clinical validation webinar

Take ACloser LookTop Coding Errors of 2013 (and How to Avoid Them In 2014)

1January 30, 2014

Presented By

Michelle Higginson MS, RN, RHIA, CPC

Director, Clinical Operations – Payment Accuracy Solutions

2

About Verisk Analytics

Publicly-Traded

Focus on The Science of Risk

Financial Services

Property & Casualty

We drive performance in the business of healthcare. By combining clinical and analytics expertise with advanced technology and services, we help payers, employers and providers solve complex problems with measurable results.

$10.2B Market Cap

15.7% Annual Growth 2009-2011

Supply Chain

Healthcare

3

Coding:An Overview

Coding and Modifiers

Code sets used for billing:

• Current Procedural Terminology – CPT

• Developed by the American Medical Association – AMA

• Healthcare Common Procedure Coding System – HCPCS

• Developed by Centers for Medicare & Medicaid Services - CMS

Modifiers:

Explain to insurance carriers that the description of the code is the same, but something about the procedure or service was changed without changing the definition of the CPT code set.

• Some modifiers are informational and some impact reimbursement

• Modifiers can increase the likelihood of getting reimbursed accurately, but they do NOT ensure reimbursement.

How are Medical Services Coded?

When Max was a newborn, he developed high bilirubin levels (or jaundice) and lost weight due to poor feeding.

At his 8 week checkup, Max’s mother mentioned that there seemed to be an issue with the umbilical cord and a possible infection.

How are Medical Services Coded?

The physician performed the following services:

• Periodic comprehensive preventive medicine

• Bilirubin Total, laboratory

• Ultrasound, abdominal, real time with image documentation; limited

How is this Claim Reimbursed?

LineCPT/

HCPCSModifier

199391 Preventive

Medicine Evaluation & Management, Infant

V20.2 Routine Infant Health Check Pay

299214 Outpatient

Office Visit25

774.30 Neonatal Jaundice779.31 Feeding Problem in Newborn

753.7 Anomaly of Urachus

Pay based on clinical review of modifier 25 criteria

3 36415 Venipuncture 774.30 Neonatal Jaundice

Pay (depending on payer, some state Medicaid rules

consider venipuncture bundled to other services)

482247

Total Bilirubin774.30 Neonatal Jaundice Pay

576705

Limited Abdominal Ultrasound

753.7 Anomaly of Urachus Pay

Diagnosis Codes

V20.2 Routine Infant Health Check Pay

774.30 Neonatal Jaundice779.31 Feeding Problem in Newborn

753.7 Anomaly of Urachus


774.30 Neonatal Jaundice



774.30 Neonatal Jaundice Pay

753.7 Anomaly of Urachus Pay

Action

Pay




Pay

Pay

The Problem

Potential Losses

Potential Annual Losses Due to Claim Waste and Abuse

$210 Billion

Correct Coding

The detection and prevention of wasteful or abusive claims.

Erroneous and abusive billing types include:

• Duplicate billing• Split billing• Unbundling• Up-coding

11

Healthcare

The Answer

Clinical Validation

Healthcare

13

The experts behind our human touch include nurses, physicians and coding specialists. A unique process to Verisk Health, this process delivers

unmatched payment accuracy and virtually eliminates overpayments.

Improve auto-adjudication rates

Decrease frequency of false-positives

Create transparency with and support for providers

Our Clinical Coding Experts

Extensive additional coding training Representing experience in virtually every area of nursing

Registered Nurses60+

Certified Professional Coders40+

Reviewed in 2013:

Claims4M

Appeals250K

Our Process

15

Claims Exported to VH Claims Processed

Releasedfor Payment

Claims Exported To Client System

Cleared

Clinical Review

Cleared

Validated & Posted to aSecure Website

Flagged

Releasedfor Payment

TheResults

59

Most Commonly Abused Modifiers: 25 & 59

Modifier 25: A Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of a Procedure or Other Service.

Modifier 59: A Distinct Procedural Service.

25

Evaluation & Management with Injections

25

Modifier 25

Coding error rate for $6 million in client savings.26%

For top 50 coding errors related to modifier 25 on established patient office visits 99212-99215:

of this savings is for claim lines where 99212-99215 was billed with a therapeutic injection, 96372. $2Mof the savings is for claim lines where 99212-99215 was billed with a joint injection, 20610. $1M

Unbundling – Modifier 25Example: Evaluation and Management Services with Therapeutic Injections

LineCPT/

HCPCSModifier

1 99213 Office visit

25281.0 Pernicious Anemia

780.79 OT Malaise/Fatigue782.0 Disturbance of Skin Sensation

Pay - diagnoses and other services reported support separate and

significant E/M service was provided in addition to the B12 injection.

296372

Therapeutic Injection

281.0 Pernicious Anemia780.79 OT Malaise/Fatigue

3J3420

Vitamin B12 Injection


436415 Routine

Venipuncture


Diagnosis Codes

281.0 Pernicious Anemia780.79 OT Malaise/Fatigue782.0 Disturbance of Skin Sensation

Pay - diagnoses and other services reported support separate and

significant E/M service was provided in addition to the B12 injection.




Action

Pay - diagnoses and other services reported support separate and significant E/M service was provided in addition to the B12 injection.

Unbundling – Modifier 25Evaluation and Management Services with Joint Injection 20610

LineCPT/

HCPCSModifier

1 99213 Office Visit

25 1/08/2014715.16 Osteoarthritis Localized

Primary Involving Lower Leg1/08/2014 Pay

220610

Drain/Inject Joint Bursa

RT 1/08/2014715.16 Osteoarthritis Localized

Primary Involving Lower Leg 1/08/2014

3J1030

Methylprednisolone 40 mg

1/08/2014715.16 Osteoarthritis Localized

Primary Involving Lower Leg1/08/2014

473562

X-Ray Exam of Knee

RT 1/08/2014715.16 Osteoarthritis Localized


Date of Service


Primary Involving Lower Leg1/08/2014 Pay


Primary Involving Lower Leg 1/08/2014





Diagnosis Codes

715.16 Osteoarthritis Localized Primary Involving Lower Leg




First Date of Diagnosis

1/08/2014

1/08/2014

1/08/2014

1/08/2014

Action

Pay

Upcoding - Hydration

For unbundling scenarios involving just the add-on hydration code 96361, we found:

Reported incorrectly, or with no support for hydration88%In ClientSavings$1.8MClient Acceptance RateOf our Recommendations93%

LineCPT/

HCPCSUnits

196360

Hydration, initial

1

296361

Hydration, add-on

3

399283

Emergency Dept. Visit

1

4 93005 EKG

1

UpcodingExample: Hydration – Not Supported

Diagnosis Codes

786.59 Other Chest Pain311 Depressive Disorder OT530.81 Esophageal Reflux

401.9 Hypertension Unspecified





786.59 Other Chest Pain401.9 Hypertension Unspecified

Action

Deny, not

supported

Deny, not

Supported

Cost of Coding Errors

If we look at only the errors related to Modifiers 25 and 59:

For the top 100 coding errors by $$ impact, we see a 36% error rate.

Acceptance Rate98%

In Client Savings$9M

Acceptance Rate87%

In Client Savings$21M

For the top 100 coding errors by line count, we see a 24% error rate.

THANK YOUQUESTIONS?

Contact us: [email protected]

www.veriskhealth.com

clinical validation webinar

Health & Medicine