Head Off Medicare Audit Risk with Strategic Self-Auditing Smarts

Posted on 22 Mar, 2019 |comments_icon 0|By Elizabeth
[addtoany]
audit-597x297

As the feds scrutinize Medicare claims more closely in 2019, now is the time to update your audit policies and improve your compliance training.

You’re probably aware that the Centers for Medicare and Medicaid Services (CMS) runs your Medicare claims through an automated system of algorithms to identify errors and improper billing practices. But did you know that it’s upping its auditing activities in 2019 — and the focus is on physician practices? Could you be flagged for a Medicare audit?

Discover your audit (and repayment) risk with our rundown of top issues and ensure your practice meets heightened claims scrutiny with flying colors.

Pay Attention to Your E/M Claims

If you’re not entirely clear on the nuances of evaluation and management (E/M) reporting, you’re not alone. This one coding area continues to stump even veteran coders, as demonstrated in the 2018 Comprehensive Error Rate Testing (CERT) report.

To avoid potential payback demands, scrutinize your E/M reporting and take special care with these three E/M codes that, together, accounted for a ghastly $1.21 billion in improper payments made by Medicare in 2018:

  1. 99223 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity…)
  2. 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity …)
  • 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient …).

Mop Up Errant Modifier Use

Habitual coding errors look a lot like fraud to auditors seeking patterns of misuse, particularly when it comes to modifier misuses. Could federal watchdog agencies construe your modifier practices as billing improprieties?

To avoid landing in hot water, your team must understand how and when to use modifiers. Modifier 59 (Distinct procedural service), for example, has long been under audit scrutiny, which is why you should review coding guidelines and payer rules before using this modifier or any other. Documentation in the medical record must satisfy all criteria to use modifiers.

In 2019, auditors will continue to home in on modifier utilization, with special focus on the following modifiers:

  • Modifier 59 (Distinct procedural service)
  • Modifier 25(Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service)
  • Modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period)
  • Modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period)

You can expect this list to expand and can also expect a lot more modifier audits.

Check Your Procedure Code Utilization by RVU

Recovery audit contractors (RACs) and private payers examine the magnitude of relative value units (RVUs). RVUs can easily be converted to cost, as in the Comparative Billing Reports administered by CMS. If reviewers discover that your costs for providing services are higher than your peers’, they may investigate further. But you can head off trouble by staying on top of these reports. Monitor your procedure code utilization by RVU and ensure that your cost of services align with your peers on both the state and national level.

Know How Frequent is Too Frequent

Many auditors such as zone program integrity contractors (ZPICs) like to focus on frequency of improperly paid claims because they can generate penalties of up to $11,000 per claim under the False Claims Act. To know whether your practice might throw up any red flags, you should check your claims frequency against national frequency norms.

Look at your 25 most frequent services and compare them to Medicare utilization data. If, for example, the national reporting frequency average for a code is 5.5 percent of all services, and you use it twice as often, prioritize a self-audit to review the service and verify that solid coding and documentation support your claims.

To give you an idea of what to look for, consider the national frequency norms of the most frequently performed services for these five specialties:

  • General surgery: Under this specialty, 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity …) is the most used code and represents 8 percent of general surgeons’ claims.
  • Gastroenterology: For gastroenterologists, 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple) is the most utilized code at 7 percent.
  • Emergency medicine: According to the Medicare utilization data, 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity…) comprises 16 percent of these specialty claims.
  • Oncology: 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity…) is the top individual code used by oncologists 7 percent of the time.
  • Family practice: CPT® codes 99213 and 99214 are tied for most used codes and put into play by family practitioners 7 percent each.

How Often Should You Audit?

A good rule of thumb to help you determine how often you should perform an audit of your claims is simply — more errors means more audits. In other words, create a timeline base on your previous audit results.

If your reviewed charts were coded correctly at least 90 percent of the time, then conduct an annual audit. Up your routine to quarterly audits if your success rate was between 75 and 90 percent. If your accuracy rate fell between 60 and 75 percent, then audit monthly. Finally, if your accuracy was below 60 percent, audit every claim before submitting it. While the workload might seem daunting, hefty payback demands will feel significantly worse.

Contributing Editor: Kristin Webb-Hollering

Learn More

Stay on top of the MPFS CY 2019 final rule and get fast and effective answers to your Medicare questions with a subscription to Medicare Compliance & Reimbursement. Every issue of this monthly newsletter delivers coding and billing guidance, as well as high-impact tips to conquer the revenue-risking challenges that threaten your claims and compliance success.

Author

Elizabeth


Elizabeth works on an array of projects at TCI, researching and writing about modern reimbursement challenges. Since joining TCI in 2017, she has also covered the nuts and bolts of cybersecurity, compliance with federal laws, and how to tap into the advantages of telehealth services.

More from this author

View More

Leave a Reply

Newsletter Signup

Top