care interactions and to promote their opportunities to participate in manage careProvide update to the AOA leadership on health care trends particularly in the areas of pay for performance and physician profiling

  • Michele Campbell, CPCResponsibilities include:Assists AOA members with coding and billing questionsAssists AOA members with coding disputes with carriersMedical record reviews in audit situations.Coordinates AOAs responses to AMA CPT coding requestsProvide physician education on coding and coding guidelinesWrite monthly coding hints and participate in articles that effect the profession

  • Kavin T. Williams, CPC, CCPResponsibilities include:Oversees and assists AOA members with payment disputes and health payment policies.Oversees the AOA Coding and Reimbursement Advisory Panel.Represents the AOA at national reimbursement policy meetings.

  • Contact InformationYolanda Doss 1-312-202-8187ydoss@osteopathic.orgSandra Peters 1-312-202-8088speters@osteopathic.orgMichele Campbell 1-312-202-8182mcampbell@osteopathic.orgKavin T. Williams,

  • The Objective is to Provide Informationon the Following Topics:Medicare 2012 UpdatesEvaluation & Management Medicare AuditsRecovery Audit Contractors (RAC)Incident To Services

  • Medicare 2012 UpdatesPhysician Fee Schedule is facing a 30 percent reductionPhysician Quality Reporting Initiative (PQRI) Bonus Payment 2%E-Prescribing Bonus Payment 2%OMT Survey

  • Physician DocumentationThis is critical to your reimbursementIf it was not documented it did not happenClear and Legible, words to document byChief complaint (this is the driver to most insurance auditors)Familiarize yourself with your documentation style- is it 1995 guidelines that you follow or 1997?

  • Documentation Guidelines The medical record should be complete and legible. The documentation of each patient encounter should include:reason for the encounter and relevant history, physical examination findings and prior diagnostic test results;assessment, clinical impression or diagnosis;plan for care

  • Documentation Guidelines [Cont.]The patients progress, response to and changes in treatment, and revisions of diagnosis should be documented.The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.Hospital visits should be included in the patients chart

  • Evaluation & Management (E/M) CodingCoding for office visitsModifier usage when billing an E/M with a procedure (OMT)Time Based Coding

  • Chief Complaint (CC)The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factors that is the reason for the encounter, usually stated in the patients own words.Documentation Guidelines states that the medical record should clearly reflect the chief complaint

  • Medical NecessityThis area is not black/whiteThere are numerous definitions of medical necessityLinking the appropriate diagnosis to the appropriate procedure to support the necessity of the procedure performed is critical. Medicare defines medical necessity as services or items reasonable and necessary for the diagnosis or treatment of illness or injury to improve the functioning of a malformed body member.

  • Coding For TimeWhen is it appropriate to code for time? What is the auditor looking for when they review a chart that was billed as time being the controlling factor?

  • Tips For Verbiage When Billing For TimeExample of correct documentation of time:In your note it should read I spent 45 minutes with the patient and over 50% of that time was spent discussing Example of incorrect documentation of time:I spent 45 minutes with the patient, discussed surgical options versus medical management.

  • How Would Code This Date of Service

  • What Is An Audit?An effective tool used by Medicare and other payors to recover monies lost to fraud and erroneous billings.

  • Why Audits Are Initiated?Suspicion (Billing Pattern)Outlier PhysiciansThe Senior PatrolWhistleblowersProcedure Codes

  • Who Are The Auditors?The Office of the Inspector General (OIG)MedicareThe Department of Justice (DOJ)The Federal Bureau of Investigation (FBI)Carriers

  • Types of AuditsPrepayment AuditsPost-Payment AuditsStatistical Sampling Method

  • What Auditors Look For?Billing for services or supplies that were not provided.Billing for non-allowable or non-covered services.Altering claim forms to receive a higher payment amount.Unbundling claims.

  • How To Respond To A Request For DocumentationReply to the audit notice in a timely fashion.Gather and submit Only the requested documentation.Be cooperative.You may want to conduct an internal audit.

  • How to Respond to the Audit FindingsIf the findings are not favorable:Attempt to discuss the findings with the reviewer. If necessary request redetermination.If necessary request a level one appeal.

  • * Medicare Recovery AuditContractors (RACs)

  • *RAC Legislation

    The RAC program was created by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 which pays incentive fees to third-party auditors that identify and correct improper payments paid to healthcare providers in fee-for-service Medicare.The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 also requires permanent and nationwide RAC program by no later than 2010

  • The RAC Demonstration ProjectThe RAC demonstration project took place of New York, Florida, and California.By 2010 the RAC covered all 50 states.

  • *RAC Program MissionTo detect and correct past improper payments,To implement actions that will prevent future improper payments.Providers can avoid submitting claims that dont comply with Medicare rulesCMS can lower its error rateTaxpayers & future Medicare beneficiaries are protected

  • The New RACs Are:

    Diversified Collection Services, Inc. of Livermore, California, in Region A, initially working in Maine, New Hampshire, Vermont, Massachusetts, Rhode Island and New York.

    CGI Technologies and Solutions, Inc. of Fairfax, Virginia, in Region B, initially working in Michigan, Indiana and Minnesota.

    Connolly Consulting Associates, Inc. of Wilton, Connecticut, in Region C, initially working in South Carolina, Florida, Colorado and New Mexico.

    HealthDataInsights, Inc. of Las Vegas, Nevada, in Region D, initially working in Montana, Wyoming, North Dakota, South Dakota, Utah and Arizona.

    Additional states will be added to each RAC region in 2009

  • *Minimize Provider Burden Limit the RAC look back period to three yearsMaximum look back date is October 1, 2007 RACs will accept imaged medical records on CD/DVD Limit the number of medical record requests

  • *Medical Record Limit ExampleOutpatient Hospital 360,000 Medicare paid services in 2007 Divided by 12 = average 30,000 Medicare paid services per month x .01 = 300Limit = 200 records/45 days (hit the max)

  • *Summary of Medical Record Limits (for FY 2009)Inpatient Hospital, IRF, SNF, Hospice10% of the average monthly Medicare claims (max 200) per 45 days per NPI Other Part A Billers (HH)1% of the average monthly Medicare episodes of care (max 200) per 45 days per NPI

  • *Summary of Medical Record Limits (for FY 2009) ContinuedPhysicians (including podiatrists, chiropractors) Sole Practitioner: 10 medical records per 45 days per NPIPartnership 2-5 individuals: 20 medical records per 45 days per NPIGroup 6-15 individuals: 30 medical records per 45 days per NPILarge Group 16+ individuals: 50 medical records per 45 days per NPIOther Part B Billers (DME, Lab, Outpatient hospitals) 1% of the average monthly Medicare services (max 200) per NPI per 45 days

  • RAC Validation Contractor (RVC)CMS has contracted with Provider Resources, Inc. of Erie, PA, to work as the Recovery Audit Contractor (RAC) Validation Contractor.The RAC Validation Contractor (RVC) will work with CMS and the RAC to approve new issues the RACs want to pursue for improper payments, as well as perform accuracy reviews on a sample of randomly selected claims on which the RACs have already collected overpayment.The RVC is another tool CMS will use to provide additional oversight and ensure that the RACs are making accurate claim determinations in the permanent program.

  • For Additional Information on RAC

  • Medicare Incident to Physician ServicesThe OIG reviews Medicare services t