ED providers: Document defensively to prevent fraud probe
Santa Ana, CA-Shaken by huge pay-outs from large teaching hospitals to settle Medicare fraud allegations, ED physicians are being advised to pay careful attention to patient documentation procedures, particularly those involving the coding for evaluation and management (E&M) services.
In May, a federal judge dismissed a suit brought by the AMA in Chicago, IL and 45 other health care groups against the U.S. Department of Health and Human Services' Office of Inspector General. The suit alleged that HHS was conducting improper audits of hospitals and potentially ruining facilities through coercive tactics under the Federal False Claims Act. The audits, which have become known as the Physicians at Teaching Hospital (PATH) initiative, have claimed several notable victims in recent months. The AMA is considering an appeal.
In the latest, some 18 clinical practice plans affiliated with the University of Pittsburgh School of Medicine agreed to pay the federal government $17 million to settle allegations that they defrauded Medicare and Medicaid with false claims between 1990 and 1996.
In April, the Greater New York Hospital Association in Albany filed a similar suit against HHS. At least three additional suits have been filed by health care groups challenging the fraud investigations.
Meanwhile, to reduce the likelihood of questionable billing practices, the Washington, DC-based American Society of Internal Medicine offers providers the following advice:
· Document only what is necessary.
A patient's medical record must include documentation to substantiate the claim submitted.
However, unless specifically requested by Medicare, the teaching physician does not have to submit these records with the claim.
Furthermore, the teaching physician does not have to re-document the information that the resident has already entered in the patient's record. However, the teaching physician must perform and document in the medical record all the necessary work to bill for an E&M service.
· Properly review the record.
Teaching physicians must review "the system or systems relevant to the patient's current illness" and document the major findings from the systems' review and exams. However, they do not have to perform a complete review or repeat documentation of past family and social history previously documented by the resident. And they must include summary notes of the key elements of the history, exam, and medical decision-making, including the diagnosis and plan of care in the patient record.
Teaching physicians must use the -GC modifier with a claim to indicate that a resident was involved in the provided service. Otherwise, the Medicare carrier will assume the service was provided exclusively by the physician and no resident was involved in the procedure.
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