Fraud squads crack down on physician upcoding
Specialists: Expect clearer guidelines
If you’ve been breathing a sigh of relief because federal upcoding investigators have focused solely on hospitals, don’t get too relaxed. HCFA’s coding cops are planning their next crackdown, and it could involve you.
Industry experts tell Physician’s Payment Update that not only has HCFA started cracking down on potential physician upcoders, but that the agency also plans to introduce revised audit guidelines later this summer that will make it harder for many physicians to justify their current going rate for patient consultations and evaluations.
"HCFA is definitely taking a closer look at physician billing procedures when it comes to upcoding," says Rita A. Scichilone, coding consultant with Professional Management Midwest in Omaha, NE.
"Upcoding rules are absolutely being applied to physicians," agrees Catherine Fischer, CPA, a reimbursement policy advisor at Marshfield (WI) Clinic. Because physicians and hospitals bill differently, standards for documenting proper coding vary as well. Hospitals upcode by improperly upgrading the seriousness of a patient’s condition to a higher-paying diagnosis-related group (DRG). However, "there are no DRGs associated with a patient’s doctor bill," notes Fischer. The physician has two choices when it comes to billing: billing as an evaluation (patient visit or consultation) or under a specific procedure’s code.
Will the chart justify the bill?
HCFA investigators will focus on determining whether the bill for the evaluation correlates with the patient’s medical needs and the doctor’s choice of code, based on the guidelines and the investigator’s judgement. "After looking at a patient’s bill and chart notes, they can come back and argue that the service was too straightforward to justify the charge," says Fischer. "In turn, they may either downcode’ the claim or completely disallow it."
For instance, in a series of recent billing audits at teaching hospitals, physicians were examined from two different angles, Fischer explains. First, the level of service charged was compared to the physician’s documentation. Second, who provided the service the practicing physician or resident was then taken into account.
Auditors use what’s known as the Evaluation and Management (E/M) Documentation Auditors Instructions (available through the Englewood, CO-based Medical Group Management Association) to determine if a physician might have padded the bill by either billing an inappropriately high level of service or by inaccurately representing the type of provider present.
The E/M manual is used to solve a matrix that scores the various activities and their related complexity associated with a visit. Specific components included in the matrix are the patient’s medical history, physical examination, and the medical decision making involved with a particular visit.
New patients require more documentation
Each documented component history, exam, and decision making is evaluated or scored to arrive at a level of service. There are three levels of service in the hospital setting and five in the outpatient setting. These requirements vary by site of service (hospital, clinic, ER, etc.) and whether the patient is new or established.
Examiners will compare patterns for established patients vs. new ones. "More documentation is required to justify the evaluation and management fees for new patients," says Fischer.
Sources tell PPU that sometime this summer, HCFA and the American Medical Association (AMA) hope to refine their E/M audit guidelines for increased accuracy.
Known as the single organ system or specialty exam, the new audit protocol is intended to more accurately allocate value to the evaluation and examination performed by different specialists.
"It’s designed to provide a more rational standard of comparison when auditing evaluations by specialists vs. primary care physicians," notes one coding expert close to the project. "In effect, it tries to lower the subjectivity in billing a level of service."
Family physicians and primary care doctors could be "winners" under the new criteria as many may qualify for higher evaluation fees than they currently charge, according to one source. In contrast, some specialists will find it harder to justify their present consultation rate. Exact numbers are not yet available.
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