MEDICARE AUDIT RISK IDENTIFICATION AND PREVENTION PRESCRIPTION Sponsored by:

American Academy of Otolaryngology Head and Neck Surgery Annual Meeting Vancouver, Canada September 29, 2013

Presented by:

Kim Pollock, RN, MBA, CPC KarenZupko & Associates, Inc. www.karenzupko.com Michael Setzen, MD, FACS, FAAP Immediate Past-President American Rhinologic Society Coordinator, Practice Affairs, AAOHNS Co Chair 3P, AAOHNS Clinical Associate Professor Otolaryngology, New York University

About The Speakers 2

Kim Pollock, RN, MBA, CPC  

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Over 30 years of Otolaryngology nursing Nationally recognized coding and reimbursement expert; teach AAO-HNS/KZA coding courses Experience with RAC, OIG, ZPIC, private payor client reviews

Michael Setzen, MD, FACS, FAAP   

President, American Rhinologic Society Coordinator, Practice Affairs, AAOHNS Clinical Associate Professor Otolaryngology, New York University

Disclosures 3

Kim Pollock, RN, MBA, CPC 

Employee of KarenZupko & Associates, Inc.

Michael Setzen, MD, FACS, FAAP 

Speaker’s Bureau: Teva, Meda

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Would You Like The Slides? 4

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Go to www.karenzupko.com

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Course: Medicare Audit Risk Identification & Prevention Prescription Username: audit Password: audit

Disclaimer 5

Slides and handout materials are the property of KarenZupko & Associates, Inc. and are for personal use only. They may not be copied, repurposed, or shared without explicit permission from KZA.

Objectives 6

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Gain insight into CMS compliance regulations Discuss “who” is auditing Importance of internal compliance: risk identification and correction

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What Is the Question to Ask? 7

OR

What Are My Risks? 8

Office of Inspector General (OIG)

Comprehensive Error Rate Testing (CERT) Recovery Audit Contractors (RAC) Zone Program Integrity Contractors (ZPIC) Private Payors

ZPIC Letter to Otolaryngologist 9

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Coding Updates and Areas of Focus in Otolaryngology

Identify Audit Risk and Revenue Opportunity (OIG and Private Payor) 11

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Evaluation and Management Services: Trends in Coding of Claims Evaluation and Management Services: Use of Modifiers During the Global Surgery Period Evaluation and Management Services: Potentially Inappropriate Payments

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Source: www.karenzupko.com/products/product_em.html

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OIG Focus Areas Applicable to Otolaryngology 13

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Evaluation and Management Services Provided During Global Surgery Periods •

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E&M with Modifier 25: •

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Modifier 24: Unrelated E&M During the Global Period of Another Service

Modifier 25: Significant Separate E&M on Same Day of Another Service

Evaluation and Management Services: Use of Modifiers During the Global Surgery Period •

Modifier 79: Unrelated Procedure During the Global Period of Another Service 13

Modifier 24 14

Modifier 24 Unrelated Evaluation And Management Service By The Same Physician During A Postoperative Period

Report E&M service for unrelated E&M and link modifier 24 to the appropriate E&M CPT® code. Link ‘unrelated’ diagnosis (serous otitis) to the E&M service. Appeal inappropriate denials.

How Did You Code This Scenario? Service Description/MD

99214-24

DX

SOM

Example: Physician performs and documents an E&M service on a patient seen in follow up for serous otitis media three weeks following a tonsillectomy.

CPT Only, ©2011 American Medical Association, Inc. All Rights Reserved

Modifier 25 15

Modifier 25 Significant, Separately Identifiable Evaluation And Management Service By The Same Physician On The Same Day Of The Procedure Or Other Service

Typically appended to an E&M Service on the same day as a minor procedure. Only append modifier 25 if E&M is significant or separate service. Remember, all minor procedures include some cognitive service Attach modifier 25 to E&M services only. CPT Only, ©2011 American Medical Association, Inc. All Rights Reserved

How Did You Code This Scenario? Service Description

9920x

Modifier

25

31575 Example: Physician performs and documents an E&M service on a new patient seen for new complaints of hoarseness. The Physician also performs a flexible fiberoptic laryngoscopy as the patient could not cooperate with attempted mirror exam.

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Modifier 25 16

Modifier 25 Significant, Separately Identifiable Evaluation And Management Service By The Same Physician On The Same Day Of The Procedure Or Other Service

Typically appended to an E&M Service on the same day as a minor procedure. Only append modifier 25 if E&M is significant or separate service. Remember, all minor procedures include some cognitive service

How Did You Code This Scenario? Service Description

9921x

Modifier

25

69210 Example: Follow up patient presents for routine removal of impacted cerumen

Attach modifier 25 to E&M services only. CPT Only, ©2011 American Medical Association, Inc. All Rights Reserved

Modifier 25: Significant Separate Service 17

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Big risk: routine reporting of an E&M service with minor procedures such as: •

Nasal endoscopy (31231)

•

Flexible fiberoptic laryngoscopy (31575)

•

Cerumen removal (69210)

Potentially increases exposure during datamining by the payors.

Modifier 79 18

Modifier 79 Unrelated Procedure Or Service By The Same Physician During The Postoperative Period Use when the patient has a procedure in the post-op period that is unrelated to the original procedure. 1. Not for complications 2. Must have a different diagnosis and make it the primary diagnosis Attach modifier 79 to the unrelated procedural service. If the new surgical procedure has a ten or ninety day global period, there will be simultaneous global periods to track.

How Did You Code This Scenario? CPT® Code/Modifier Diagnosis

31237-79

Maxillary / ethmoid sinusitis

Example: Right endoscopic ethmoid and maxillary sinus debridement one week post op right endoscopic maxillary and ethmoid surgery and septorhinoplasty.

CPT Only, ©2011 American Medical Association, Inc. All Rights Reserved

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Potentially Inappropriate Payments 19

Thou Shalt Not Clone! 

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“Identical” notes from visit to visit, from provider to provider on the 2013 OIG Work Plan Use copy/paste with caution Templates are great, but should all notes be word for word the same? Is medical necessity present at each visit to perform the exact same level of services?

Cloned Notes 20

DOS 12/26/12

DOS 2/7/13

OIG Focus: Physicians: Incident-To Services 21

“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 pays for certain services billed by physicians that are performed by nonphysicians incident to a physician office visit.”

How are NPP’s Utilized in Your Practice? PA/NP/CNS Speech Pathologist • Auxiliary Personnel (e.g., RN, LPN/LVN, MA) • •

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How Risky Is Our Business? 22

Get Place of Service Right 

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Physicians paid differently based on place of service: higher in office (POS 11) than facility (POS 22) Continuing issue on 2013 Work Plan Audit this at submission and payment

OIG Recovery 23

OIG recovered $3.8 billion in the first half of FY2013.

How Risky Is Our Business? 24

Examples 

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Billing the incorrect CPT code because it has a higher RVU value than the one performed (92511 vs 31575) Wrong ICD-9 code—diagnosis code establishes medical necessity for the service. Always billing an E/M service for every visit. Physicians billing audiologic diagnostic testing codes. Medicare says to bill using audiologist’s NPI. Be sure you are billing correctly using doctor NPI for oto-tech services. Changing the CPT code because the payor doesn’t reimburse the one you really did (allergy services!).

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Risk Identification And Reduction Steps 25

How do you ensure accurate reporting of in-office endoscopy? • • •

Nasal endoscopy (31231) Flexible fiberoptic laryngoscopy (31575) Microscopy (92504)

What needs to be documented to ensure medical necessity? Ask yourself, can you do this via speculum or mirror exam? If yes, should you bill for the “scope service?”

Use AAOHNS Clinical Indicators 26

Source: www.entnet.org/Practice/clinicalIndicators.cfm

BCBS Audit Initial Letter 27

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BCBS Audit Results 28

BCBS Audit Results 29

BCBS Audit Results 30

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Risk Identification and Reduction Steps 31

Use of Electronic Health Records/Electronic Medical Records 

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Can the EMR/EHR protect you from an audit or reduce your risk? Can the use of EMR/EHR pose risk? Point / Counterpoint Conduct E&M audits

Recovery Audit Contractors 32

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Keeping us up at night

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Identify and recover overpayments

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Automated and complex reviews

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Can refer practice for OIG/Department of Justice investigation •

RACs are still paid a percentage of what they return to the Medicare Trust Fund

RAC Reviews 33

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Automated Review: • Based on clear policy on overpayment • Based on a medically unbelievable service • No timely response received in response to a medical record request Complex Review: • Request for selected medical records • Notice of on-site review of records • GOOD CAUSE REQUIRED OIG findings, data analysis, comparative analysis …

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How Many of These Can They Look At? 34

CMS receives 1.2 billion claims/year or

4.5 million per day 9,579 per minute 574,000 per hour So, they have to sort through the ones they want to look at somehow!

OIG Report on RACs 35

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OIG says “high amounts of improper payment may continue” Wants RACS to “develop additional performance evaluation metrics to improve RAC performance”

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How Risky Is Our Business? 37

Compare Your Data 

Use of modifiers • •

Pay particular attention to use of modifiers 24, 25, 59, 58, 79 Compare each individual E&M profile distribution with CMS norms and practice average

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Most frequently billed codes

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E/M level of service

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Audit, Audit, Audit

Don’t Delay! 38

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Review before you get audited! Deadlines are tight. Physicians without effective compliance programs run the risk of claims being denied simply because they can’t show that they crossed all the “t”s and dotted the “i”s in time.

Review – Be Ready! 39

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Designate a Compliance Officer Stay up to date by signing up for email lists (e.g., CMS RAClistserve) and checking your RAC website. Designate a team member responsible for responding to RAC requests and NOTIFY your RAC with that information. Make sure ALL RAC correspondence goes to that person! Check your compliance policies/procedures. Have extension request and appeal template letters ready. Have response plans in place so you can respond quickly!

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Recoupment Notice Received 40

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Log and date stamp the day request is received. Automated Review • Remittance advice discussion period Complex Review • Review results letter • Discussion period • Demand letter (MAC/Carrier)

You Did Call Your Attorney, Didn’t You? 41

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Work should be done under attorneyclient privilege There are implications for further review, referral to Department of Justice

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Extrapolation….

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Who is reviewing what your sending? •

Be meticulous about the package, dates of service, supporting documentation, page numbers

Review – Respond! 42

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Track and document all communication

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Submit clear, complete documentation for all services

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Sequentially number all medical record pages

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Include: • • • • • •

Complete medical record Original request letter/account listing (copy) Physician query documents Coding summary sheet Original request letter (copy) CMS 1500

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Your To-Do List 43

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Look at your top billed codes.

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Look at your use of modifiers.

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Volume is a risk area Don’t just slap on a modifier and assume it’s ok to bill Beware of the coder who “knows how to get a claim paid”

Educate everyone about the rules for these codes and modifiers. Conduct audits of high risk areas and for that matter, even areas that you may not consider to be high risk!

Would You Like The Slides? 44

1.

Go to www.karenzupko.com

2.

Click on Workshops

3.

Click on Course Alumni

4.

Look at AAO-HNSF Annual Meeting

5.

6.

Course: Medicare Audit Risk Identification & Prevention Prescription Username: audit Password: audit

Upcoming AAO-HNS Sponsored Courses Presented by KZA 45

Date

Location

Hotel

October 25-26, 2013

Las Vegas, NV

The Westin Las Vegas

November 8-9, 2013

Chicago, IL

The Hyatt Chicago Mag Mile

Attend an ICD-10-CM training course in 2014 – Use of ICD-10-CM is mandatory on October 1, 2014 Visit www.karenzupko.com or call (312) 642-5616 for more details! 45

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