Part B Insider (Multispecialty) Coding Alert

Published on Fri May 23, 2003 PDF

Stop! Are you dangling audit bait in the water?

Certain codes are almost guaranteed to attract carrier scrutiny, experts say. That doesn't mean you shouldn't bill for these codes, just that you should be aware of the extra need to back up your claims with documentation.

The "hot button" codes change all the time, and remaining aware of them all is difficult, says Garnet Dunston, CPC, MPC, president and CEO of Dunston Enterprises in Bouse, Ariz. But one important tip is to look at which services the HHS Office of Inspector General has singled out for scrutiny. So it's important to keep track of OIG audit reports and the OIG's Work Plan (see story, in article "Fraud & Abuse: OIG Heats Up....").

But keeping track of what you're billing for most frequently is also important, Dunston says. Any code you bill on a regular basis could become audit-worthy. If the carriers run reports and "see that there's high utilization of certain codes, they're going to audit those codes," insists Dunston, who worked for a carrier.

These reports may be provider-specific or specialty-specific, so either way your billing patterns help to determine the carriers' focus.

In Transmittal AB-00-72, dated Aug. 7, 2000, CMS instructed the carriers that "the decision to conduct medical review should be data-driven," says consultant Jim Collins with Compliant MD in Matthews, N.C.

"Before September 2000, the government used to audit physician records on what they called a random prepayment basis," he says. They'd pick a level-four office visit at random and demand documentation. Now, they audit based on statistical evidence, such as whether physicians are billing for level-four services at a higher rate than the national norm.

For example, carriers may see a lot of practices billing exclusively for CPT 99213 (expanded office visit) instead of 99212 (focused office visit) and launch a probe of that code, says Catherine Brink, CMM, CPC, president of HealthCare Resource Management Inc. in Spring Lake, N.J. Or if providers decide to bill the higher-paying 99214 (detailed office visit), that code may also attract attention.