Advanced E/M Compliance: Risk Areas for Physician Practices March - PowerPoint PPT Presentation

NJ HFMA CARE and Physician Practice Issues Forum Advanced E/M Compliance: Risk Areas for Physician Practices March 10, 2015 Gretchen Segado, Manager EY Fraud Investigations and Dispute Services +1 (215) 841-0377 Gretchen.Segado@ey.com

Agenda da Climate ► E&M risk areas ► New vs established patients ► Place of service ► Working with Non-physician Practitioners ► Time based billing ► EHR issues ► Improving E&M compliance ► Monitoring E&M trends ► Minimizing your risk ► Page 2 Advanced E&M Compliance G.Segado

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Department of Health and Human Services Office of the Inspector General Improper Payments for E&M Services Cost Medicare billions in 2010 ► Medicare inappropriately paid $6.7 billion for claims for E&M services in 2010 that were incorrectly coded and/or lacked documentation representing 21% of Medicare Part B payments for E&M services. ► 42% of claims for E/M services in 2010 were incorrectly coded, which included both upcoding and downcoding (i.e., billing at levels higher and lower than warranted, respectively), and 19 percent were lacking documentation. Page 4 Advanced E&M Compliance G.Segado

Department of Health and Human Services Office of the Inspector General Improper Payments for E&M Services Cost Medicare billions in 2010 ► Additionally, we found that claims from high-coding physicians were more likely to be incorrectly coded or insufficiently documented than claims from other physicians. ► E&M services are 50% more likely to be paid in error than other Part B services Page 5 Advanced E&M Compliance G.Segado

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E&M Risk Areas: New vs Established New Patient ► Has not received any professional services from the physician or another physician of the same specialty, same group practice, within the past three years. Established Patient ► Has received professional services from the physician or another physician of the same specialty, same group practice, within the past three years. Page 7 Advanced E&M Compliance G.Segado

Evaluation and Management Coding Categories & Sub Categories ► Consultations** ► Office or other ► Office of Other Outpatient Outpatient Services Consultation ► New and Established ► Inpatient Consultation Patients ► Emergency Department ► Hospital Observation Services Services ► Critical Care Services ► Initial Hospital Care ► Home Visits ► Subsequent Hospital Care ► New or Established ► Hospital Inpatient Services ► Preventive Visits ► Initial Hospital Care ► New or Established ► Subsequent Hospital Care **Medicare does not recognize consultation codes Page 8 Advanced E&M Compliance G.Segado

E&M Risk Areas: New vs Established ► a NEW patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years. ► if a professional component of a previous procedure is billed in a 3 year time period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. ► An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to- face service with the patient does not affect the designation of a new patient. Page 9 Advanced E&M Compliance G.Segado

E&M Risk Areas: New vs Established Decision Tree If yes, established patient Exact Same Subspecialty? Yes If no, new patient Exact same Has the patient Yes specialty? received any professional service from the No physician or another physician New Patient in the group of the same specialty within the last three years? No New patient. Page 10 Advanced E&M Compliance G.Segado

E&M Risk Areas: New vs Established ► Does your EHR have the ability to alert when a patient is billed as a new patient when they have been seen during the past three years? ► Can your billing system edit a claim when a new patient visit is billed on an established patient or vice versa ► Do you rely on patient “visit types” in a scheduling system to pick your E&M codes? Page 11 Advanced E&M Compliance G.Segado

E&M Risk Areas: Place of Service ► Place of Service coding errors have been identified on the OIG Workplan frequently ► Jan 2005 audit by OIG found 88 of 100 claims billed with POS Office that were performed in a facility setting ► POS Office has higher practice expense RVUs because of the overhead costs ► Mismatching of POS to code category can lead to denials ► Emergency room visits are outpatient hospital POS not inpatient ► POS also is a key factor in correct billing of physician extenders ► “Incident-to” services can only be billed in POS 11 (Office) ► Shared services never in POS 11 Page 12 Advanced E&M Compliance G.Segado

E&M Risk Areas: Place of Service ► Dr. Cardio has an office in the hospital complex. He pays FMV value to lease the space, and the space is considered physician office space and is carved out of the hospital cost report. ► Mr. Jones sees Dr. Cardio every three months for CHF. ► While Mr. Jones is in the hospital recovering from a hip replacement, its time for his regular visit with Dr. Cardio. ► Mr. Jones is wheeled down to see Dr. Cardio. ► How is this service billed?? Page 13 Advanced E&M Compliance G.Segado

E&M Risk Areas: Place of Service ► Is your EHR set up to capture the correct place of service or to detect mismatches? ► Do you have non-physician practitioners in your practice? If so, do they understand how to bill for their services based on the location in which they are practicing? Page 14 Advanced E&M Compliance G.Segado

E&M Risk Areas: Time Based Billing ► Time must be documented for ALL CPT codes where time is a required element, i.e. time is specified in the CPT description ► Hospital discharge day management, 30 minutes or less ► Critical care evaluation and management; first 30-74 minutes ► Medical team conference, 30 minutes or more Page 15 Advanced E&M Compliance G.Segado

E&M Risk Areas: Time Based Billing ► For some E&M codes, services can be coded based on elements documented or based on time. ► Providers can bill based on the face-to-face time spent in counseling and coordinating care for a patient ► Physician must document amount of time spent ► Time spent in counseling and coordinating care must be more than 50% of the total visit ► Document the content of the discussion or the coordination(i.e. counseled patient on risks and benefits, dietary precautions, discussed surgical options, spoke with referring physician’s office, arranged for home health care) Page 16 Advanced E&M Compliance G.Segado

E&M Risk Areas: Time Based Billing ► Documentation requirements: Total face-to-face time of the encounter 1. Total counseling/coordination time 2. Content of the counseling/coordination 3. ► Start and stop times are not required ► Time spent performing procedures is not counted as part of the total face-to-face time Page 17 Advanced E&M Compliance G.Segado

E&M Risk Areas: Time Based Billing ► With some EHRs, time based documentation can become just another “default” ► Does the EHR have a section where providers can document time based services? ► How can the provider capture the content of the counseling and coordination of care? ► If the EHR uses smart phrases or templates, have they been reviewed by compliance? Page 18 Advanced E&M Compliance G.Segado

E&M Risk Areas: EHR Issues ► The medical record for each date of service should reflect in indiv dividu idualiz ized documentation relevant to the medical necessity of the service or procedure rendered and/or patient care provided on that date of service Page 19 Advanced E&M Compliance G.Segado

US Department nt of Health and nd Human n Servi vices Of Office of the Ins nspe pector G Gene neral Workp kplan for for F FY2 Y2014 Eval aluatio ion and nd mana nagem emen ent serv services—In Inappr ppropr opriate te paymen ents Billing and Payments. We will determine the extent to which selected payments for evaluation and management (E/M) services were inappropriate. We wi will also review multiple E/M servic vices associa iated wit with the same providers and th nd benefic icia iarie ies to to determine th the extent nt to to whi hich ch electronic or or pa pape per me medical cal records had document had ntation vu vulnerabil ilit ities. Context—Medicare contractors have noted an increased frequency of medical records with identical documentation across services. Medicare requires providers to select the billing code for the service on the basis of the content of the service and to have documentation to support the level of service reported. (CMS’s Medicare HHS OIG Work Plan | FY 2014 Medicare Part A and Part B Page 18 Claims Processing Manual , Pub. No. 100-04, ch. 12, § 30.6.1.) (OEI; 04-10-00181; 04-10-00182; expected issue date: FY 2014; work in progress) Page 20 Advanced E&M Compliance G.Segado