Tag Archives: audit
Posted on 16. Sep, 2010 by jennifer.godreau.
Don’t let nurses do the doctor’s work, or risk downcoded E/Ms upon audit.
The only parts of the E/M visit that an RN can document independently are the Review of Systems (ROS), Past, Family, and Social History (PFSH) and Vital Signs, according to a June 4, 2010 Frequently Asked Questions (FAQ) answer from Palmetto GBA, Part B carrier for Ohio. The physician or mid-level provider must review those three areas and write a statement that the documentation is correct or add to it.
Only the physician or non-physician practitioner who conducts the E/M service can perform the History of Present Illness (HPI), Palmetto says.
Exception: In some cases, an office or Emergency Department triage nurse can document “pertinent information” regarding the Chief Complaint or HPI, Palmetto says. But you should treat those notes as
Posted on 24. May, 2010 by Editor.
You’ve got so many compliance acronyms flying at you every day that you may not be able to differentiate your RAC from the OIG. Know these quick facts about RACs to stay better informed.
- Recovery audit contractors (RACs) detect and correct past improper payments so CMS and the MACs can prevent such problems in the future
- RACs are hired as contractors by the government, and they can can collect “contingency fees,” which means that they get a percentage of the amount that they recover from providers who were paid inappropriately The maximum RAC lookback period is three years, and they cannot review claims paid prior to Oct. 1, 2007
Posted on 12. May, 2010 by atif.adnan.
Most Part B practices have grown accustomed to tucking consult regulations into the backs of their minds, since Medicare no longer pays for these services. However, if an auditor comes calling and wants to review your consult notes, he will be judging you based on the Medicare rules as of the date of service.
Some practices assume that any audits taking place in 2010 or thereafter that involve consult notes will be based on CPT consult rules, and not Medicare’s, since Medicare does not recognize consult payment as of 2010. Because Medicare’s consult regulations were generally more strict than CPT’s, practices consider this a small victory. But this is inaccurate, experts say.
Posted on 26. Apr, 2010 by Editor.
If your physician bills a lot of high-level office visits, he may be at risk of an audit — which may not be cause for concern — if his documentation justifies his code choices.
“Some physicians believe their patients are sicker than others’, so they feel they’re justified using more 99215s, when in fact that may not be the case,” says Crystal S. Reeves,CPC, CPC-H, consultant with Coker Group in Alpharetta, Ga. “The CPT manual outlines the requirements of the E/M codes, there are clinical examples in the back of CPT, and CMS publishes a Table of Risk that can help guide you, so use all of those resources to determine whether you’re billing properly,” she advises.
Training is Key: If you advise your physician that he is overbilling the high-level codes and he says, “But all of our patients are really sick,” show the doctor CMS’s Table of Risk, “which can be an eye opener for physicians,” Reeves says.
Posted on 07. Jan, 2010 by atif.adnan.
MACs are looking for ‘red flags’ to halt additional global period pay
Billing for additional services during a global surgery period is always tricky, but now you can expect special scrutiny for modifier 79 claims.
After the OIG got wind of fraudulent surgery billing with modifier 79 (Unrelated procedure or service by the same physician during the postoperative period), CMS contractors have been on the hunt for modifier 79 abuse. Implement our expert tips below to keep your 79 claims clean.
Obey Global Package Model
The starting point for clean modifier 79 claims is not breaching the global surgical billing concept. Once you understand the global package rules, you’ll know when you have an exception that warrants an additional claim with an appropriate modifier.
Posted on 25. Oct, 2009 by .
The OIG is watching your ultrasound orders and code combinations — and it doesn’t like what it sees. Take note of these problem spots to keep your claims in the clear.
An OIG audit of ultrasound services billed in 2007 found that nearly one in five ultrasound claims “had characteristics that raise concerns about whether the claims are appropriate,” according to a July 2009 audit report titled “Medicare Part B Billing for Ultrasound.”
The most common error: Roughly 17 percent of 2007 Part B ultrasound claims lacked prior service claims by the ordering physician, the OIG indicated.
What this means: Several physicians ordered ultrasounds for patients that they hadn’t treated within the last year. “The OIG would wonder why the doctor would order an ultrasound for a patient who [the ordering physician] hasn’t examined,” notes Allison Larro, Esq., an Atlanta-based attorney.
Posted on 20. Oct, 2009 by .
Turns out the old saying is true: If you haven’t done anything wrong, an OIG audit is nothing to worry about.
A New York cardiologist who collected over $1.3 million over a three-year period for 5,061 claims caught the OIG’s eye due to a “high volume of Medicare claims in comparison to other cardiologists throughout New York state,” according to the OIG’s report on the topic, which was released on Oct. 14.
The OIG reviewed the cardiologist’s records for the three-year period, but found that the physician, who specialized in non-invasive procedures, complied with Medicare reimbursement requirements. Therefore, the OIG made no recommendations and did not request any fund recovery from the physician.
What your practice can learn: If you have a physician who specializes in a particular condition or procedure and treats lots of Medicare patients, the feds’ data mining techniques may very well flag your practice for an audit. But if your coding and documentation are correct, you can breathe easier as your physician does what she does best.
Posted on 20. Oct, 2009 by .
Heads up: These vaccine admin codes are excluded from incident-to requirements.
Incident-to rules don’t always apply to diagnostic services, but many medical practices aren’t aware of that.
And based on a new wave of scrutiny directed toward incident-to claims, you should know physician supervision rules inside and out.
A recent audit from the HHS Office of the Inspector General audit found that unqualified nonphysician practitioners performed 21 percent of incident-to services examined, and that’s sure to have Medicare scrutinizing your incident-to claims even more thoroughly than in the past.
The presumption: Many practices believe that as long as they meet the minimum requirements of incident-to (the physician is on-site and sees patients for any new problems), they can report all types of NPP services incident-to and collect their extra 15 percent of Medicare reimbursement.
Posted on 13. Oct, 2009 by .
If your practice does lab panels, sleep studies, hospice visits and more, take heed.
The HHS Office of Inspector General has published its 2010 Work Plan, which should give us all a heads up on what the watchdog agency will be auditing and evaluating this year.
Why you should care: The 115-page document is like a map for what regulators will be looking at this year, and what potential problems they’ll be passing to MAC, RAC and private payer auditors. Don’t worry. Physician issues are clustered around page 15. However, if you code for other things in your health system besides physician services, you should have a look at the table of contents.
Here’s a summary of what the OIG wants to know about physician reimbursement:
Posted on 26. Aug, 2009 by .
Thanks to a 2006 OIG audit, MACs are on the lookout for incorrectly-billed facet joint injections, so it’s time to scrutinize your claims. Medicare guidelines are very strict about when you can append modifier 50 (Bilateral procedure) to a facet joint injection code — so you should know when to report this modifier versus when you must bill add-on codes instead.
CMS revised MLN Matters article MM6518 (effective date August 31). In the article, CMS clarifies that you should append modifier 50 to your facet joint injection code (64470, 64475) if the doctor injects the patient “on both the right and left sides of one level of the spine.”
If, however, the doctor performs facet joint injections on multiple levels on the same side of the spine, you should use the appropriate add-on codes (+64472, +64476) instead of modifier 50.
A 2006 OIG audit found that doctors incorrectly reported facet joint add-on codes to bill bilateral injections, when they should have appended modifier 50, the MLN Matters article notes.