Acceptable levels of variance in E/M coding

[kevbshields]

I have been asked to find literature or an industry authority that in some way addresses the acceptable level of variance between an auditor's findings and the billed service level.

Although I can come up with many articles that discuss how subjective E/M is, or how payers develop their own interpretations, I'm coming up frustrated without any specific guidance.

Even if it is just a suggestion or allusion, I'll take it. Personally, I believe it is entirely up to who audits the case, the employment atmosphere and the payer or review service. However, it has to be addressed for the project I'm working on.

Any input will be helpful and thanks!

[btadlock1]

Originally Posted by kevbshields

I have been asked to find literature or an industry authority that in some way addresses the acceptable level of variance between an auditor's findings and the billed service level.

Although I can come up with many articles that discuss how subjective E/M is, or how payers develop their own interpretations, I'm coming up frustrated without any specific guidance.

Even if it is just a suggestion or allusion, I'll take it. Personally, I believe it is entirely up to who audits the case, the employment atmosphere and the payer or review service. However, it has to be addressed for the project I'm working on.

Any input will be helpful and thanks!

I'm using this: http://www.ttuhsc.edu/billingcomplia...rov_042111.pdf as a model to develop our audit/education process. I think the point-system is awesome.

[kevbshields]

Thanks for the help. I'll have a look at what you've suggested.

Let's just say for this project I'm looking at it from the payer's perspective. Would there be a specific methodology to apply in that case?

[btadlock1]

Originally Posted by kevbshields

Thanks for the help. I'll have a look at what you've suggested.

Let's just say for this project I'm looking at it from the payer's perspective. Would there be a specific methodology to apply in that case?

I think you could keep basically the same point system for determining what actions are appropriate, since that's based on how detrimental the various mistakes are to the providers' efforts to be compliant - you could just modify the action plan, to maybe conduct a larger scale audit, select providers for pre-payment reviews, or just send them a letter advising them of your findings, depending on how bad they really screwed up, in relation to how much it affected your company. (For example, providers that made minor mistakes that have little or no bearing on the payment might just get an FYI, while one that consistently upcoded in the sample audit, might have to undergo a full-scale retrospective review for a code identified as having a high error rate.) You could even build in steps to impose future restrictions on the provider's conditions of participation, which could work to your advantage during contract negotiations.

Whatever you do, though, make sure that your policies are incorporated into you provider contracts, so you won't be in breach, with any actions taken. Good luck!

[j.berkshire]

Have you reviewed the information on the CERT page on CMS's website?

[kevbshields]

I'm familiar with CERTS, but perhaps I'm unaware of exactly which information on CERTS you're referring to.

In visiting the CMS website today, I see information on Improper Payment Acts, various error rate reports and so on. Are you suggesting that there is specific language in CERTS that defines how CMS determines acceptable variance in E/M from payer versus auditor? That would be a great start for me.