Medicare Compliance & Reimbursement

If you utilize certain unique codes too often, that could be a problem. You may be labeled an outlier and catch the attention of auditors.

Case study: One physician learned that lesson the hard way in January and was indicted by a federal grand jury after the Department of Justice (DOJ) accused her of defrauding Medicare out of $46 million on unnecessary balloon sinuplasty services (31295-31297).

On Jan. 5, the DOJ reported that Raleigh, North Carolina ENT Anita Louise Jackson billed over $46 million to Medicare for at least 1,200 balloon sinuplasty procedures across 700 patients. Her sinuplasty billings were so numerous that she became the top-paid provider of balloon sinuplasties in the country. In addition, she was accused of reusing single-use balloon sinuplasty devices on patients, “sometimes inserting the same device into more than one patient on the same business day,” the government alleged. She also used cloned notes to substitute for original operative reports, which lacked documentation of why each specific patient required a balloon sinuplasty.

The ENT physician faces up to 20 years in prison for one count, 10 years for another, and five years for a third. She also faces potential fines of more than $250,000.

When Medicare auditors asked to review the ENT physician’s records, she and her employees allegedly forged, backdated, and fabricated medical records to prevent the auditors from seeing exactly what was being performed.

Check Necessity for Every Procedure

The physician in question was said to have performed and billed for services that may not have been rendered for medically necessary reasons. A qualified coder should be able to spot medical records that are missing proof of medical necessity, and those that contain cloned notes.

It’s the physician’s responsibility to ensure that all medical records contain proof of medical necessity and details about the patient’s encounter. Members of the coding staff can look for these details and raise flags if they don’t see them in the documentation.

In addition, keep the following best practices in mind as you work to maintain appropriate documentation that shows medical necessity for the services provided.

Document Only Authentic Information

Cloned notes are on payers’ radar screens, with Medicare Administrative Contractors (MACs) releasing directives reminding providers that using cloned notes and submitting these as documentation for payment for services, whether intentional or unintentional, does not meet the threshold of medical necessity.

Reminder: “Some [Promoting Interoperability] PI Programs’ technologies auto-populate fields when using templates built into the system. Other systems generate extensive documentation on the basis of a single click of a checkbox, which if not appropriately edited by the provider may be inaccurate. Such features produce information suggesting the practitioner performed more comprehensive services than were actually rendered,” according to Part B MAC Palmetto GBA.

Cut and paste issues: If your software suggests signs and symptoms that frequently correlate with a diagnosis, you should avoid any temptation to cut and paste. You must document what the provider identifies as the presenting symptoms and the final diagnosis rendered from clinical evidence and possibly a final pathology report.

“Obviously, if you use the same medical software, you’re going to have a lot of similarities; but payers are looking for cloned notes, meaning the exact same thing for different patients for the exact type of medical record of what’s being submitted, and that’s where it becomes a problem,”says Terry Fletcher, BS, CPC, CCC, CEMC, SCP-CA, ACS-CA, CCS-P, CCS, CMSCS, CMCS, CMC, QMGC, QMCRC, owner of Terry Fletcher Consulting Inc. and consultant, auditor, educator, author, and podcaster at Code Cast, in Laguna Niguel, California.

Prioritize Patient Safety

With the Centers for Medicare & Medicaid Services (CMS) reinstating claims reviews after lifting its COVID-19-inspired hiatus, fraud audits and Medicare reimbursement snafus are likely on your organization’s watch list. These are obvious concerns that impact your fiscal viability, but you mustn’t forget about your top documentation priority — patient safety.

“It’s inappropriate to perform clone note documentation, because it not only can damage the trustworthiness and integrity of the record for patient care, but now you’re also dealing with safety,” Fletcher cautions.

Critical: Inaccurate information in the patient’s medical record — perhaps lifted from another encounter with the same diagnosis or automatically populated by your software’s template — can lead to care decisions that are dangerous for that patient.

And don’t forget with EHR technology and interoperability between systems, your patients’ medical records follow them. Myriad clinicians within a larger provider network easily have access to that information. All providers must look to the medical record and hope that the documentation is accurate.

Implement Documentation Best Practices

Simply avoiding the cloning pitfall won’t ensure that providers necessarily update charts with quality documentation.

To accomplish the best medical record for optimum patient care and payment, make sure the clinician’s notes meet the following criteria:

• Reliability: The documentation should support the rationale for the diagnosis and medical necessity for the procedure. If it doesn’t, you should question the reliability of the note and ask the provider for clarification. Most denials occur when at least part of the documentation doesn’t support the codes you report.
• Precision: Clinical documentation must be exact, and strictly defined. Make sure the practitioner uses terms precisely.
• Completeness: Good documentation fully addresses all necessary items, including complete patient information, procedure description, diagnosis statement, and physician identification.
• Consistency: Documentation shouldn’t be contradictory. If there are conflicting statements in the record, such as a difference between the rule-out diagnosis and the final diagnosis based on the pathology report, make sure you address them.
• Clarity: Documentation should be unambiguous. Vague op reports that don’t clearly state pertinent information such as a specific surgical approach or extent of a procedure could lead to unsupported claims.
• Timeliness: Documentation must be up to date to help ensure optimal patient care.

Bottom line: The entire staff of your physician practice should be watching out for these issues, and should call attention to any coding and billing instances that don’t add up.

Resource: Read about the case of the ENT accused of sinuplasty fraud at www.justice.gov/usao-ednc/press-release/file/1460746/download.