Part B Insider (Multispecialty) Coding Alert

Published on Sun Apr 23, 2006 PDF

Start a dialogue with your carrier, and get your physician involved

When it comes to dealing with prepayment audits of evaluation and management (E/M) claims, time really is money.

Once you receive notification that your carrier is auditing your E/M claims, you should collect your information and send it to the carrier as quickly as possible, advises Tammy Young, a former Cigna Healthcare auditor now working as an independent coder/auditor in New Jersey.

The process of dealing with the carrier's request for documentation can add up to 45 days to your claim's processing time. "The sooner you correct the problem, the sooner you get off audit," adds Young.

Once you're on prepayment audits, the carrier assesses your error rate every three months until the rate drops below a certain percentage. "There are some providers that I've taken off within one month, because they quickly resolved the coding errors," Young notes.

She and other experts offer more tips on how to cope with prepayment audits:

• Know the rules. Find out which guidelines your auditor is using. "It is important to know the workings of your carrier at anytime, but especially while you are being reviewed," says Suzan Hvizdash, medical auditor with University of Pittsburgh Physicians department of surgery.

"We used the 1995 E/M guidelines unless the provider was a specialist and requested us to use the 1997 guidelines," explains Young. In most cases the 1995 guidelines favor the provider more than the 1997 ones, she notes.

Some carriers are starting to use their own home-brewed guidelines. Most notably, TrailBlazer Health Enterprises is using its own E/M audit guidelines, notes consultant Pam Biffle, approved PMCC instructor and product development director with Custom Coding Books in Bellevue, WA. You should check with your individual carrier to find out if it has any guidelines of its own.

• Download your auditor's scoresheet. If your carrier doesn't make its E/M scoresheet available, chances are it uses one similar to Pennsylvania Medicare's, Young notes. This is available online at www.hgsa.com/professionals/pdf/8985.pdf.

• Provide all relevant charts, even from different dates. Your carrier may only request charts from a particular date in question. But if your physician's documentation says something like, "Reviewed history of" a particular date, then you should also include the chart from that date, advises Barbara Cobuzzi, president of CRN Healthcare Solutions in Tinton Falls, NJ.

Similarly, if your physician refers to telephone decisions from another date in the medical decision-making section, you should include documentation of those.

• Effect an exit strategy.  Once you've been on prepayment review for a while, initiate a conversation with the carrier medical director or audit department to detail your improvement. Bring any information you've gleaned from your time under the microscope, advises Hvizdash.

Explain how you've educated your physician about proper billing and documentation practices--and provide documentation of this training,  if possible. If you've   been providing all the documentation the carrier has requested, and it's substantiated the levels of service billed, point that out. Also, explain how the hit to your revenue cycle is hurting your practice's day-to-day operations.

• Appeal your denials if you feel the carrier downcoded your service incorrectly or if you can provide more supporting documentation, says Young. The majority of E/M downcodes seem to be overturned in appeals.

It can improve your chances in an appeal if your physician is directly involved and addresses issues with the carrier, says Hvizdash.

• Hire a professional consultant if your error rate seems really high, advises Young.