Category Archives: Compliance & RACs

Regulatory Audit Contractors; ABN; Advanced Beneficiary Notice; Centers for Medicaid & Medicare Services; CMS news; CMS rules; CMS regulations; Medical Necessity; Recovery Audit Contractors; Compliance; RAC audit

Whodunnit? Let’s be honest!

At the start of the New Year, I can’t help but reflect on how much patient care has changed in my 25+ years. Many things that were common practice back then were either not necessary or even sometimes harmful. An example would be Foley catheter placements. Foleys for “everyone” whether they needed them or not!

However, the advent of superbugs with increasing antibiotic resistance has also meant an increase in catheter-related UTIs. Organizations became focused on prevention, using different catheter materials thought to prevent colonization, and by evaluating the need for insertion and/or continued placement. It certainly didn’t hurt that catheter-associated UTIs (CAUTIs) were determined to be hospital-acquired preventable conditions that CMS would not reimburse, and were also factored into quality outcomes metrics by quality assessment programs or organizations. Continue reading

Resolution 2015: Time to Audit

Like many, the end of the year is a time of reflection and planning for me. Where did I succeed in 2014 and where do I need to focus in 2015?

One of my plans for 2015 is cleaning the basement. I know, I hate doing it too – that’s why I had to make it a resolution – give it more emotional power.

My daughter graduated from college in 2006 and wanted to “leave some of my stuff here temporarily.” It’s now 2015 and that stuff is still in my basement. Does she need it? Likely not, since it hasn’t seen the light of day in nine years. But before it’s moved, we’re going to go through it and throw out what’s no longer needed. I’ve learned that it makes more sense both from a time and cost perspective, to clean up before a move than to pack, move, unpack and then throw out the same stuff. Continue reading

CMS is Serious about Overuse of Modifiers: More on 59

On September 10, 2014, OIG announced it settled with a physician group practice in Illinois for overuse of modifiers.  The practice exceeded the number of units allowed for certain services as regulated by CMS. According to the OIG, the physician practice used a code to bypass computer edits that otherwise would have rejected their claims. The group entered into a $590,763.45 settlement to resolve allegations of submitting false or fraudulent claims to Medicare. In addition, OIG contends the group upcoded services and submitted claims for high complexity tests when it performed less expensive, low or moderate complexity tests.

My take:

In September, I posted a blog regarding the modifications CMS plans to make to modifier 59 by creating four new, more specific modifiers that can be used to bypass an NCCI edit. CMS is requiring providers to be more specific with regard to what they believe a separate service really is. What is not new is that using the new modifiers will require documentation that adequately supports their use. A few thoughts on the new modifiers: Continue reading

E&M Coding: The Final Level of Care

In keeping with the theme of previous blog posts–the professional realm of E&M coding–I’d like to discuss medical necessity as it relates to the final level of care. CMS has stated that medical necessity is the over-arching criterion for payment of E&M services, which, in pure CMS fashion, gives us a goal, but not guidelines as to how to get there. We have no medical necessity policies for the differing E&M codes.

I think we all understand the intent of that statement, which I interpret as “don’t game the system”. But how do I, as a coder, teach a provider how to do that? And, how does the provider document a record to reflect the medical necessity clearly? So, let’s put a pin in that and talk about the calculation of the E&M codes, then circle back. Continue reading

Warning: Abuse of Modifier 59 – CMS Makes Changes

In 1996, CMS implemented the National Correct Coding Initiative or NCCI, sometimes referred to as CCI. The claim system edits were developed to “promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims.” CMS realized that even if they created edits that bundled or disallowed procedures performed on the same date of service, there would be rare instances that would support using a modifier to override an edit. Thus, certain CPT modifiers were given that designation – modifier 59 among them.

On August 15, 2014, CMS released Transmittal 1422, CR8863 “Specific Modifiers for Distinct Procedural Services” effective January 1, 2015. The Transmittal explains that modifier 59, which is the most highly utilized of the CPT modifiers that CMS allows to override for NCCI edits, has been overused. It is associated with considerable abuse of high-level, costly manual audits, reviews, appeals and even cases of fraud and abuse. Continue reading

E&M Guidelines: HPI and Chronic Conditions

Last month, I blogged about the History of Present Illness (HPI) portion of an E&M note. The HPI section details the specifics of why the patient is seeing their physician. Prior to that, I wrote about the two sets of E&M guidelines, specifically the different exams within those guidelines to guide physicians and/or coders to select a level of care provided during that visit. This month, I’d like to dig into the point at which these two sets of guidelines converge: chronic conditions.

The 1995 E&M documentation guidelines stipulate that to support the higher levels of care, a provider must document four or more elements of the HPI. The 1997 E&M documentation guidelines added a chronic conditions option. These guidelines state that a provider could document the status of three or more chronic conditions rather than four or more elements of the HPI. Continue reading

Medical Necessity Documentation – the Critical Component for CAC

Whether or not you can quote chapter and verse of the Medicare statute that first detailed medical necessity, most of us in healthcare are familiar with its premise1. But from this basic tenant we begin to diverge widely in our understanding of the concept. This is especially true for Medicare inpatient services since CMS does not have specific standards the industry can follow. This issue dates back to the late 1980s when then HCFA admitted, “Current regulations are general and we have not defined the terms ‘reasonable’ and ‘necessary’ nor have we described in regulations a process for how these terms must be applied…”2 Continue reading

A Gift from the OIG That Could Be Worth Millions

Not convinced of the importance of administrative and financial data integrity in health care? Consider – both OIG and OCR (Office of Civil Rights) are monitoring healthcare provider’s (facility and professional) compliance patterns. Whether it is a HIPAA violation or claim error, they are able to determine if the problem is due to a simple mistake or emblematic of larger systems issues. Repeated non compliance patterns are revealed in monitored data.

On June 5, 2014 the OIG released results of an audit performed on a large medical center for calendar years 2010 and 2011. Unfortunately, the medical center was found to be in non compliance with about 50 percent of the claims reviewed. The OIG’s data monitoring efforts identify areas of concern – even when an organization believes it is compliant. Just like banking and other regulated industries, data integrity is crucial to both providers and monitors. Every aspect of compliance – especially those that are most complicated – becomes critical. Continue reading

Why Are We Complaining about ICD 10? The Cost of Non-Compliance (Again)

In my May blog, I talked about the cost of non-compliance versus the cost of implementing ICD-10. My hypothesis: human nature is the real cost driver in health care – not code set changes. A recently released study by OIG revealed that physicians increased the billing of all E/M (Evaluation and Management) services from 2001 to 2010 (the years studied). The higher the level of E/M codes assigned, the greater the reimbursement. CMS found that E/M services are 50 percent more likely to be paid in error than other Part B services. Why? Because they are coded to a higher level which results in more money paid to the provider – physician and non physician alike. CMS identified the root cause of the overpayments – no surprise here, coding error and poor documentation. Continue reading

A Culture of Openness Pays Off

When I read the results of a recent survey on helpline calls completed by the two prominent compliance associations, the Society of Corporate Compliance and Ethics (SCCE) and the Health Care Compliance Association (HCCA), I started to think about the organizations I’ve worked for in the past. What made me comfortable telling the organization of a perceived situation requiring change? How was the report received?

As noted in the survey results, employees are mainly reporting through internal means. While a company may not know for years of a whistleblower lawsuit, the survey respondents did not indicate a significant rise in these reports made outside of the organization even with the increased attention being paid to whistleblowers and the incentives involved.

What can we do to create an environment where employees are willing to report to their organization? Continue reading