Practice Management Feature - June 2010
Tex Med. 2010;106(6):41-45.
By Crystal Conde
Texas Diabetes & Endocrinology received an unwelcome wake-up call earlier this year from Humana. The health care payment plan threatened to exclude endocrinologist Valerie Espinosa, MD, from its network after it reviewed her Level 4 coding and documentation.
The Austin practice called on its long-standing relationship with TMA Practice Consulting and challenged Humana's determination. The practice performed an internal audit while TMA Practice Consulting did an independent audit of the 10 charts in question.
Humana's auditors judged nine out of 10 charts as containing incorrect coding. The assessment by TMA Practice Consulting and the practice's auditor, however, could find only one chart in error.
TMA's practice consultant helped Texas Diabetes & Endocrinology write an appeal letter, and in the end, Humana agreed that the physician had incorrectly coded only one chart, not nine.
Tiffany Reichle, Texas Diabetes & Endocrinology practice manager, says excluding Dr. Espinosa from Humana's network would have been detrimental to the practice.
"It paid off to have the expertise of TMA Practice Consulting when going through the appeal process," she said.
Patients would have suffered, as well.
"There aren't that many endocrinologists in Austin," Dr. Espinosa said.
After Dr. Espinosa's experience with Humana, all six physicians and 10 midlevel practitioners in the practice received a refresher training course in coding from TMA Practice Consulting.
"I'm actually glad that I went through an audit," Dr. Espinosa said. "We're all much more careful about our coding and documentation now. We each have coding cards on our desks for reference to make sure we've fulfilled all requirements to justify a certain level of coding."
The pervasive menace of a potential audit by an insurer or Medicare's Recovery Audit Contractor (RAC) program has physicians more concerned than ever about their coding and documentation. Physicians and experts agree that one of a practice's best lines of defense lies in regular coding and documentation audits, whether performed internally or by an outside consulting group.
TMA Practice Consulting set up Texas Diabetes & Endocrinology in 2001 and performs coding and documentation training and reviews twice a year. Dr. Espinosa credits the regular reviews and training sessions by TMA Practice Consulting with giving her more confidence in her coding and documentation. (See "TMA Takes the Sting Out of Audits.")
"I feel assured I'm doing things the right way. I'm no longer living in fear that I'll get audited," she said.
Self Audits Worth It
For medical practices that lack the financial resources to contract with outside firms, a self audit is a valuable method for ensuring coding and documentation are in line.
Jonnie Massey, director of payers and audits for the American Academy of Professional Coders, says a practice needs first to examine billing and coding trends for errors when it decides to audit itself. Staff members should look for red flags, such as potential upcoding, frequent rebilling of claims, high levels of denied claims, and patient complaints about bills.
"It really helps a practice to conduct an aggressive self audit," she said. "A practice that's conducting self audits and feels confident about its billing and coding compliance is less likely to be an outlier."
But a self audit does no good if problems aren't corrected.
"It's important for a practice to monitor the results of a self audit and follow up to complete the circle," Ms. Massey said. "Once the problems have been identified, the physicians need to be made aware of them, and the entire staff needs to be educated in how to solve the problems and how to continue to improve."
One of the benefits of a self audit, she says, is that it's less expensive than contracting with a consulting firm, if a certified professional coder or auditor on staff is available to conduct it. (See "Meet Your TMA Certified Coders.")
And in the event of an audit by the RAC program or an insurance company, there is a record of self audits, as well as a compliance plan, to help a practice show it's trying to code and document correctly.
The U.S. Department of Health and Human Services Office of Inspector General (OIG) developed voluntary compliance program guidance for individual and small group physician practices. Compliance plans help physicians prevent the submission of erroneous claims to federal health care programs and private insurance plans.
The OIG's guidance emphasizes a seven-step approach a practice can follow in developing and implementing a voluntary compliance program:
- Conduct internal monitoring and auditing;
- Implement compliance and practice standards;
- Designate a compliance officer or contact;
- Conduct appropriate training and education;
- Respond appropriately to detected offenses and develop corrective action;
- Develop open lines of communication; and
- Enforce disciplinary standards through well-publicized guidelines.
For more information, you may refer to the Federal Register , Vol. 65, No. 194 [PDF].
To aid in the self audit process, Ms. Massey also recommends internal audit tools, such as the Centers for Medicare & Medicaid Services Evaluation and Management (E&M) Coding and Documentation Reference Guide [PDF].
She says the Marshfield audit sheet [PDF] from Medical Reimbursement Systems Inc. also is a helpful tool.
A "Necessary Expense"
David Lee, MD, owner of Uptown Physicians Group, says TMA Practice Consulting's work on appropriate coding was "eye opening" for the practice's two internists, one general practitioner, two infectious disease physicians, and staff.
Dr. Lee hired TMA Practice Consulting to conduct E&M coding and documentation training in January.
"I've been to other coding courses, and they always focus on patient history and physical exam. TMA Practice Consulting gave an in-depth explanation of medical decision making and elaborated on the complexity of coding for a Level 3 visit versus a Level 4 visit. None of us fully understood that before the training," he said.
Dr. Lee says his group, like many, wants to make sure its coding and documentation are in line due to increased recoupment efforts by Medicare under the RAC program. Any entity or individual that bills Medicare is fair game for a RAC audit. The RACs examine Medicare Part A and Part B claims to identify both underpayments and overpayments. (See "TMA's RAC Resources.")
RACs work on a contingency-fee basis and receive a percentage of the overpayments they recover. Therefore, they're more likely to subject physicians to recoupment of overpayments. They have a financial incentive to examine high-cost services and abnormal billing patterns to find instances in which physicians have been overpaid. (Read "Getting Ready for RACs," pages 49-52 in the August 2009 issue of Texas Medicine.)
Stephen Raley, MD, a family physician with Hillcrest Family Health Center in Waco, says an external coding audit is a "necessary expense" that gives a practice peace of mind.
"Since consulting with TMA, our group is better educated on the importance of proper documentation in a timely manner. We have implemented a chart completion policy, and we hope our coding accuracy has improved, resulting in increased revenue and improved compliance."
Dr. Raley says Hillcrest Family Health Center, a network of family medicine clinics that includes 35 family physicians and pediatricians, as well as two midlevel practitioners, has worked with TMA Practice Consulting for about the past five years. In that time, he estimates TMA Practice Consulting did three E&M coding and documentation reviews, the most current having taken place last year.
Dr. Raley adds that Hillcrest Family Health Center does monthly internal chart reviews. Dr. Lee says consulting with professionals who have been through insurer or government payer audits is worth the investment.
"You can save so much time by working with an outside firm," he said. "We treat our patients well, but we need to make sure the documentation reflects that to justify our payments."
Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail at Crystal Conde.
TMA's RAC Resources
TMA and the Texas Medical Liability Trust (TMLT) sponsored "RAC Reviews: Self-Audit Is Your Best Defense" seminars in eight Texas cities this spring. The course helps physicians and their employees ensure that they're not the target of the Recovery Audit Contractor (RAC) program.
The course, available on the TMA website this month, explains the RAC program, highlights common billing and coding errors, and shows a practice how to conduct a self audit as part of an overall billing and coding compliance plan. Course participants can earn AMA PRA Category 1 Credits ™ and a possible TMLT discount, if they pair the course with two additional approved risk management Webinars .
Presented by Jonnie Massey, director of payers and audits for the American Academy of Professional Coders, the course explains how medical decision making drives code choice, helps staff members develop a billing and coding compliance plan, and reviews evaluation and management (E&M) guidelines to ensure compliance, eliminate undercoding, and streamline documentation.
In addition, TMA developed a training session on the RAC program for physicians, available as a prerecorded discussion and as a PowerPoint presentation on its website. With input from the Centers for Medicare & Medicaid Services and Connolly Healthcare, the session covers the RAC review and collection processes, appeal time frames, documentation request limits, preparation tips for physicians, and other helpful topics.
TMA also makes available to members on its website an updated report from TrailBlazer Health Enterprises, the Texas Medicare carrier, that details the frequency of E&M coding by specialty.
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Meet Your TMA Certified Coders
Heather Bettridge , BA, CPC, CPMA, is a practice management consultant with more than 10 years of experience developing and refining private practices. She's certified as a professional coder and a professional medical auditor by the American Academy of Professional Coders.
Misha Diden , BA, CPC, CMPE, is a practice management consultant with more than 15 years of experience in the health care field, including medical practices, federally qualified health centers, and the health plan sector. She's a certified professional coder through the American Academy of Professional Coders.
Erin Gregorcyk , CPC, is a TMA staff reimbursement specialist in the Payment Advocacy Department. She educates physician practices on proper billing and coding techniques, as well as advocates on their behalf with insurance companies to resolve reimbursement hassles.
Liz Jero , CPC, is a TMA staff reimbursement specialist in the Payment Advocacy Department. She's a member of the American Academy of Professional Coders and the Professional Association of Health Care Office Management.
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TMA Takes the Sting Out of Audits
The Texas Medical Association encourages physicians and their staff to be proactive in preventing an audit and can help medical practices avoid nightmares if they occur.
TMA Practice Consulting offers evaluation and management (E&M) coding and documentation reviews that include a claims coding and medical record documentation analysis of 10 records per physician. An abbreviated checkup and a full review are available.
TMA Practice Consulting also can conduct a coding and documentation quarterly review to determine whether a medical practice is following payers' guidelines for appropriate billing year-round.
TMA Practice Consulting reviews a practice's documentation for:
- Accurate CPT coding, appropriate application of CPT coding guidelines, E&M coding guidelines, and correct use of modifiers;
- Accurate ICD-9-CM coding, appropriate application of ICD-9-CM coding guidelines, and documentation of medical necessity; and
- Encounter forms, claims, and corresponding explanations of benefits to ensure accurate billing and reimbursement levels.
And TMA offers an E&M coding and documentation training program for practices that need help understanding documentation guidelines or identifying inappropriate or inaccurate coding and weaknesses in medical record documentation. The two-hour session covers a review of 1995 and 1997 E&M documentation guidelines, time-based coding, modifiers, audit triggers, prolonged services, preventive medicine, and E&M utilization patterns, among other topics. Services are available for a fee based on a practice's needs.
To get an idea of your practice's coding pattern, call TMA Practice Consulting at (800) 523-8776 or e-mail TMA Practice Consulting .
TMA also published TMA Practice E-Tips Greatest Hits, Vol. 3: Coding [PDF]. Available free of charge, the publication has helpful information and resources for ensuring correct coding.
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