Part B Insider (Multispecialty) Coding Alert

Published on Mon Jan 12, 2015 PDF

If you get frustrated over auditors’ reviews of your claims, you aren’t alone. A caller to CMS’s Jan. 7 Open Door Forum questioned whether CMS is just performing fishing expeditions, finding practices guilty until proven innocent—and one CMS official explained why.

“Observation management codes, if they’reless than eight hours, they don’t count,” the caller said. Auditors, however, have no idea about whether submitted observation care codes reflect services performed for less than eight hours or not until they receive the practices’ paperwork. “We always give the information and it’s always legitimate and they keep asking for it, and it’s a real hassle to keep getting this information,” the caller said. “They just keep fishing for it…is that okay? Is that why we’re doing that? I thought we were just looking for the bad actors.”

“We are looking for the bad actors,” responded CMS’s William Rogers, MD, who acknowledged that as a physician he always wishes it were easier to submit information when auditors request it, but as a CMS official, “to see the amount of erroneous and fraudulent billing going on, it’s just unbelievable.”

“Unfortunately, we can use the types of technique that credit card companies use to look for aberrant patterns, and that’s helpful,” Rogers said. “But to a certain extent some of it just has to be brute force asking for information and looking for problems that don’t pop up when we look at billing aberrancies and it is a huge hassle for you, but like all rules, if everyone was honest we wouldn’t need these rules and our lives would be much simpler.”

“Unfortunately,” Rogers added, “there are a whole lot of people who are either not reading the instructions or are intentionally defrauding the taxpayer and we are held responsible for those payments,” he said. “Of course there is a cost to the taxpayer so we don’t want to do it excessively.” So CMS must stick to a balance, which can be frustrating for practices but is a necessary evil.