Category Archives: Compliance & RACs

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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

Accepting the Status Quo: Cost of Non-Compliance vs. ICD-10

Like many in the healthcare industry, I’ve spent the last few weeks reading about the ICD-10 delay. Depending on which camp you are in, the opinions are lining up predictably. I’ve read a lot of comments about the ”cost of ICD-10.” Though many agree the adoption of a more sophisticated code set brings important benefits, the conversation always circles around to the expense of implementation.

If high costs are really the issue with ICD-10, why do we continue to ignore known cost-saving measures that would easily offset the expense of implementation for the average physician practice? For instance, I find the willingness to accept the enormous cost of years of non-compliance with medical necessity perplexing. Or consider the continued practice of submitting poorly coded claims based on subpar clinical documentation. What about the cost of claim denials, write-offs, and fraud in ICD-9 – or any other coding language for that matter? In my opinion, complaints about the cost of doing business have less to do with the expense of implementing ICD-10 and more to do with human nature. Continue reading

Listen so we don’t have to Drop, Cover, and Hold On

Each region of the country has emergency preparedness according to the area’s potential natural disasters. Living in Utah, we have to be prepared for a possible earthquake and there was the recent Drop, Cover and Hold On efforts to test our readiness. In the workplace, we also have to prepare for situations that may arise suddenly and unexpectedly. It’s the way we prepare in advance that will determine if we have to drop, cover, and hold on or are able to systematically handle the situation.

The tool at the heart of good management is to listen to those around you. Sometimes that means hearing what a customer is saying, picking up on the complaint of an employee, or learning about something new in the organization. We have to listen beyond what is being said, focusing on the nonverbal communication as well as how this issue could impact others. Years ago my manager told me to stop and listen to the people who you dread the most. You know the type, the person who is always complaining, who seems to drain you of all your energy. Continue reading

Employees as the Teachers: What an Organization Can Learn

As a compliance officer I have the opportunity to publish training on various compliance topics to our workforce. We just completed a required training and I think I learned as much about how the organization works as the workforce may have learned from the training.

From an employee’s perspective, completing a required compliance training course may be the last thing they want to do, yet from the organization’s standpoint, it’s one of the most important things for them to do. Protecting the privacy and security of patient data is of utmost concern for any compliance officer in health care. The Ponemon Institute just published its Fourth Annual Benchmark Study on Patient Privacy and Data Security which emphasized the role employees have in detecting data breaches, while at the same time noted that employee negligence is considered a worry by many of the respondents to their survey. Organizations in the Ponemon study reported that they rely upon policies and procedures to achieve compliance and secure data. What this tells us is that training employees on proper security methods, policies and our code of conduct, as well as guidelines for how to report an issue is paramount. Continue reading