June 2009 Issue

Don’t be caught off guard if you receive a letter requesting documentation for a claim you submitted to Medicare.  CMS has doubled its efforts to recoup millions of dollars in overpaid claims… and have hired contractors who are paid based on the amount they collect to do so.   

There are two audit programs that you and your staff must be familiar with and prepared to respond to:

1. Comprehensive Error Rate Testing (CERT) – program to monitor the accuracy of Medicare Fee-For-Service (FFS) payments and to determine which services are experiencing high error rates.
   
2. Recovery Audit Contractors (RAC) – audit program to identify improper Medicare payments, specifically those that do not meet Medicare’s coding or medical necessity policies.

CERT 

Top 5 Incorrect Codes:

1. Office/outpatient visit, est (99214)
2. Office/outpatient visit, est (99215)
3. Office consultation (99244)
4. Office/outpatient visit, est (99213)
5. Office/outpatient visit, new (99204)

Errors that CERT are measuring:

• Incorrect Coding
• Insufficient Documentation
• No Documentation
• Medically Unnecessary Services
  

How to Protect Your Money from Being Taken Back

ASSH Members Receive Special Pricing on E&M Analyzer

• Use the E&M Analyzer to review your coding patterns against state and national averages.  If you are an outlier, dig deeper.  It’s OK to be a outlier, just make sure your documentation supports it.  Be wary of undercoding too.  Not only do you leave money on the table, undercoding is considered an error and is subject to the audits.  And just because you follow the pack, doesn’t mean you’re off the hook either.       

• Conduct an internal assessment to ensure that your chart documentation substantiates the claims submitted meet the Medicare rules.  Make sure your coding and documentation is rock solid.  Consider hiring a coding expert to conduct the assessment.

• Discontinue the practice pattern of day 91, 92, 93 post-op visit scheduling. 

• Provide refresher training to your billers, coders, and physicians.  When is the last time your staff attended a coding workshop?  Rules change constantly.  You all need to be current on coding rules. 

• Update written policies and procedures to ensure your practice’s compliance with Medicare’s requirements.  

• Be prepared to respond promptly to RAC or CERT requests for medical records.

• Know your rights – if you don’t agree with an auditors conclusion, you have the right to appeal and should appeal.  Keep in mind, that overall 34% of appeals during the demonstration period were successful.  You can file an appeal with an RAC determination up to 120 days.
  

The Fine Print of a RAC review:

• Auditors can review medical records from three years prior but not before October 1, 2007.
• For 2009 limits for the number of medical records the RACS may request per National Provider Identifier (NPI) are:
• 10 medical records per 45-day period for solo practitioners;
• 20 medical records per 45-day period for two- to five-provider offices;
• 30 medical records per 45-day period for groups of six to 15 providers; and
• 50 medical records per 45-day period for groups of 16 or more providers.

• You have 45 days to provide medical records to the RAC.
• Keep track of denied claims and correct previous errors. 
• Consult your health care lawyer if you find a problem.
• You are responsible for copying medical charts but can submit them on a CD instead.  (pdf copies)