By Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC
President, Edelberg Compliance Associates, Baton Rouge, LA.
Ms. Edelberg discloses that she is founder, chairman, majority stockholder, and consultant for Edelberg and Associates.
The increase in payer audits has turned into a major resource drain for many hospitals and emergency medicine practices. Without established processes for managing these audits, providers stand to lose revenues through lost/repaid payments and increased resource costs associated with managing the complexities involved with defending coding.
To review what is happening across the country, private and governmental payers are using medical necessity issues to deny claims, determining payment levels based on internal pay and no-pay diagnosis lists, and redefining elements of the documentation guidelines to facilitate paying lower E/M levels than billed.
Compounding such problems significantly, hospitals that bill for their emergency physicians and/or faculty practice plans often fail to respond to record requests or audit findings in a timely manner, resulting in providers being placed on pre-payment audits. Although it is simple to say that many revenue cycle processes appear to be broken, it is far more difficult to ensure that the individuals managing each of the processes are knowledgeable in the nuances of coding and audit rebuttal. This is not something every billing manager can handle well.
A well-designed audit management process requires focused attention to several elements. Hospitals that bill for their provider groups (e.g., faculty practice plans, recently acquired practices, etc.) seem to have a tougher time of it. In general, there must be a mechanism for identifying payer communications relating to record audits.
This should start a timeline/process to ensure that a trained, certified coder can review the record(s) in question, and the provider responsible for the record will have an opportunity to defend the documentation on the record with a written response as necessary. In addition, the auditor must prepare a well-written response or rebuttal to the payer within the time allocated and continue to track the incoming correspondence for a response while monitoring the payer website for any policy updates.
As this day-to-day process occurs, notification of the provider and/or coding staff is required to alert responsible individuals about payer activities and the issues on which payers are focused.
When we look across the country at what coding/payment issues seem most prevalent, a few continue to pop up on the compliance radar. Let’s dissect some of the more pressing issues emergency medicine sees today.
What Constitutes a ‘Work-up’?
As ED patients are considered “new,” the choice for this MDM component is between “additional work-up planned” and “no additional work-up planned.” There are no nationally published criteria that define “work-up” for purposes of scoring this element of MDM. However, the Marshfield Clinic coding tool in use by many providers and payers, provides a scoring mechanism for the elements of an Evaluation and Management level and offers a more objective approach to determining each level of service.
However, absent an objective scoring system or clear guidance as to what constitutes “work-up,” some payers are attempting to define “work-up” as diagnostic testing performed after the patient leaves the ED, which seldom happens on any level of ED patient. This approach is problematic, as patients who receive no work-up according to the payer definition would qualify for a lower level for this element of MDM — not to mention the narrow definition of “work-up” as being related only to diagnostic testing.
This will require monitoring on a state and national payer basis so ED providers and supporting coding and billing vendors can be aware and push back when this creeps into coding and audit programs for resolution.
Determining Medical Necessity by ICD-10 Codes
Several payers are studying the final diagnosis code to determine whether the billing of higher level ED E/M codes is justified. As often may be the case, the problems identified in the HPI may point to a significant medical problem that can be ruled out only after a medically appropriate diagnostic work-up. It’s a different spin but is similar to the down-code/payment reduction activities of the 1990s when Medicare reduced the ED provider payment for E/M services that were not determined to be a “bona fide emergency” by whatever criteria du jour payers were using at the time.
It is important to address this issue on a state and national level before it takes hold and further reduces ED provider income. The final diagnosis, determined by established coding rules, may not significantly address the reason for ED interventions and testing. Payers often require our assistance to help them understand that the nature of the presenting problem and elements referenced in the HPI, ROS, and PFSH are more accurate indicators of a patient’s need to be in the ED prior to work-up.
Prepayment Audits
Before your Medicare Administrative Contractor (MAC) places an ED provider in prepayment audit status, a process has taken place in and around your practice. Long before the notification goes out, the ED practice or institution has been notified that it has been audited, the billed services are under question, and records for a designated number of patients have been requested. If this request for records is ignored, each is considered an error, a return of funds is requested, and the provider is expected to provide a corrective action plan. If no corrective action plan is received within the designated time, generally 45 days, the provider is placed on prepayment review. If records are provided, the payer audits, scores, and notifies the provider of their findings, which may or may not result in a take back of previously paid claim amounts.
The rebuttal process is the most critical. This is your right as a provider to dispute Medicare’s findings with a written review of your own. If this does not happen, Medicare assumes you agree with their findings, generally down-coded from the original codes assigned by the practice, and places you on prepayment review. This means that your records will be reviewed by Medicare, and payment for the level determined to be appropriate by Medicare will be paid.
This seems to be a good place to establish a “stop sign” in the process that gives emergency medicine providers a perfect opportunity to educate the payer. Defend coding as accurate based on existing industry standards and published coding criteria, and begin the process of constant vigilance, which is occurring in many ED practices and hospital compliance departments across the country.
Ongoing Coding and Billing Policy Revisions
The MACs stay busy these days modifying, clarifying, and developing coding policy. Generally, this is published in each MAC’s frequently asked questions sections or in policy statements. Here are a few examples you might want to know about:
National Government Services (NGS) will be implementing a new policy defining the content of 99283 and 99284 physical examinations. For services on or after July 1, 2017, NGS will require performance and documentation as follows: The 99283 Expanded Problem Focused physical examination is defined as an exam of two to five organ systems or body areas; the 99284 Detailed exam should consist of six to seven organ systems or body areas. This is a significant departure from current expectations.
From Noridian comes an interesting take on medical necessity (which payers often confuse with medical decision-making) that could benefit emergency medicine, assuming that providers appropriately document the elements listed below. Also, this is an excellent audit response template, although certainly not intended as one by Noridian:
“Medical necessity cannot be quantified using a points system. Determining the medically necessary [length of stay] involves many factors and is not the same from patient to patient and day to day. Medical necessity is determined through a culmination of vital factors, including, but not limited to: clinical judgment, standards of practice, why the patient needs to be seen (chief complaint), any acute exacerbations/onsets of medical conditions or injuries, the stability/acuity of the patient, multiple medical co-morbidities, and the management of the patient for that specific DOS.”
The underlying message of all this recent payer activity is to stay vigilant, prepare your defense strategy, and stay the course. Time has proven that constant interaction with payers on these issues results in improved payment, greater communication, and a better understanding of issues.
Time has proven that constant interaction with payers on these issues results in improved payment, greater communication, and a better understanding of issues.
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