cracking the code - a practical approach to managing...

Cracking The Code: A Practical Approach ToManaging & Preventing Carrier Audits

TAOP Fall Meeting - 2016

J. Rumpakis, OD, MBAPractice Resource Management, Inc. – [email protected]

www.JustAskJohn.info – www.CodeSAFEPLUS.comwww.PRMI.com – WhatsMyPracticeWorth.com

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Cracking The Code

A PRACTICAL APPROACH TO CORRECT CODING & PREVENTING CARRIER AUDITS

© 2008 - 2016 PRACTICE RESOURCE MANAGEMENT, INC. – J. RUMPAKIS, OD, MBADUPLICATION PROHIBITED WITHOUT PERMISSION. ALL RIGHTS RESERVED. 1

John Rumpakis, OD, MBAPractice Resource Management, Inc.

© 2008 - 2016 PRACTICE RESOURCE MANAGEMENT, INC. – J. RUMPAKIS, OD, MBA DUPLICATION PROHIBITED WITHOUT PERMISSION. ALL RIGHTS RESERVED. 2

John Rumpakis, OD, MBA

Dr. Rumpakis is currently President & CEO of Practice Resource Management, Inc., a firm that has been providing a full array of consulting, appraisal, and management services for healthcare professionals and industry partners for the past 32 years. He has developed some of the leading Internet-based software applications for the medical/eye care field such as CodeSAFEPLUS.com® (www.CodeSAFEPLUS.com), the industry leading cloud-based CPT & ICD Code Data and Information Service, and offers personal medical coding consultation through JustAskJohn (www.JustAskJohn.info). He is also the founder of Opt-ED® Professional Continuing Education (www.Opt-ED.com) which creates and delivers top tier continuing education around the country as well as Opt-IN® which provides optometric marketing and promotional services.

Named the Chief Medical Coding Editor for Review of Optometry & Optometric Management, he has been extensively published on the topics of third party coding & billing, strategy development and execution, practice management, team building, maximizing effectiveness and profitability, including the textbook “Business Aspects of Optometry”. Dr. Rumpakis is a popular lecturer both nationally and internationally. In addition to having had a successful solo practice, Dr. Rumpakis developed the practice management curriculum at Pacific University College of Optometry and taught optometric & medical economics there for over a decade and was recently named the University of Houston College of Optometry’s Benedict Professor for 2016-2017.

A 1984 graduate of Pacific University College of Optometry, he served as a volunteer for the AOA for near 17 years and sits on numerous advisory boards, and board of directors for companies both in and out of the ophthalmic industry.

Chief Medical Clinical Coding Editor – Review Of Optometry & Optometric Management

Financial Disclosures – John Rumpakis, OD, MBA

• Alcon Laboratories• Carl Zeiss Meditec• Optos• Vistakon• CooperVision• Maculogix• EMRLogic• TearLab

• Allergan• Beaver-Visitec• OfficeMate• Maximeyes• Luxottica• MacuRisk• Paragon• SynergEyes


• Eye-Tel Imaging• Bausch & Lomb• Essilor of America• Wal-Mart• Macuscope• Topcon• CyclopsEMR• MacuHealth

• RevolutionEHR• VisionWeb• Opticare• United Health Care• Vision Source• Bio-Tissue• ECRVault• Freedom-Meditech

I Am A Project Based Consultant & Have Received Honoraria From:(Partial Listing)

JustAskJohn – Personalized Medical Coding Consultation (www.JustAskJohn.info) CodeSAFEPLUS (www.CodeSAFEPLUS.com)Founder – Opt-ED, Professional Optometric Continuing EducationFounder – Opt-IN, Optometric Marketing & PromotionsWhatsMyPracticeWorth.com - Online Practice Appraisals

• ArcticDX• Modernizing Medicine• Annidis• Kowa Optimed• HeartSmart• Diopsys• Nicox• Crystal PM





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Disclosures• All fees represented within this presentation are the 2016 Medicare Maximum

Allowable Reimbursements for each procedure listed as of October 13th, 2016 for this zip code.

• All information regarding policies, procedures, guidelines and definitions is current as of October 13th, 2016.

• Each viewer is responsible to be current in their own geographical jurisdiction interpretation of policies, procedures, guidelines and definitions prior to implementation within their own practice.

• The coding examples contained this presentation are examples only and each practitioner should apply these coding guidelines to what is actually recorded in the patients’ medical record before submitting any claim to a third party carrier.


Abstract & OutcomesABSTRACT

• In today’s world of third party relationships between payer and provider, audits of all types are becoming increasingly more frequent and more economically impactful. Practitioners need to know how to identify the specific type of audit, and how to properly (legally) respond to protect themselves and their practices.

OUTCOMES

• Be able to understand the current market landscape for third party payer audits and the type of behaviors that trigger an audit.

• Be able to properly identify the type of audit for which they are being targeted.

• Be able to determine what the audit is pertaining to and the scope of the audit.

• Be able to know how to respond and the impact of how your response can affect the outcome of the audit.

• Be able to know when and what type of professionals they should have assisting in their defense.

• Be able to understand common goals of a payer and provider from the outcome of an audit.

• Be able to develop an internal compliance plan to minimize future exposure.


2017 Coding Requires 2017 Rules & Resources•Get Your Resource MaterialoBy Book CPT 2017 ICD-10 2017HCPCS Level II 2017

•Or Get Everything Updated AUTOMATICALLY oOnline Cloud-Based Resourceswww.CodeSAFEPLUS.com & www.JustAskJohn.info






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Three Resources You Are Going To Need…

[email protected]

www.JustAskJohn.info© 2008 - 2016 PRACTICE RESOURCE MANAGEMENT, INC. – J. RUMPAKIS, OD, MBA

DUPLICATION PROHIBITED WITHOUT PERMISSION. ALL RIGHTS RESERVED. 7

But John, I’m So Confused…EVERYBODY’S AN EXPERT??? THERE ARE SO MANY DIFFERENT PEOPLE THAT SAY SO MANY DIFFERENT THINGS…


TRANSPARENCY






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We Make It Harder Than It Really Is!•The patient’s condition determines everything that you do.History that was required understand the patient’s complaint Exam that was required to properly diagnose the condition Assessment of the condition(s) Plan to provide the best outcome in the most efficient way that is

concurrent with local standard of care•What you do with the patient determines what you write

down in the medical record.•What you have written down determines the codes you

use to describe the care required.© 2008 - 2016 PRACTICE RESOURCE MANAGEMENT, INC. – J. RUMPAKIS, OD, MBA


Bottom Line

The individual patient presentation or what you have them returning for determines everything

that you do with them, and therefore determines the services performed and the

subsequent coding of those services.


A Couple Of Foundational Documents That MatterU.S. FALSE CLAIMS ACTAND EACH SPECIFIC CARRIER CONTRACT YOU HAVE SIGNED






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The U.S. False Claims Act•A person does not violate the False Claims Act by

submitting a false claim to the government;•To violate the FCA a person must have submitted, or

caused the submission of, the false claim (or made a false statement or record) with knowledge of the falsity. In §3729(b)(1), knowledge of false information is defined as being (1) actual knowledge, (2) deliberate ignorance of the truth or falsity of the information, or (3) reckless disregard of the truth or falsity of the information.


Reference: http://www.justice.gov/sites/default/files/civil/legacy/2011/04/22/C-FRAUDS_FCA_Primer.pdf

The U.S. False Claims ActDefinition Of A Claim:

•It is a demand for money or property made directly to the Federal Government or to a contractor, grantee, or other recipient if the money is to spent on the government’s behalf and if the Federal Government provides any of the money demanded or if the Federal Government will reimburse the contractor or grantee.


Reference: http://www.justice.gov/sites/default/files/civil/legacy/2011/04/22/C-FRAUDS_FCA_Primer.pdf

Provider RelationshipsThe Basics of Professional Ethics

•Other than the doctor/patient relationship (the most important relationship), ethical behavior of providers is organized around:oRelationships with payersoRelationships with fellow providersoRelationships with vendors






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Relationships With Payers•Relationships with patients is increasingly dominated by a

third party – the payer•Components of the provider/payer relationship include:oAccurate coding and billingoAccurate medical records documentationoPrescription authorityoAssignment within the Medicare system


Relationship With PayersAccurate Billing and Coding

The main issues involved in billing for rendered services include:•Billing only for:omedically necessary careo services actually performed

•Not Billing for: o services with no benefit or beneficial outcomeo services provided by improperly trained or improperly supervised careo services provided by a provider included in the Exclusion Statute


Special Note!•The OIG is VERY serious about “worthless” services –

patient services that provide no real diagnostic or therapeutic benefit to the patient. The last three convictions in 2014 all resulted in CRIMINAL convictions with federal prison sentences up to 10 years






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“Worthless Services” – Per CMS• is not accepted as safe and effective by the medical community• is not supported in peer-reviewed medical literature• is experimental or investigational • is not medically necessary in a specific case or specific medical Dx• is furnished at a level, duration, dosage or frequency not appropriate

for a specific patient or clinical condition• is not furnished in a manner consistent with standards of care• is not furnished in a setting (place of service) consistent with the

patient's medical needs and condition• is furnished in a manner for patient or provider convenience• is a device is not approved by the FDA• is a test or service now considered obsolete


Fundamental Principles Are IMPORTANT!


What do you do?(hint… think evidence based medicine)What does this patient need?(hint… not what do you want to do)

What is in the patient’s best interest?

Medical Necessity Is…“Services or supplies that are proper and needed for the diagnosis or treatment of the patient’s medical conditions, are provided for the diagnosis, direct care and treatment of the patient’s medical condition, meet the standards of good medical practice in the local area and aren’t mainly for the convenience of the patient or the physician.”


Source: www.Medicare.gov





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So What Exactly Does That Mean?The medical record must clearly

demonstrate that the service, procedure, or test ordered &

performed was absolutely necessary in order to diagnose, treat, or monitor the treatment

of the patient’s condition.


E&M Medical Necessity -Medical Necessity of E&M Services• Section 1862(a)(1)(A) of the SSA, “Exclusions From Coverage and Medicare as

Secondary Payer” does not include expenses acquired for items and services which are not deemed necessary for the diagnosis or treatment of illness or injury. This applies to all services.

• CMS IOS Publication 100-04, Chapter 12, Section 30.6.1 states:“Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.”


Relationship With PayersMedical Records Documentation

By contract with the payer, providers attest that the patient’s medical records are:•Accurate•Complete•Show justification of medical necessity

•Have you ever read the back of your CMS - 1500 form?•It is a LEGAL CONTRACT assuring the necessity and

truthfulness of your services.






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The Contract You Sign 20x Per Day

•In submitting this claim for payment from Federal Funds, I certify that:

1. The information on this form is true, accurate and complete2. I have familiarized myself with all laws, regulations and program

instructions available from the Medicare contractor3. I have provided or can provide sufficient information required to

allow the government to make an informed eligibility and payment decision

4. This claim complies with all Medicare program instructions

(and have never read…)


And The Icing On The Cake…

“My signature is to certify that the foregoing information is true and accurate. I understand that any false claims or

statements or concealment of a material fact may be prosecuted under applicable Federal and Stark laws.”


Important DefinitionsFRAUD

• When someone intentionally falsifies information or deceives Medicare.

ABUSE• When health care providers or

suppliers don’t follow good medical practices, resulting in unnecessary costs, improper payments, or services that aren’t medically necessary.


The Only Difference BetweenFraud & Abuse Is Intent.

http://www.cms.gov/Outreach-and-Education/Training/CMSNationalTrainingProgram/Downloads/2013-Fraud-and-Abuse-Prevention-Workbook.pdf





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CMS Fraud Detection - Past & PresentPAST

• Providers suspected of fraudulent activity were put on prepay review, sometimes indefinitely

• CMS initiated overpayment recovery• Law enforcement determined if an

arrest is appropriate

PRESENT• Denies individual claims• Its contractors use prepay review as an

investigative technique• Revokes providers for improper practices• Collaborates with law enforcement

before, during and after case development

• Addresses the root cause of identified vulnerabilities


http://www.cms.gov/Outreach-and-Education/Training/CMSNationalTrainingProgram/Downloads/2013-Fraud-and-Abuse-Prevention-Workbook.pdf

Health Care FraudWHERE DOES THE LEGAL OBLIGATION OF USING THE CPT & ICD SYSTEMS COME FROM? IT IS CRITICAL TO KNOW!


Who Is The OIG?THE OFFICE OF INSPECTOR GENERAL






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The OIG & Their Mission•The mission of the Office of Inspector General (OIG), as

mandated by Public Law 95-452 (as amended), is to protect the integrity of Department of Health and Human Services (HHS) programs, as well as the health and welfare of the beneficiaries of those programs.


The OIG & Their Mission•OIG has a responsibility to report both to the Secretary and

to the Congress program and management problems and recommendations to correct them. OIG's duties are carried out through a nationwide network of audits, investigations, inspections and other mission-related functions performed by OIG components.

http://oig.hhs.gov/© 2008 - 2016 PRACTICE RESOURCE MANAGEMENT, INC. – J. RUMPAKIS, OD, MBA


The OIG Work Plan• The OlG Work Plan sets forth various projects to be addressed during the fiscal year by

the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General. The Work Plan includes projects planned in each of the Department's major entities: the Centers for Medicare & Medicaid Services; the public health agencies; and the Administrations for Children, Families, and Aging.

• Information is also provided on projects related to issues that cut across departmental programs, including State and local government use of Federal funds, as well as the functional areas of the Office of the Secretary. Some of the projects described in the Work Plan are statutorily required, such as the audit of the Department's financial statements, which is mandated by the Government Management Reform Act.

http://oig.hhs.gov/publications/workplan.asp






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What Is The Current Audit Environment?UNDERSTANDING THE CARRIER ENVIRONMENT IS CRIT ICAL TO EVERYTHING

35© 2008 - 2016 PRACTICE RESOURCE MANAGEMENT, INC. – J. RUMPAKIS, OD, MBA DUPLICATION PROHIBITED WITHOUT PERMISSION. ALL RIGHTS RESERVED.

The Government RecoveryIs Hitting Records!


Technology Is Driving Monetary Recoveries…

...And At A Blistering Pace


Using “Big Data” analysis returned an

increase from 2014 to 11.6 to 1 return on

investment in 2016!





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Obama Administration Announces Ground-BreakingPublic-Private Partnership to Prevent Health Care Fraud

July 26, 2012 – For Immediate ReleaseHHS Secretary Kathleen Sebelius and Attorney General Eric Holder announced the launch of a ground-breaking partnership among the federal government, State officials, several leading private health insurance organizations, and other health care anti-fraud groups to prevent health care fraud. This voluntary, collaborative arrangement uniting public and private organizations is the next step in the Obama administration’s efforts to combat health care fraud and safeguard health care dollars to better protect taxpayers and consumers.

The new partnership is designed to share information and best practices in order to improve detection and prevent payment of fraudulent health care billings. Its goal is to reveal and halt scams that cut across a number of public and private payers. The partnership will enable those on the front lines of industry anti-fraud efforts to share their insights more easily with investigators, prosecutors, policymakers and other stakeholders. It will help law enforcement officials to more effectively identify and prevent suspicious activities, better protect patients’ confidential information and use the full range of tools and authorities provided by the Affordable Care Act and other essential statutes to combat and prosecute illegal actions.

One innovative objective of the partnership is to share information on specific schemes, utilized billing codes and geographical fraud hotspots so that action can be taken to prevent losses to both government and private health plans before they occur. Another potential goal of the partnership is the ability to spot and stop payments billed to different insurers for care delivered to the same patient on the same day in two different cities. A potential long-range goal of the partnership is to use sophisticated technology and analytics on industry-wide healthcare data to predict and detect health care fraud schemes.


Former Optometrist Sentenced in Medicaid Fraud Case

FOR IMMEDIATE RELEASE : Wednesday, December 5, 2012CONTACT: Sara Rabern (605)773-3215

PIERRE, S.D.- Attorney General Marty Jackley announced today that Cary Stephen Feldman, 60, Spearfish, was sentenced to serve 15 years in prison for committing Medicaid fraud.

Seventh Circuit Court Judge Janine M. Kern suspended the execution of sentence on several conditions. Judge Kern ordered Feldman to serve 180 days in jail and ordered him to pay a total of $363,049.90 in restitution to Medicaid and Medicare. Feldman turned over a coin collection with an estimated value of $157,000, and paid an additional $80,000 to the government, so his remaining restitution balance is $126,049.90. Feldman was also ordered to serve 300 hours of community service, pay costs of $712.20 to the State and court costs of $208. Feldman allowed the South Dakota Board of Optometry to revoke his license in October.

Feldman entered a plea of guilty on October 11, 2012, to grand theft by deception, a class 4 felony, and making false claims, a class 5 felony, pursuant to a plea agreement reached with the State. Feldman admitted that he knowingly and intentionally submitted false claims to the South Dakota Medicaid program and to Medicare. Feldman admitted that he submitted claims to Medicaid and to Medicare for consultation services, even though he had not provided such services. Feldman began submitting the false claims in late 2008, and continued until early 2012.

The case was investigated and prosecuted by the South Dakota Medicaid Fraud Control Unit, with assistance from the South Dakota Department of Social Services, the federal Department of Health and Human Services Office of Inspector General, the South Dakota Division of Criminal Investigation, the Spearfish Police Department, the Rapid City Police Department, the Pennington County Sheriff’s Office, the Pennington County Office of State’s Attorney, the Minnehaha County Sheriff’s Office, and the South Dakota Office of United States Attorney.

Seventh Circuit Court Judge Janine M. Kern ordered him to pay a total of $363,049.90 in restitution to Medicaid and Medicare. Feldman allowed the South Dakota Board of Optometry to revoke his license in October.

Feldman entered a plea of guilty on October 11, 2012, to grand theft by deception, a class 4 felony, and making false claims, a class 5 felony, pursuant to a plea agreement reached with the State. Feldman admitted that he knowingly and intentionally submitted false claims to the South Dakota Medicaid program and to Medicare. Feldman began submitting the false claims in late 2008, and continued until early 2012.

The case was investigated and prosecuted by the South Dakota Medicaid Fraud Control Unit, with assistance from the South Dakota Department of Social Services, the federal Department of Health and Human Services Office of Inspector General, the South Dakota Division of Criminal Investigation, the Spearfish Police Department, the Rapid City Police Department, the Pennington County Sheriff’s Office, the Pennington County Office of State’s Attorney, the Minnehaha County Sheriff’s Office, and the South Dakota Office of United States Attorney.



Medicare Urges Seniors To Join The Fight Against FraudIn mailboxes across the country, people with Medicare will soon see a redesigned statement of their claims for services and benefits that will help them better spot potential fraud, waste and abuse. Because of actions like these and new tools under the Affordable Care Act, the number of suspect providers and suppliers thrown out of the Medicare program has more than doubled in 35 states. Update on CMS’ Anti-Fraud EffortsThe Affordable Care Act has enabled CMS to expand efforts to prevent and fight fraud, waste and abuse.Over the last four years, the Obama administration has recovered over $14.9 billion in healthcare fraud judgments, settlements, and administrative impositions, including record recoveries in 2011 and 2012. Since the Affordable Care Act, CMS has revoked 14,663 providers and suppliers’ ability to bill in the Medicare program since March 2011. These providers were removed from the program because they had felony convictions, were not operational at the address CMShad on file, or were not in compliance with CMS rules. In 18 states, the number of revocations has quadrupled since CMS put the Affordable Care Act screening and review requirements in place, as well as the implementation of proactive data analysis to identify potential license discrepancies of enrolled individuals and entities. These efforts are ensuring that only qualified and legitimate providers and suppliers can provide health care products and services to Medicare beneficiaries.

June 6, 2013 – Press Release





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Everyone Is Looking To Be Rewarded!


And It’s Not Just CMS We Need To Worry About!


What Is A “Red Flag” ThatTriggers An Audit?

• Using codes under review by the OIG• Not reviewing your submitted claims against recovery audit issues• Abusing codes• Aberrant or inconsistent billing patterns• Maximizing revenue without sufficient documentation• Cloning of documentation• Not understanding definitions of modifiers and inappropriate use of

modifiers






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The Top Three Issues For Audit Failure1. Lack of medical necessity noted in record

a) Special ophthalmic testing that falls outside of profile2. Improper coding of office visits

a) Using codes out of habit and not based upon patient needs3. Improper use of modifiers -25 and -59

a) Not understanding rules and definitions of modifiers and proper application of them to clinical circumstances


The Yates Memo…•A recent memorandum issued by U.S. Deputy Attorney

General Sally Yates to the U.S. Department of Justice outlined the governments renewed focus on seeking accountability from individuals who engaged in wrong doing.o Impact on practices – anyone, including staff can have liability if

participating in a known practice that is wrong.

• http://www.justice.gov/dag/file/769036/DOWNLOAD


Where Can I Get Information On Myself?

•www.ProPublica.org

•www.FindTheBest.com

•www.CMS.gov






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Uh Oh, I Think I’m Getting Audited•First, read your notice very carefully. What did you actually

receive?oHeralding Notice – This alerts all providers that the payer intends

to conduct audits system wide. It DOES NOT necessarily mean that you are getting audited.

oNotice of Audit – This is an official notification that you ARE getting audited.


Determine The Scope Of The Audit•Key Questions/Issues•Is the audit for recovery or fraud?•Is it an education or network-wide audit?•Is the payer asking for specific records?•How many records is the payer asking for?o There is a significant difference between asking for 20 records or 100

records. The higher the number indicates a more comprehensive review and the expectation of a higher recovery.

• Is the payer suspecting improper coding or billing issues?•Be aware of medical necessity language


Types Of Audits•Pre-payment Audit – Generally automated and you may never

even know about it. If the payer requests documentation, they are looking at a specific issue.

•Post-payment Audit – After the claim is paid, the payer requests specific information to support the coding and claim.

•Automated Review Audit – A computer generated review performed to identify violations in standard rules or edits. The review is usually associated with a very clear and concise policy. The objective is to make sure that the claim meets all of the edits and rules for payment.






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Types Of Audits•Comprehensive Review Audit – This is a review of the entire

medical record performed by a certified reviewer. The payer may apply standard criteria (i.e. CMS standards) to identify and determine medical necessity requirements or to validate that the service was provided.

•Fraud & Abuse Audit* – This is an audit that has been elevated within the carrier when there is specific suspicion of intentional violation of coding rules.

•Claim Recovery (Administrative Review) Audit – An audit that is focused on violation of coding rules, where intentional fraud is not suspected.


Types Of Audits•Claim Focused Audit – The payer is looking at specific types of

claims or services, but is not necessarily focusing on your particular practice.

•Provider Focused Audit – An audit that is focusing specifically on your practice or a specific provider within your practice with concern surrounding specific coding and billing behaviors.

•*If an audit is being conducted by the SIU (Special Investigations Unit), it is because there is a very high degree of suspicion that there is intentional fraudulent behavior and the potential penalties can be much more significant.


Build Your Team•Audits are a serious issue and should be treated

accordingly.•Find out who at the carrier is conducting the audit?o Learning the department within the carrier that is conducting the

audit can provide you with insight on the level of seriousness.•Don’t go it aloneoBuild your team with individuals who can properly assist you in

audit defense. An OD based firm that specialized in audit defense. An attorney, who can help you understand your rights and responsibilities under your

provider contract.






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Develop A Plan•If the audit is for recovery or fraud•Get your team together•Assign someone in the office as the primary contact point

for the carrier (someone familiar with medical records)•Create a depository for all communication•Retain an attorney and a audit expert to assist in building a

defense, if possible.


Deadlines Matter•Pay attention to all date specific deadlines that are

communicated.•General time limits to pull records is 45 days, but can vary

based upon your individual contract and your states Prompt Payment Law.

•Assemble the correct information to send. Don’t fail an audit because you failed to submit the requested information

•Send copies of records, not the originals. If you can’t find a record in question, request more time.

•Never send less than what the carrier is requesting


They Found Something, Now What?•If an audit leads to a request for recoupment of claims

payment, ask for time to review the demand letter.•Was the demand letter received within the proper time period

following the audit?•Was proper rationale and justification provided with

explanation of how they determined the recovery amount?•Did the payer provide an explanation for each claim incorrectly

paid or coded?•Did the payer explain statistical sampling and extrapolation?•Did the payer provide information regarding your rights of

appeal and the timeframe and requirements of it?






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How Can You Fight Big Data & Technology?LET’S FIGHT BACK WITH REAL-TIME DATA & INFORMATION THAT IS SPECIFIC TO YOUR ZIP CODE & ALWAYS ACCURATE!


CodeSAFEPLUS.comTHE INDUSTRY LEADER IN CLOUD-BASED CPT & ICD DATA SERVICES


www.JustAskJohn.infoONE-ON-ONE PERSONAL CODING CONSULTATION SERVICES


And When A More Personal Solution Is Needed…





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The Key Items To Remember•Provide only the care that is necessary for the individual

patient presentation on that specific day.•Know, understand, and adhere to the CPT definitions of the

office visit codes.•When using a modifier – understand the definition and use

them judiciously•Follow the rules that you have agreed to with your carrier.

If you don’t agree with the rules, then re-evaluate your relationship with that specific carrier.


Protecting Your Practice For The Future• Conduct internal audits on a regular basis• Make sure that you have current rules, are using current codes, and

that you are following them properly for your location• Insure that your documentation supports the level of service being

provided• Make sure that the patient’s condition supports the procedures

performed and the level of complexity billed. Scrutinize your records for statements of medical necessity.

• Compare how you practice with your peers. Usually, a physician is targeted for an audit because of being an outlier, or having unusual billing practices. Patients can also alert carriers as well.


The Best Defense Is A GREAT Offense•Understand the use of codes under review by the OIG•Constantly review your submitted claims against recovery audit

issues•Learn your codes and their definitions to prevent abusing them•Avoid aberrant or inconsistent billing patterns•Be consistent in your billing patterns and charges between all

payer types. Don’t discriminate by carrier or private pay.•Make sure your documentation is PERFECT – avoid cloning•Learn and understand definitions of modifiers and avoid

inappropriate use of modifiers in your practice






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Cracking The Code

A PRACTICAL APPROACH TO CORRECT CODING & PREVENTING CARRIER AUDITS


John Rumpakis, OD, MBAPractice Resource Management, Inc.