Improper Billing Trends Resources

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Hi - My job involves to find most recent improper billing trends performed by physicians . If you know any resource or any groups please share .... So far I go to OIG work plan , CMS Improper Data or RAC audits reports to find the most current trends .

Thanks
Vani
 

ggoode66

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are you looking for the most often misbilled items by physicians in general, by speciality? ? Or what your group of physicians are doing. if it's your group first you have to find out what is being improperly billed and then determine the root cause to identify the trend. If it's by physicians in general you can see which the bell curve is for certain cpt's billed to CMS. So for E/Ms for example, it would show the percentage of what Med Onc' for each E/M code then see if that compares with your group of Med Oncs. or whichever speciality it may be
 

TThivierge

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Lithonia, GA
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Hi Sahni:)
I can name a few improper billing trends. Here are some.....providers not putting minutes down in medical record documentation for the day if using phone or telehealth processes, listing the assessment or dx codes then give details in discussion if illness, if doing follow up they should list what specific body organ or system checking with ROS, and be specific in telling which bilateral limb or organ system caring for. Also it does depend on what medical specialty treatments done in because some require differ documentation data(general medicine vs psychiatry vs orthopedics). Understanding incident to services vs split shared vs consultations documentation all done properly but in differ formats. Another thing you can do is look at insurance denials per provider by type of payer and medical specialties help you too. Is a modifiers 59 vs 51 vs XS required due to differ areas of body treated on. Are providers using the most detailed dx used for differ stages of diseases in the medical record. Some staged or differ level diseases are: CHKD, Hypertension, type of Fracture, various substance abuses , & Depression, Diabetes Mellitus, Heart/Cardiac conditions, Burns, Etc. Provider should distinguish in their notes if pt. has chronic conditions vs illness happened years ago by entering a date so medical coder can selected correct ICD10 code. Oh yes if pt. suffers a current injury ensure put date, how it happened and where in the medical record for the day.. Insurance companies will deny if this detailed data regarding injury is not put on record and claim.
Did I help you with this data? I hope so
Lady T;)
 
Last edited:
Messages
40
Best answers
0
Hi Sahni:)
I can name a few improper billing trends. Here are some.....providers not putting minutes down in medical record documentation for the day if using phone or telehealth processes, listing the assessment or dx codes then give details in discussion if illness, if doing follow up they should list what specific body organ or system checking with ROS, and be specific in telling which bilateral limb or organ system caring for. Also it does depend on what medical specialty treatments done in because some require differ documentation data(general medicine vs psychiatry vs orthopedics). Understanding incident to services vs split shared vs consultations documentation all done properly but in differ formats. Another thing you can do is look at insurance denials per provider by type of payer and medical specialties help you too. Is a modifiers 59 vs 51 vs XS required due to differ areas of body treated on. Are providers using the most detailed dx used for differ stages of diseases in the medical record. Some staged or differ level diseases are: CHKD, Hypertension, type of Fracture, various substance abuses , & Depression, Diabetes Mellitus, Heart/Cardiac conditions, Burns, Etc. Provider should distinguish in their notes if pt. has chronic conditions vs illness happened years ago by entering a date so medical coder can selected correct ICD10 code. Oh yes if pt. suffers a current injury ensure put date, how it happened and where in the medical record for the day.. Insurance companies will deny if this detailed data regarding injury is not put on record and claim.
Did I help you with this data? I hope so
Lady T;)
Thank You !
 
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Hi - My job involves to find most recent improper billing trends performed by physicians . If you know any resource or any groups please share .... So far I go to OIG work plan , CMS Improper Data or RAC audits reports to find the most current trends .

Thanks
Vani
Those are great sources. The audit reports and various enforcement actions related to improper coding/billing that are posted on the OIG's website are also helpful. Private payers also post information on fraud and abuse schemes.
 

amyjph

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457
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Munising, MI
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Along with what you said you are using, state Medicaid sites and state OIG usually have information on this as well. And agree with the suggestion for private payers. There's usually "top claim errors" FAQ or places on the sites.
Also, take a look at what audit and medical records requests your particular practice is receiving, that can clue you in on what payers are looking for currently. What denials and rejections are you getting? That can help too. Claim clearinghouses may also have resources.


A basic starting point is usually modifiers 25 & 59, high level E&Ms and and any high reimbursement codes. Right now it's also telehealth and Covid related services.
 

rbordes

Contributor
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TICKFAW, LA
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A laboratory gets specimens with no DX provided, and the billing manager is requesting we use Z51.81. How is this possible? Doesn't the DX have to be provided by the DR sending the specimen to the lab? I have been in coding for 10+ years and have never just picked a DX to apply to a claim. Can someone advise, on this, just to make me sure I am not crazy, and this is fraud
 
Messages
40
Best answers
0
Along with what you said you are using, state Medicaid sites and state OIG usually have information on this as well. And agree with the suggestion for private payers. There's usually "top claim errors" FAQ or places on the sites.
Also, take a look at what audit and medical records requests your particular practice is receiving, that can clue you in on what payers are looking for currently. What denials and rejections are you getting? That can help too. Claim clearinghouses may also have resources.


A basic starting point is usually modifiers 25 & 59, high level E&Ms and and any high reimbursement codes. Right now it's also telehealth and Covid related services.
Thank you Very much for info. I will definitely look into NHCAA or may take there training . My job profile demands to be more proactive in sensing abuse and fraud on codes by providers or be on alert on latest billing trends ( Yes covid and telehealth are on our radar) .I am always hunting for new billing trends --our recent findings were on Shockwave therapy on Skeletal issues or Unlisted codes -with emerging services . If you have any more resources please share and once again thank you .
 

Pam Brooks

True Blue
Local Chapter Officer
NAB Member
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Location
South Berwick, ME
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your local MAC will have a list of TPE (Target, Probe, Educate) letters that they are sending out related to services that they've identified as possibly being reported inappropriately. I use that list as well as the other resources above to create my annual audit work plan.
 

Pam Brooks

True Blue
Local Chapter Officer
NAB Member
Messages
2,237
Location
South Berwick, ME
Best answers
1
A laboratory gets specimens with no DX provided, and the billing manager is requesting we use Z51.81. How is this possible? Doesn't the DX have to be provided by the DR sending the specimen to the lab? I have been in coding for 10+ years and have never just picked a DX to apply to a claim. Can someone advise, on this, just to make me sure I am not crazy, and this is fraud
without a diagnosis on the order, the order is invalid, and you should not provide the service. It's a risk for sure.
 
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