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Issue #1 - September 19, 2012

Auditing/Compliance Tips and Resources

Capture Revenue and Stay Safe with Surgical Chart Audits

To help ensure accurate surgical coding and provide peace of mind if an outside audit occurs, you should regularly perform internal reviews of surgical code selection. The goal of an internal audit is to strengthen documentation weaknesses and mend holes in claims management to help you capture all revenue.

Know What to Look For

According to Charla Prillaman, CPC, CPMC, CPC-I, CCC, CEMC, CPCO, an essential part of audit efforts in a surgical practice should include:

  • Checking the accuracy of evaluation and management (E/M) levels and reviewing surgical services charts.
  • Looking for erroneously selected CPT® codes, missing charges, and missing or inaccurate modifier selections.
  • Reviewing inaccurate ICD-9-CM diagnosis code selections.

Apply Complex Coding Principles and Payer Policies

Surgical services auditing has unique coding guidelines and rules to follow. When auditing, Prillaman says to pay close attention to:

  • Surgical global package concept
  • Correct modifier application
  • Payer policy
  • Screening vs. diagnostic vs. therapeutic procedures
  • Place of service (POS) reporting
  • National Correct Coding Initiative (NCCI) edits
  • E/M services provided during the global period
  • Complex rules surrounding services furnished by mid-level providers

Dissect the Op Report

When reviewing op reports, be sure to catch overlooked surgery details such as headings that inadequately or incompletely describe rendered services. An example of an incomplete heading, according to Prillaman, is "colonoscopy with polypectomy." She said, "Selecting a code from just the heading might lead to a claim submission of 45384 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery. The detailed description in the body of the operative report, however, may reveal the surgeon removed two polyps using hot biopsy forceps, and removal of a separate polyp by snare."

Prillaman continued, "A qualified auditor will recognize that an additional procedure (45385 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique) should be reported, with modifier 59 Distinct procedural service appended because the National Correct Coding Initiative (NCCI) indicates this code pair usually is ‘mutually exclusive.' As a result, reimbursement may increase nearly $500 per case where this type of error has occurred."

Take Coding Issues Seriously

When an audit reveals miscoding, formulate steps to improve coding and weaknesses. Don't be afraid to call in the expertise of a surgical specialty auditor to help you with the audits and come up with a plan of attack. Proper audits will reduce claim denials and lost revenue and boost your billing confidence and your practice's bottom line.

Meaningful Use Bonus Recipients Audited

The process starts with a mailed letter sent from the Centers for Medicare & Medicaid Services (CMS) to physicians who have received an incentive check, saying he or she is being audited. Practices are required to reply within two weeks upon receiving the letter.

The auditing process is a 2009 federal stimulus package Congressional requirement for professionals authorized to receive EHR bonuses. In 2011 and 2012, more than 55,000 physicians demonstrated meaningful use and received incentives.

If during the post-payment audit a physician or hospital is found ineligible for EHR meaningful use incentives, the bonus payment must be returned. As long as the practice has supporting documentation and reports attesting to meaningful use, they won't have to send back the money.

The audit letters ask physicians to provide these three things:

  1. Proof that the EHR system is certified to meet meaningful use requirements. See the Office of the National Coordinator for Health Information Technology's (ONC) website for a list of certified EHRs.
  2. Supporting documentation proving that 15 core objectives were met to achieve Stage 1 meaningful use. EHR systems that are certified to meet meaningful use can generate electronic or paper reports showing the objectives were met.
  3. Documentation supporting that meaningful use of five of the 10 menu objectives in Stage 1 were met. EHR-generated reports supporting clinical quality measures can show these objectives were met.

Hospitals need documentation supporting emergency department admissions reporting methods in addition to the above.

No one can tell for sure which eligible professionals or hospitals will be chosen for a meaningful use post-payment audit. Selection may be based on specific information or risk factors, but some audits are random, according to CMS spokesman Joseph Kuchler.

Source:, "CMS Starts Auditing Recipients of Meaningful Use Bonuses"

Any Claim is Fair Game for an Audit, Appeals Court Rules

A recent appeals court ruling upholds Medicare regulations that give recovery auditors the right to reopen claims paid one to four years previous. Auditors need only good cause to reopen such claims and, per Medicare regulations, a good-cause determination cannot be challenged, the court said. The implications of this ruling have industry experts worried.

The 9th U.S. Circuit Court of Appeals ruling on Aug. 22 comes after three years of administrative appeals brought forth by Escondido, Calif.-based Palomar Medical Center. In the original 2009 lawsuit, Palomar challenged auditors' reopening and overpayment determination of a claim paid 20 months previous, according to American Medical News.

An administrative law judge (ALJ) found that Palomar was overpaid for the medical services, but the recovery auditor had not demonstrated good cause to examine the claim. The ALJ decision was overturned by a Centers for Medicare & Medicaid Services (CMS) administrator, however, based on Medicare regulations that stipulate the reopening of a claim deemed to have good cause was not subject to appeal. Further, Medicare regulations prevent medical professionals from challenging an audit's good-cause determination, CMS said.

The ruling is harmful to physicians, who must accept audits without being afforded the opportunity to question the reasoning behind reopening old claims, said Long X. Do, legal counsel for the California Medical Association (CMA).

"Any audit is going to be very disruptive to a physician's practice," Do said. "The longer the audit goes back, the more burdensome it is on physicians. ... The court has upheld the ability of the auditor to [reopen claims] without being subject to physicians' challenges."

In This Issue
Surgical Chart Audits Meaningful Use Audits
Any Claim is Fair Game

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