4/17/2012
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Presented byMaggie Mac, CPC, CEMC,
CHC, CMM, ICCE
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� CMS
� OIG
� RAC’s
� PSC’s
� ZPIC’s
� Private Payers
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4/17/2012
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� National and Local Carrier Determinations
� Physician Regulatory Issues Team
� Transmittals (Sometimes with effective dates that are months prior to the release date of the guidance) - Issued, Rescinded, Re-issued, Deleted
� C.E.R.T. Studies
� Demonstrations
� Medically Unlikely Edits
� National Correct Coding Initiative (NCCI) Edits
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� OIG Work Plan 2012
◦ http://oig.hhs.gov/reports-and-publications/workplan/index.asp#current
� Audit Reports
� Self Disclosure Information
� Exclusion Programs and Database
◦ http://oig.hhs.gov/fraud/exclusions.asp (HHS/OIG)
◦ http://www.epls.gov (General Service Administration)
� Compliance Guidance
� Fraud Prevention and Detection
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4/17/2012
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� Physicians: Incident-To Services (New)
� We will review physician billing for “incident-to” services to determine whether payment for such services had a higher error rate than that for non-incident-to services. We will also assess CMS’s ability to monitor services billed as “incident-to.” Medicare Part B pays for certain services billed by physicians that are performed by nonphysiciansincident to a physician office visit.
◦ Not really new……
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� Evaluation and Management Services: Trends in Coding of Claims
� We will review evaluation and management (E/M) claims to identify trends in the coding of E/M services from 2000-2009. We will also identify providers that exhibited questionable billing for E/M services in 2009.
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� Whistleblowers
◦ Employee
◦ Former employee
◦ Patients
◦ Competitors
� Allegations or suspicion of:
◦ Fraud
◦ Abuse
� Successful prosecutions result in criminal and administrative remedies to include fines and exclusions.
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� Region A: Diversified Collection Services (DCS)
� Home Page:
� www.dcsrac.comwww.dcsrac.comwww.dcsrac.comwww.dcsrac.com
� Current Issues:
� http://www.dcsrac.com/IssuesUnderReview.aspxhttp://www.dcsrac.com/IssuesUnderReview.aspxhttp://www.dcsrac.com/IssuesUnderReview.aspxhttp://www.dcsrac.com/IssuesUnderReview.aspx
� Region B: CGI Federal
� Home Page:
� http://racb.cgi.comhttp://racb.cgi.comhttp://racb.cgi.comhttp://racb.cgi.com
� Current Issues:
� http://racb.cgi.com/Issues.aspxhttp://racb.cgi.com/Issues.aspxhttp://racb.cgi.com/Issues.aspxhttp://racb.cgi.com/Issues.aspx
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� Region C: Connolly Healthcare
� Home Page:
� www.connollyhealthcare.com/RACwww.connollyhealthcare.com/RACwww.connollyhealthcare.com/RACwww.connollyhealthcare.com/RAC
� Current Issues:
� http://www.connollyhealthcare.com/RAC/pages/aphttp://www.connollyhealthcare.com/RAC/pages/aphttp://www.connollyhealthcare.com/RAC/pages/aphttp://www.connollyhealthcare.com/RAC/pages/approved_issues.aspxproved_issues.aspxproved_issues.aspxproved_issues.aspx
� Region D: HealthDataInsights (HDI)
� Home Page:
� https://racinfo.healthdatainsights.comhttps://racinfo.healthdatainsights.comhttps://racinfo.healthdatainsights.comhttps://racinfo.healthdatainsights.com
� Current Issues:
� https://racinfo.healthdatainsights.com/Public1/Nehttps://racinfo.healthdatainsights.com/Public1/Nehttps://racinfo.healthdatainsights.com/Public1/Nehttps://racinfo.healthdatainsights.com/Public1/NewIssues.aspxwIssues.aspxwIssues.aspxwIssues.aspx
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� Once in a lifetime – services billed more than once
� Newborn Pediatric – services that should be billed with specifc codes based on age
� Facility vs Non-facility – where did the physician perform the procedure
� Global vs TC/PC – billed globally and also separately
� Excessive Units – untimed codes billed with more than one unit
� Date of death – billing for services after the patient’s date of death
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� Medically Unlikely Edits – services billed together subject to medically unlikely edits (e.g. same procedure billed with different surgical approach)
� NCCI Edits – review of unbundled services --use of modifiers -59, LT, RT
� Procedures performed during global surgery periods – use of modifiers 58, 78 or 79
� Multiple surgeries performed on the same patient on the same date of service – use of modifier 51
� E/M services with procedures that include pre-op and post-op payment – use of modifiers 25 or 57
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� E/M services during global days – use of modifier 24
� Co-surgeries billed by one physician without modifier and the other surgeon with modifier 62
� Duplicate claims for E/M services by physicians of same specialty within same group
� Add-on codes billed without primary codes
� Not a new patient E/M billed as new patient
� Medicare Claim Review Programs httpshttpshttpshttps://://://://www.cms.gov/MLNProducts/downloads/Mwww.cms.gov/MLNProducts/downloads/Mwww.cms.gov/MLNProducts/downloads/Mwww.cms.gov/MLNProducts/downloads/MCRP_Booklet.pdfCRP_Booklet.pdfCRP_Booklet.pdfCRP_Booklet.pdf
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� Complex review – when the RAC makes an over/under payment determination after evaluating the medical record
◦ Medical necessity reviews started in 2010
� Automated review – when the RAC is able to make an over/under payment determination without evaluating the medical record
◦ Excessive unit audits – the RAC searches for claims for two or more identical or bundled surgical procedures for the same beneficiary on the same day at the same hospital or office
◦ Claims for services that should not be reported more than once in a lifetime
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� PSCs conduct investigations; refer cases to law enforcement; and take administrative actions, such as referring overpayments to claims processors.
◦ In their investigative work, PSCs review Medicare payments and may identify overpayments which they are required to refer to Medicare claims processors for collection and return to the Medicare program
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� AdvanceMed
� Cahaba Safeguard Administrators, LLC
� Computer Sciences Corporation
� IntegriGuard, LLC
� SafeGuard Services, LLC
� TriCenturion
� TrustSolutions, LLC
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� The transition of PSCs to ZPICs is part of CMS’s consolidation of fraud-fighting work so that Parts A, B, C, and D will be under one type of contractor, the ZPIC.
� Parts A and B (hospital, skilled nursing, home health, provider and durable medical equipment claims);
� Part C (Medicare Advantage health plans);
� Part D (prescription drug plans) and coordination of Medicare-Medicaid data matches (Medi-Medi).
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Zone 1 – SafeGuard Services, LLC
Zone 2 – NCI, Inc. (previously AdvanceMed)
Zone 3 – Cahaba
Zone 4 – Health Integrity, LLC
Zone 5 – NCI, Inc. (previously AdvanceMed)
Zone 7 – SafeGuard Services, LLC
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� According to CMS staff, ZPICs that cover high-fraud regions will be expected to focus on quick response to fraud and administrative actions
Focus Areas:Focus Areas:Focus Areas:Focus Areas:
� Identify and deter Medicare fraud and abuse
� Develop high quality fraud cases for referral to the Office of Inspector General
� Respond to requests for Medicare data and support from law enforcement
� Identify and report program vulnerabilities to CMS
� Refer recommendations to the appropriate entity for a variety of corrective actions including provider education, overpayment recovery, licensure considerations
� Develop and validate methodologies for the early detection and prevention of fraud schemes and abusive billing to the Medicare Program
� Over-Utilization
◦ Bell Curves
◦ Focused reviews
� Use of Non-Physician Practitioners
◦ Incident-to, Shared/Split
� High Risk Areas of Coding
◦ Consultations
◦ Unbundled services – modifiers 25 and 59
4/17/2012
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Family Practice – New Patient Visits
-20.00%
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
99201 99202 99203 99204 99205
Practice
National
`
Family Practice – Follow-up Visits
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
99211 99212 99213 99214 99215
Practice
National
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4/17/2012
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� How many?
� How often?
� All providers?
� Who will perform?
� E/M?
� Procedural? Labs?
� Retrospective, Prospective?
� Attorney Client?
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� Not statistically valid nor random
◦ Judgmentally selected
◦ “Review” vs. “Audit”
◦ “Under-coded” and “Under-documented”
◦ AMA/CMS E/M Documentation Guidelines:
� 1995 or 1997
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� Judgmental Selection based on Utilization of billed services:◦ CPT Codes Analysis◦ E/M Risk Areas◦ E/M Specialty Bell Curves◦ E/M to E/M Ratios◦ E/M to Procedural Ratios
� Use of Non Physician Practitioners (NP, PA, CNS and CNM)◦ Incident-to◦ Shared/Split ◦ State scope of service
� Use of Ancillary Personnel (Nurse, Therapist, Audiologist, Social Workers, Nutritionists, etc.)
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� Supervision Requirements
◦ General, Direct, Personal (Over-the-shoulder)
� E/M codes and Residents and/or Locum Tenens
◦ Attestation statement for TP-R
� Procedural codes
� Modifiers
� Consultations
� Unbundled Services – Modifier 25 and 59
� Diagnosis Codes
◦ Coded but not documented
◦ ICD-9
◦ ICD-10?
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� Medical Necessity and Standard of Care
� Date of Service
� Place of Service
� Services Based on Time
� Diagnostic Statement Clarity
� Legibility
� Author Identification and Signature Requirements
� Allergies
� Cross-outs, Errors and Conflicts on Medical Record
� Sign-off on Test Results
� Written Interpretation and Report
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� Electronic Medical Records
◦ Evaluate templates
◦ Evaluate process of documentation capture
◦ Does EMR “Suggest” level of service?
◦ Was the level of history and exam necessary?
◦ Identify high risk areas
� “Cloned” records
� Medically necessary vs. medically appropriate
◦ Assist with implementation of creating EMR templates
◦ Provide training to new providers
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� Compliance Program Updated
� Educational Feedback
� Physicians, NPP’s, Coding and Billing Staff
� Implementation of Compliance Program
� Policies and Procedures for Coding/Billing Updated and Readily Available
� Ad hoc Support
� Follow-up Reviews Based on Problematic Areas
� On-going Awareness of Focus Areas
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� Maggie Mac
� 727-639-2030
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