Overcome Coders’ TOP 10 Compliance Concerns

Part 1: Make numbers 10 through six part of your compliance plan.

By Marcella Bucknam, CPC, CPC-H, CPC-P, CPC-I, CCC, COBGC, CCS-P, CCS

No matter what your specialty or the size of your practice, certain issues should be part of your compliance plan. Over the next two months, we will focus on the top 10 compliance concerns for a physician practice. You can tailor this list using additional information from the Office of Inspector General’s (OIG) work plan, your specialty societies, and your own experience to develop a plan that will effectively address compliance issues in your office.

Certified Professional Compliance Officer - CPCO

Resource Tip: For more information on how to incorporate the 2012 OIG Work Plan into your compliance plan, see Jillian Harrington’s, MHA, CPC, CPC-P, CPC-I, CCS-P, article “Hospitals: Set a Course for Compliance,” in this issue of Coding Edge, and check out “Make the 2012 OIG Work Plan Work for You” in January’s issue.

No. 10: Certifying Home Health and Ordering DME

In 2010, Medicare and the federal government made clear they are cracking down on fraud, waste, and abuse in home health and durable medical equipment (DME), and that they expect physicians and non-physician practitioners (NPPs) who order these services to assist them in the effort. They are also willing to hold ordering providers responsible for assuring the medical necessity for these services and supplies.

Ordering providers are now required to personally see the patient before certifying the need for home health care, or for ordering (or re-ordering) DME. The ordering provider must also keep a copy of the order in the patient’s medical record. This is a logical requirement for most cases, but consider, for example, an otherwise healthy amputee who needs a DME order to replace the battery in his wheelchair. That patient must now wait for an appointment before he can get the DME he needs.

For home health services, the certifying provider must document a face-to-face encounter with the patient, related to the condition for which home health services are ordered, within 90 days prior to, or 30 days after, initiation of home health care services. Physicians must certify that these services are needed, but an NPP in the same specialty and practice may see the patient and document the encounter. The certifying physician must specify that the patient was seen, and how the patient’s clinical condition supports a homebound status and the need for skilled services. These rules apply to new certifications. Re-certifications may be done without a face-to-face visit.

Don’t forget to bill Medicare for these certifications. Use G0180 Physician certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care that meets patient’s needs, per certification period for an initial certification and G0179 Physician re-certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care that meets patient’s needs, per re-certification period for re-certification.

DME is any equipment (excluding prosthetics and orthotics) that is reusable and is not typically used for people without a medical condition. Examples include:

  • Wheelchairs (and wheelchair batteries)
  • Crutches, walkers, and canes
  • Bedpans
  • Diabetes treatment supplies (like monitors)
  • Lymphedema pumps
  • Heat lamps
  • Alternating pressure pads and mattresses

The patient must have had a face-to-face visit with the ordering physician or NPP within the last six months. This applies to all DME orders for Medicare patients, including replacement parts or replacement equipment. Under federal law, providers must see the patient before these orders are written, even when this is expensive or inconvenient. Failure to follow these rules could result in federal prosecution.

No. 9: Grading E/M on a Curve

The OIG analyzes billing trends and patterns for providers billing evaluation and management (E/M) codes by comparing billing patterns to a bell-shaped curve of billing levels by other providers. The analysis considers the practitioner’s specialty, type of service provided, setting, patient status, and the service’s complexity, and compares this to claim information for similar practices and patients. Practitioners who fall outside the curve will have their documentation and claims scrutinized more closely for errors or fraud.

You can find standard bell curve information for your specialty by viewing the Part B National Summary Data file, found on the CMS website. By comparing your own E/M utilization rates against the national average, you can determine if this may be an issue for your practice.

If you find that you’re an outlier, don’t panic. First, consider your practice. Your curve may be appropriate based on patient type or subspecialty. Then, check your documentation. If the documentation supports the levels you’re billing, you’re probably OK. Be sure to check your documentation for medical necessity. Do the notes seem appropriate to the patient’s problems? If so, there’s probably nothing to worry about, except the cost of extra scrutiny.

No. 8: E/M Services in the Global Surgical Period

This may be a bigger potential problem for non-surgeons than for surgeons, especially for those who don’t know what’s included in the global package.

The packaged surgical payment includes one related E/M service on the day of, or day before, surgery. This includes the history and physical prior to surgery, no matter when it is done. The service is not separately billable—even if performed by another physician—unless there is a medically necessary clearance prior to the surgery. Physicians providing preoperative E/M services without adequate documentation of medical necessity are violating the global package.

The package also includes all typical follow-up care and—for Medicare and other payers that use the Medicare definition of the surgical package—all care of complications that doesn’t require a return to the operating room. This includes pain management, unless there is adequate documentation of complex or acute on chronic pain issues that require specialty management. Surgeons are expected to round on their patients after surgery, even if a specialist manages the patient’s other problems after surgery.

Services for care of pre-existing or co-morbid acute or chronic conditions are not included in the global package. Care of any underlying disease process that created the need for surgery also is separately billable unless the condition was cured by the surgical procedure. Care of a new, unrelated condition that arises in the postoperative period also can be billed separately; but documentation of these separate conditions and a note that focuses on the separate conditions is necessary. Don’t use any components that would be bundled (e.g., examination of the operative wound) to support the level of the separately billable service.

Be sure you know the global period of the surgical procedures you bill. Many codes have had changes in the global periods, with resultant changes in their relative value units (RVUs). If a procedure has been changed from 90 days to 0, you can be sure reimbursement has also been reduced, and you will need to bill those post-op visits to maintain your revenue.

No. 7: Error-prone Providers

The OIG will use Comprehensive Error Rate Testing (CERT) program data from the past four years to identify error-prone providers and look more closely at their claims. The OIG is defining an error-prone provider as any provider with an identified billing error during the program period. This includes any of the following:

  • Wrong CPT® code
  • Wrong ICD-9-CM code
  • Medical necessity errors
  • Wrong date of service
  • Missing or incomplete documentation (including non-response to requests for documentation)

Do not ignore CERT requests for documentation, and review documentation before you send it to CERT. Challenge any CERT findings you feel are in error. A clean CERT report will take one issue off your plate.

No. 6: Place of Service Errors

We’ve known place of service (POS) was a concern of Medicare’s for several years, and the 2012 OIG Work Plan has several items addressing this. Of particular concern to physician practices are services billed as office visits (POS 11) that were actually performed in hospital outpatient locations (POS 22). Services performed in hospital outpatient locations are reimbursed to physicians at a lower rate than they are in physician offices. Billing POS 11 in error is considered duplicate billing. For more information, see MLN Matters® SE1104.

For hospitals, the big POS issue is related to the medical necessity for admissions, especially short admissions. Medicare has advised that if the patient could be treated and discharged within 48 hours, the patient should be in observation status rather than being placed in inpatient status.

Next month: We’ll continue with the top five compliance concerns for a physician practice, with tips for effective compliance in your practice.

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Marcella Bucknam, CPC, CPC-H, CPC-P, CPC-I, CCC, COBGC, CCS-P, CCS, is the manager of compliance education for a large university practice group. She is the long-time consulting editor for General Surgery Coding Alert, and has presented at five AAPC National Conferences.

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