Wiki Identified Over Coding

[sarahpoe]

I am trying to get a sense of what other compliance programs are doing in regards to identified over coding in relation to E/M services. For example, a provider may report new patient E/M 99204; however, upon an annual internal audit the PFSH was incomplete or there were only 9 ROS documented instead of 10. All other elements are documented appropriately in regards to exam and MDM, and the nature of the presenting problem may warrant the complexity of the service. Another example may be if the same new patient 99204 was reported with a comprehensive history, and moderate decision making, but the physical exam only included 7 organ systems instead of 8 for the comprehensive exam. When the documentation falls just short of the requirements for a 99204, do you resubmit a corrected claim for a lower level of service? A previous employer only resubmitted corrected claims if the level of service was off by more than 1 level, or if the wrong E/M category was reported. New employer does not have a policy on this so I am trying to determine what is the appropriate action.

The same would go for perhaps an established patient 99214. One auditor may warrant the 99214, and another auditor may only warrant 99213 depending on how the documentation is interpreted following the ambiguous documentation guidelines.

When RAC audits are performed the medical necessity can be warranted for a higher level of service even if there are elements that are lacking. I sometimes feel uncomfortable changing the level of service after an internal audit when the requirements are not met if there would be potential to appeal medical necessity IF needed. I do meet with the providers and educate them on the internal audit findings to help improve their future documentation. As you all know this is still difficult for the providers to grasp all of the required elements when they are focusing on actually practicing medicine. I do not want to demonstrate fraudulent behavior. At what point are we as auditors required to refund/resubmit corrected claims when over coding is potentially identified?

Any recommendation are much appreciated.

 

[Kris Cummings]

Great questions, Sarah. Especially when one is developing auditing procedures and policies.

Anytime the documentation guidelines haven't been met for a certain level of E/M then they're simply not met. For example, one can't say well there was high complexity so even though this new patient didn't have a comprehensive exam, I'd still count it as a 99205. This will not stand in a court of law. The documentation guidelines read that one has to meet or exceed each of the three key components (unless billing based on time). That is a fact.

Also, I recommend you and the other auditor(s) have discussions and determine agreement on the ambiguous areas of E/M. Then create policies on that, or at least have it in writing that you all can go back to when needed. It makes defending documentation during RAC or other health plan audits, so much easier too. We refer to these as our "grey areas" and our lives are definitely easier once we have these worked out. Some items that may be included here are:

• What everyone thinks each HPI element means
• What everyone thinks CC means
• What the status of three or more chronic or inactive conditions means
• When is a problem new to a provider.

Second, yes, if you discover an over-payment in auditing, I recommend submitting corrected claims to the health plan(s). Understanding these are for educational purposes, it still is an over-payment discovered by the practice and needs to be corrected. Remember Medicare's newer 60-day policy on refunding over-payments.

Good luck!