4/17/2012

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Presented byMaggie Mac, CPC, CEMC,

CHC, CMM, ICCE

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� CMS

� OIG

� RAC’s

� PSC’s

� ZPIC’s

� Private Payers

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4/17/2012

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� National and Local Carrier Determinations

� Physician Regulatory Issues Team

� Transmittals (Sometimes with effective dates that are months prior to the release date of the guidance) - Issued, Rescinded, Re-issued, Deleted

� C.E.R.T. Studies

� Demonstrations

� Medically Unlikely Edits

� National Correct Coding Initiative (NCCI) Edits

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� OIG Work Plan 2012

◦ http://oig.hhs.gov/reports-and-publications/workplan/index.asp#current

� Audit Reports

� Self Disclosure Information

� Exclusion Programs and Database

◦ http://oig.hhs.gov/fraud/exclusions.asp (HHS/OIG)

◦ http://www.epls.gov (General Service Administration)

� Compliance Guidance

� Fraud Prevention and Detection

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� Physicians: Incident-To Services (New)

� We will review physician billing for “incident-to” services to determine whether payment for such services had a higher error rate than that for non-incident-to services. We will also assess CMS’s ability to monitor services billed as “incident-to.” Medicare Part B pays for certain services billed by physicians that are performed by nonphysiciansincident to a physician office visit.

◦ Not really new……

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� Evaluation and Management Services: Trends in Coding of Claims

� We will review evaluation and management (E/M) claims to identify trends in the coding of E/M services from 2000-2009. We will also identify providers that exhibited questionable billing for E/M services in 2009.

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� Whistleblowers

◦ Employee

◦ Former employee

◦ Patients

◦ Competitors

� Allegations or suspicion of:

◦ Fraud

◦ Abuse

� Successful prosecutions result in criminal and administrative remedies to include fines and exclusions.

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� Region A: Diversified Collection Services (DCS)

� Home Page:

� www.dcsrac.comwww.dcsrac.comwww.dcsrac.comwww.dcsrac.com

� Current Issues:

� http://www.dcsrac.com/IssuesUnderReview.aspxhttp://www.dcsrac.com/IssuesUnderReview.aspxhttp://www.dcsrac.com/IssuesUnderReview.aspxhttp://www.dcsrac.com/IssuesUnderReview.aspx

� Region B: CGI Federal

� Home Page:

� http://racb.cgi.comhttp://racb.cgi.comhttp://racb.cgi.comhttp://racb.cgi.com

� Current Issues:

� http://racb.cgi.com/Issues.aspxhttp://racb.cgi.com/Issues.aspxhttp://racb.cgi.com/Issues.aspxhttp://racb.cgi.com/Issues.aspx

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� Region C: Connolly Healthcare

� Home Page:

� www.connollyhealthcare.com/RACwww.connollyhealthcare.com/RACwww.connollyhealthcare.com/RACwww.connollyhealthcare.com/RAC

� Current Issues:

� http://www.connollyhealthcare.com/RAC/pages/aphttp://www.connollyhealthcare.com/RAC/pages/aphttp://www.connollyhealthcare.com/RAC/pages/aphttp://www.connollyhealthcare.com/RAC/pages/approved_issues.aspxproved_issues.aspxproved_issues.aspxproved_issues.aspx

� Region D: HealthDataInsights (HDI)

� Home Page:

� https://racinfo.healthdatainsights.comhttps://racinfo.healthdatainsights.comhttps://racinfo.healthdatainsights.comhttps://racinfo.healthdatainsights.com

� Current Issues:

� https://racinfo.healthdatainsights.com/Public1/Nehttps://racinfo.healthdatainsights.com/Public1/Nehttps://racinfo.healthdatainsights.com/Public1/Nehttps://racinfo.healthdatainsights.com/Public1/NewIssues.aspxwIssues.aspxwIssues.aspxwIssues.aspx

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� Once in a lifetime – services billed more than once

� Newborn Pediatric – services that should be billed with specifc codes based on age

� Facility vs Non-facility – where did the physician perform the procedure

� Global vs TC/PC – billed globally and also separately

� Excessive Units – untimed codes billed with more than one unit

� Date of death – billing for services after the patient’s date of death

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� Medically Unlikely Edits – services billed together subject to medically unlikely edits (e.g. same procedure billed with different surgical approach)

� NCCI Edits – review of unbundled services --use of modifiers -59, LT, RT

� Procedures performed during global surgery periods – use of modifiers 58, 78 or 79

� Multiple surgeries performed on the same patient on the same date of service – use of modifier 51

� E/M services with procedures that include pre-op and post-op payment – use of modifiers 25 or 57

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� E/M services during global days – use of modifier 24

� Co-surgeries billed by one physician without modifier and the other surgeon with modifier 62

� Duplicate claims for E/M services by physicians of same specialty within same group

� Add-on codes billed without primary codes

� Not a new patient E/M billed as new patient

� Medicare Claim Review Programs httpshttpshttpshttps://://://://www.cms.gov/MLNProducts/downloads/Mwww.cms.gov/MLNProducts/downloads/Mwww.cms.gov/MLNProducts/downloads/Mwww.cms.gov/MLNProducts/downloads/MCRP_Booklet.pdfCRP_Booklet.pdfCRP_Booklet.pdfCRP_Booklet.pdf

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� Complex review – when the RAC makes an over/under payment determination after evaluating the medical record

◦ Medical necessity reviews started in 2010

� Automated review – when the RAC is able to make an over/under payment determination without evaluating the medical record

◦ Excessive unit audits – the RAC searches for claims for two or more identical or bundled surgical procedures for the same beneficiary on the same day at the same hospital or office

◦ Claims for services that should not be reported more than once in a lifetime

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� PSCs conduct investigations; refer cases to law enforcement; and take administrative actions, such as referring overpayments to claims processors.

◦ In their investigative work, PSCs review Medicare payments and may identify overpayments which they are required to refer to Medicare claims processors for collection and return to the Medicare program

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� AdvanceMed

� Cahaba Safeguard Administrators, LLC

� Computer Sciences Corporation

� IntegriGuard, LLC

� SafeGuard Services, LLC

� TriCenturion

� TrustSolutions, LLC

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� The transition of PSCs to ZPICs is part of CMS’s consolidation of fraud-fighting work so that Parts A, B, C, and D will be under one type of contractor, the ZPIC.

� Parts A and B (hospital, skilled nursing, home health, provider and durable medical equipment claims);

� Part C (Medicare Advantage health plans);

� Part D (prescription drug plans) and coordination of Medicare-Medicaid data matches (Medi-Medi).

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Zone 1 – SafeGuard Services, LLC

Zone 2 – NCI, Inc. (previously AdvanceMed)

Zone 3 – Cahaba

Zone 4 – Health Integrity, LLC

Zone 5 – NCI, Inc. (previously AdvanceMed)

Zone 7 – SafeGuard Services, LLC

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� According to CMS staff, ZPICs that cover high-fraud regions will be expected to focus on quick response to fraud and administrative actions

Focus Areas:Focus Areas:Focus Areas:Focus Areas:

� Identify and deter Medicare fraud and abuse

� Develop high quality fraud cases for referral to the Office of Inspector General

� Respond to requests for Medicare data and support from law enforcement

� Identify and report program vulnerabilities to CMS

� Refer recommendations to the appropriate entity for a variety of corrective actions including provider education, overpayment recovery, licensure considerations

� Develop and validate methodologies for the early detection and prevention of fraud schemes and abusive billing to the Medicare Program

� Over-Utilization

◦ Bell Curves

◦ Focused reviews

� Use of Non-Physician Practitioners

◦ Incident-to, Shared/Split

� High Risk Areas of Coding

◦ Consultations

◦ Unbundled services – modifiers 25 and 59

4/17/2012

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Family Practice – New Patient Visits

-20.00%

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

99201 99202 99203 99204 99205

Practice

National

`

Family Practice – Follow-up Visits

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

99211 99212 99213 99214 99215

Practice

National

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� How many?

� How often?

� All providers?

� Who will perform?

� E/M?

� Procedural? Labs?

� Retrospective, Prospective?

� Attorney Client?

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� Not statistically valid nor random

◦ Judgmentally selected

◦ “Review” vs. “Audit”

◦ “Under-coded” and “Under-documented”

◦ AMA/CMS E/M Documentation Guidelines:

� 1995 or 1997

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� Judgmental Selection based on Utilization of billed services:◦ CPT Codes Analysis◦ E/M Risk Areas◦ E/M Specialty Bell Curves◦ E/M to E/M Ratios◦ E/M to Procedural Ratios

� Use of Non Physician Practitioners (NP, PA, CNS and CNM)◦ Incident-to◦ Shared/Split ◦ State scope of service

� Use of Ancillary Personnel (Nurse, Therapist, Audiologist, Social Workers, Nutritionists, etc.)

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� Supervision Requirements

◦ General, Direct, Personal (Over-the-shoulder)

� E/M codes and Residents and/or Locum Tenens

◦ Attestation statement for TP-R

� Procedural codes

� Modifiers

� Consultations

� Unbundled Services – Modifier 25 and 59

� Diagnosis Codes

◦ Coded but not documented

◦ ICD-9

◦ ICD-10?

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� Medical Necessity and Standard of Care

� Date of Service

� Place of Service

� Services Based on Time

� Diagnostic Statement Clarity

� Legibility

� Author Identification and Signature Requirements

� Allergies

� Cross-outs, Errors and Conflicts on Medical Record

� Sign-off on Test Results

� Written Interpretation and Report

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� Electronic Medical Records

◦ Evaluate templates

◦ Evaluate process of documentation capture

◦ Does EMR “Suggest” level of service?

◦ Was the level of history and exam necessary?

◦ Identify high risk areas

� “Cloned” records

� Medically necessary vs. medically appropriate

◦ Assist with implementation of creating EMR templates

◦ Provide training to new providers

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� Compliance Program Updated

� Educational Feedback

� Physicians, NPP’s, Coding and Billing Staff

� Implementation of Compliance Program

� Policies and Procedures for Coding/Billing Updated and Readily Available

� Ad hoc Support

� Follow-up Reviews Based on Problematic Areas

� On-going Awareness of Focus Areas

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� Maggie Mac

� maggie@maggiemac.com

� 727-639-2030

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