Practice Management Alert

Focus on tightening these areas to reduce risk of audits.

During the COVID-19 public health emergency, the Centers for Medicare & Medicaid Services (CMS), other government agencies, and commercial insurance carriers suddenly greenlit scores of changes across coding, billing, and healthcare spheres. While the combination of the easing of restrictions alongside emergency funding from the Department of Health and Human Services (HHS) and other relief has been a means of keeping some practices afloat, be aware that audits may be around the corner.

Although the relief funding was sorely needed by some practices and larger healthcare institutions, the stipulations attached have worried some experts from the start. And the lack of oversight meted out at the beginning, before or when the funds became available, means that audits may be lurking around the corner now.

“Audits take time and resources that you quite honestly don’t have. You want to be compensated fairly for the work that you’re performing, and to do what you do best: providing quality care for your patients,” says Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMCSC, CMCS, ACS-CA, SCP-CA, owner of Terry Fletcher Consulting Inc. and consultant, auditor, educator, author, and podcaster at Code Cast, in Laguna Niguel, California.

Know the Payer’s Perspective

One major stipulation of much of the relief funding was that it needed to be used to help mitigate COVID-19’s effects on healthcare businesses or COVID-19 patients. However, the funding allocation also said that almost any patient could be considered a COVID-19 patient, due to the extenuating circumstances and far reach of the pandemic — but now some payers are walking that back a bit.

The payer’s perception matters — not yours, as a practice manager or coding or billing expert — when determining fraud, Fletcher notes. She points out that the development and implementation of newer technology, like artificial intelligence systems, means that audits and, subsequently, denials have already been on the rise.

“The shift is producing more audits of physicians than ever before, and directly contributing to higher rates of denials. You’re probably already seeing that, even though we were promised this great windfall when telehealth took over during the pandemic,” she says.

Focus on the Numbers

Understanding how your practice compares to others is a big first step in mitigating your risk for an audit, because your practice may be an outlier. “Differences between you and your billing and that of national averages can be due to inappropriate billing and insufficient documentation. It also can be a loss of revenue in the future if it hasn’t already,” Fletcher says.

Top tip: Understand your data. Although Medicare can set many precedents for billing, commercial carriers may have different rules. Don’t bill only by Medicare’s standards because you may be missing out on revenue. “Understanding your specialty and what you can code for is huge,” she says.

Numbers matter for denials, too. Knowing your rate of denials is important because it can illuminate why you aren’t getting paid for your work. Think of it like this, Fletcher says: “If you’re coding for anything and reporting anything to an insurance payer, you’re expecting to get paid, you’re not hoping to get paid.” Getting a handle on your denial rate can show you potential gaps in your coding and billing processes, but also simply paint a clearer picture of what payers are seeing that you may not be realizing.

Don’t Stray From Coding Guidance

Fletcher emphasizes that coders really need to be on top of the guidance for the various coding systems used within their profession and specialty. “You’re responsible for keeping up on current code sets and guidelines,” she says.

This goes beyond staying on top of new code sets, however. Overusing modifiers, over-relying on time-based codes, overcoding and undercoding, and improper unbundling are all poor coding practices — and red flags for an audit.

There’s a common misconception among some coders that claims won’t get paid unless they feature a modifier, but that’s not how modifiers work. “Modifiers should only be used if certain criteria can be met; unnecessary use can land you in an audit,” Fletcher warns. Luckily, there are various resources available to check your work against, including the National Correct Coding Initiative (NCCI) and Medically Unlikely Edits (MUEs).

Payers are doing the math, Fletcher says, and they’re scrutinizing time-based codes heavily. Take a close look at your time-based coding now because payers are, but also because 2021 office evaluation and management (E/M) code updates will force the issue even more. For example, Level 5 codes for established patients start at 40 minutes and go up to 60 minutes and higher on a new patient, but if you’ve billed 15 patients, you’re going to have to prove that the physician was in the office for 15 hours, Fletcher says.

Other nits to pick: Submitting claims for excessive hours in a day, not just to one payer but cumulatively; noting counseling on claims but not providing any explanation on the reason for the discussion with the patient nor the need for timing. Time is money, and any massaging like this can get you into serious audit trouble, Fletcher says.

Over- and undercoding, when the code you bill for is more or less expensive than the services documented, respectively, or coded at an inaccurate level, can flag you for an audit. While overcoding may sound like a bigger target for sharp-eyed payers and auditors, undercoding can also raise alarm bells because your practice is evaluated against others in your specialty, Fletcher says, and they’re looking for a bell curve that indicates a realistic mix of patients and encounters. That’s why levels 2, 3, 4, and 5 all exist; because patients’ sicknesses run the gamut of intensity, she adds.

Don’t give in to the temptation to unbundle codes, either. “You may find it more lucrative to bill for multiple CPT^® codes even when a single code would suffice, but this is a huge red flag. This leads to intentional forms of overcoding,” Fletcher says. Stay abreast of the latest CPT^® codes used by your specialty.

Note the Details

Telehealth may have eliminated certain location requirements temporarily, but pay attention to the details on your claims. Specifically, services considered incident-to still have certain requirements, Fletcher says. This includes the physician being accessible and available — which means physically in the office, or wherever the midlevel provider is. If the physician is on vacation or working elsewhere, coding incident-to services as if they are indeed in the office can be an issue for audits and defrauding the system. As practices move back toward in-person visits, make sure your incident-to rules are ship shape, Fletcher recommends.

Don’t forget documentation, either. This includes evidence that the encounter entailed the services you’re coding and billing for, information that justifies the use, and dotting the i’s and crossing the t’s for your signature lines, etc. Do your homework on what documentation is needed, too; check plan information, understand contracts, and follow national or local coverage policies. Don’t experiment when sending documentation for claims submissions, Fletcher emphasizes.