Part B Insider (Multispecialty) Coding Alert

Published on Thu Sep 08, 2005 PDF

Use physician forums to make your concerns known

Part B carrier TrailBlazer Health Enterprises has issued new audit guidelines for evaluation and management, and you need to be aware of them before auditors start using them to judge your claims, say experts. And if you don’t like what you see, speak up.

If TrailBlazer is your carrier, be sure your E/M levels will comply by doing some chart audits yourself, suggests consultant Quin Buechner with ProActive Consultants in Cumberland, WI. Pick a representative sample of your E/M claims to see how the levels match up with TrailBlazer rules.

These new guidelines aren’t intended to replace national Medicare guidelines for E/M audits, insists Debra Patterson, the TrailBlazer medical director. The carrier imposed the guidelines to make sure claims reviewers are being consistent on areas where the CMS guidelines are “either silent or subjective,” she tells PBI.
 
TrailBlazer needs to drive down the high error rate for E/M payments in the Contractor Error Rate Testing program, Patterson adds. “The CMS guidelines are not all-inclusive, complete, stand-alone rules for coding or auditing E/M services ,” she claims.

Downside: Unfortunately, Centers for Medicare & Medicaid Services officials have said they won’t prevent TrailBlazer from improvising its own guidelines, says Buechner. Officials have said that the Marshfield Clinic score sheet, widely used by consultants, is not a Medicare document. And at least one version of the Marshfield score sheet is “incorrect.”

What to do: You can still raise a fuss about these guidelines with your local medical society, says Buechner.

If TrailBlazer downcodes your claims, you can appeal to your Qualified Independent Contractor (QIC), advises Barbara Cobuzzi, president of CRN Healthcare Solutions in Tinton Falls, NJ. The QIC will be independent of the carrier and may consider your claims based on national guidelines, she advises.  

Watch out: If you win too many appeals, the carrier may place you on prepayment review.

You can also complain about the new policy at the Medicare open door forum for physicians, Cobuzzi adds.