Coding Strategy

Practice size does not matter when dealing with compliance — even solo practitioners have to stay on the straight and narrow.

Even small dermatology practices have to stay compliant with government regulations — and although this sounds like a simple fact, it’s one that many Part B providers may overlook.

Ensuring physician practice compliance can be a complex path, and many practices think of it is something that large hospitals should focus on — after all, those are the entities that get all of the media exposure when they violate compliance rules. But every practice is responsible for compliance, no matter how big or small.

Doctors Take Note

In some cases, small practices think compliance rules don’t affect them — but also don’t realize they’re at risk of being noncompliant.

Example: “I met with a solo practitioner a few years ago who hired me as a consultant,” says Laura E. Hill, CPC, CPC-I, an Arizona- based compliance consultant.

“It was my sad duty to let him know that his office manager,who submitted all of his claims, was upcoding all of his office  visits as she entered them into the computer so that she could pay his quarterly malpractice-insurance premiums,” Hill says. “She had been working for him for 10 years and was a loyal and trustworthy employee.”

The fault was the physician’s, because he never took the time to review the monthly reports that the office manager gave to him, Hill says. He also never looked closely at his deposits into his corporate checking account, where there was an obvious trend toward increased deposits every third month.

Pay attention to your advisors: In the example above, the physician’s accountant had pointed the problem out to him, “but he accepted his office manager’s explanation that insurance companies often held payments until the end of the quarter so that they made more money on interest collected during the three months they delayed paying on claims,” Hill says. “He was very upset when I advised him he would have to self-disclose to all of the insurance companies for the 10 years she had been doing his billing and that he would have to send a check for the overpayments along with the letters.”

Why? It was the physician’s responsibility to handle the overpayments since he owned the practice and the claims were submitted using his provider number. “He is charged with the oversight of the billing and coding procedures,” says Mark C. Rogers, Esq., with The Rogers Law Firm in Braintree, Mass.

The following four considerations should come into play in a scenario such as this, Rogers advises:

• The physician should immediately terminate the office manager’s employment.

• A full audit of the practice’s billing should take place since the office manager began her employment (if there is a problem with upcoding in one area; there are likely problems elsewhere, Rogers says).

• As part of his self-disclosure, the physician should indicate what he has done to ensure that such a scenario will not happen again. In particular, the termination of the employee and the implementation of an effective corporate compliance program.

• Fully document the above steps.

Know How to Avoid These Issues

The scenario described above can affect practices of all sizes.“Few practices have a set compliance plan that they work and they keep alive,” Hill says. Following are two tips that she has gleaned through her auditing work, which you can use to make sure your practice stays on the straight and narrow.

• Internal audits are a must, with a minimum of quarterly physician education included. “Making money as a physician today is a constant challenge,” Hill says. “Most physicians see 10 times as many patients than they did 10 years ago just to make the same amount of money. All too often, the corners that are cut are related to the quality and integrity of their staff.”

• Keep an eye on HIPAA: Complete disregard for even the basic HIPAA laws is common as well, Hill says. “The longer the practitioner has been in practice, the worse the infractions are.”

@ Dermatology Coding Alert (Editor: Jerry Salley, CPC).

Sign up for the upcoming live audio conference, Risk Management Strategies for Healthcare Providers, or order the CD/transcripts.

Be a hero. Sign up for Supercoder.com, and join the coding community at the Supercoder.com Facebook Fan Page.

RACs are just another tool in the government’s arsenal to collect improper payments.

You’ve got so many compliance acronyms flying at you every day that you may not be able to differentiate your RAC from the OIG. Know these quick facts about RACs to stay better informed.

• Recovery audit contractors (RACs) detect and correct past improper payments so CMS and the MACs can prevent such problems in the future
• RACs are hired as contractors by the government, and they can can collect “contingency fees,” which means that they get a percentage of the amount that they recover from providers who were paid inappropriately The maximum RAC lookback period is three years, and they cannot review claims paid prior to Oct. 1, 2007
• Between 2005 and 2008, RACs involved in the original demonstration project recovered over $1.03 billion in Medicare improper payments, but referred only two cases of potential fraud to CMS, according to a February OIG report on the topic, which noted that “because RACs do not receive their contingency fees for cases they refer that are determined to be fraud, there may be a disincentive for RACs to refer potential cases of fraud.”
• Unlike RACs, the OIG is a government entity. Although the OIG also performs reviews and audits and seeks improper payments, the OIG does not collect contingency fees.

For more on the RAC program, visit www.cms.gov/rac.

@ Part B Insider. Editor: Torrey Kim, CPC

Sign up for the upcoming live Webinar, You Can Use the Appeals Process Like a Pro, or order the CD/transcripts.

Be a hero. Sign up for Supercoder.com, and join the coding community at the Supercoder.com Facebook Fan Page.

Plus: The OIG recovered over $1.5 billion in fiscal year 2009, and is on the lookout to collect more.

With less than two weeks to go before Medicare payments once again threaten to decrease by 21 percent, a new report sheds light on the financial outcome of Congressional actions.

Although the 2010 Physician Fee Schedule originally included a conversion factor that would have been 21 percent lower than the 2009 level, practices haven’t felt that cut yet this year,because legislators have voted several times to freeze payments, which now use the conversion factor of $36.0791. That freeze will expire on May 31, after which your Medicare payments will drop considerably unless Congress steps in once more.

However, one government entity’s calculations show that the freeze is costly. According to a May 7 Congressional Budget Office report, freezing payments at the current levels for the rest of 2010 would cost the government… … $6.5 billion. The AMA has turned up the heat on Congress to replace the current payment method, releasing a print ad aimed at Congress to demonstrate that “more delays of permanent reform now increase the cost for taxpayers,” and that the association “calls on Congress to fix the flawed Medicare physician payment formula now.”

Congress has not yet introduced a bill to extend the payment freeze past May 31. Keep an eye on the Insider for more information as this story develops.

To read the Congressional Budget Office’s calculation sheet,visit www.cbo.gov/budget/factsheets/2010b/SGR-menu.pdf.

@ Part B Insider. Editor: Torrey Kim, CPC

Sign up for the upcoming on-demand Webinar, 5 Steps to Optimize Your Office’s Coding & Billing Practices, or order the CD/transcripts.

Be a hero. Sign up for Supercoder.com, and join the coding community at the Supercoder.com Facebook Fan Page.

Keep signature, modifier 59, and ‘Incident To’ guidelines front and center.

If you’ve been worrying that the oncologist’s illegible signature on an order is going to come back to haunt your practice in an audit, CMS has offered
answers on when you’re in the clear and when that untidy scrawl could have reviewers requesting additional information.

1. Get Signature Guidelines Down Pat

With few exceptions, Medicare requires a signature for services and orders. CMS updated the rules and added e-prescribing language to the mix in Transmittal 327, CR6698. The rules instruct contractors reviewing claims on what counts as a signature and when the services or orders must have signatures.

One important exception to the signature requirement is that “diagnostic orders need not be signed by the physician,” says Kelly Loya, CPC-I, CPhT, consultant with California-based Sinaiko Healthcare Consulting Inc. Still, the medical record must include information verifying the ordering physician intended the test to be performed, and “a progress note in the medical record must be signed,” Loya explains.

A very helpful feature of the transmittal is a chart that “gives very specific facts as to what meets the requirements or requires follow up with the provider to meet the requirements,” says Loya. For example, if you scan the chart, you can quickly see that an illegible signature written above a typed name is OK, but contractors won’t count just an unsigned typed note with a typed name. “The reviewer can explore alternate methods in order to verify the signature requirement,” Loya notes. “Not complying with an attestation request (within 20 days of the request)” could lead to a denial, she warns.

If you’ve been reporting G8553 (At least one prescription created during the encounter was generated and transmitted electronically using a qualified ERX system), be sure to give the transmittal a close look. The new e-prescribing language solidifies that for non-controlled substances, “as long as a ‘qualified’ e-prescribing system (per Medicare Part D requirements) is used, a pen and ink copy” of the signed prescription order is not required, Loya says. But physicians can’t e-prescribe controlled substances — for example, addictive pain medications — so CMS requires a pen and ink order for these.

Watch for change: The Drug Enforcement Agency recently released its interim final rule on e-prescribing controlled substances. If your oncologist is willing to jump through the multi-step authentication hoops, e-prescribing controlled substances may be a possibility in the future.

Transmittal 327 is effective March 1 with an April 16 implementation date.

2. OIG Is Watching Mod 59; Are You?

In other news, the OIG released its 202-page “Compendium of Unimplemented OIG Recommendations,” which revealed that many OIG suggestions have been ignored.

Case in point: In 2003, the OIG found a 40 percent error rate on claims that contained modifier 59 (Distinct procedural service) when used to separate Correct Coding Initiative (CCI) edits, resulting in Medicare paying $59 million in improper payments.

The OIG encouraged carriers to institute prepayment and postpayment reviews of the use of modifier 59, and suggested that CMS should update carriers’ claims processing systems so they pay claims with modifier 59 “only when the modifier is billed with the correct code,” the OIG report indicates. The OIG now says that CMS has not yet instituted such system edits, and notes that it will “continue to monitor CMS’s efforts to implement edits to ensure correct coding.”

What this means: “The OIG lists modifier 59 as a priority nearly every year, and it’s possible that the agency feels that CMS should be looking more closely at its use,” says Randall Karpf with East Billing in East Hartford, Conn. “The bottom line is that if all of these entities are watching modifier 59, make sure you’re using it properly.”

In particular, past OIG investigations have shown that one of the more common modifier 59 mistakes is incorrectly unbundling 38220 (Bone marrow; aspiration only) and 38221 (… biopsy, needle, or trocar), so be sure you keep a careful eye on this code pair.

Plus: The OIG examined services billed using the “incident to” guidelines, which you should know well if you report oncology services to Medicare. As a result of the OIG scrutiny, CMS is revising its incident to policies to reflect the fact that “no one except licensed physicians perform the services or nonphysicians who have the necessary training, certification, and/or licensure, pursuant to state laws, state regulations, and Medicare regulations perform the services under the direct supervision of a licensed physician.”

Although many practices already follow this rule, the OIG “wants an explicit rule rather that the current implicit rule,” says Quinten A. Buechner, MS, MDiv, CPC, ACSFP/ GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis.

@ Oncology Coding Alert, Editor: Deborah Dorton, JD, MA, CPC

Master complicated modifiers and boost your reimbursements with these tips and tricks. Attend this on-demand Webinar: How to Mitigate Modifier Mishaps. Can’t make it? Order a transcript/CD.

Be a hero. Sign up at Supercoder.com and join the coding community at the Supercoder.com Facebook Fan Page.

Following 10-year-rule eliminates G0121 rejection.

If you slip up on screening colonoscopy claims’ frequency guidelines and eligibility requirements, Medicare will pay you zilch.

Use this guidance to capture every screening dollar your gastroenterologist deserves.

Home in on Eligibility Requirements for Average-Risk Test

Any Medicare patient 50 years or older is eligible for a covered Medicare screening, explains Dena Rumisek, CPC, biller at Grand River Gastroenterology PC in Michigan. These patients can have a colorectal cancer screening only once every 10 years. You’d be wise to pay attention to the frequency guidelines, as “Medicare is very stringent on the date … it has to be 10 years or longer — it can’t be 9 years and 360 days” between covered screening colonoscopies, Remise warns.

Example: A 73-year-old established Medicare patient with average risk for colorectal cancer reports for a screening colonoscopy on Feb. 11, 2009. The patient’s records indicate that he last had a covered screening on Jan. 31, 1999. On the claim, you should report G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).

One bit of simplicity: Report G0121 if there is no need for any therapeutic intervention during the colonoscopy. All G0121 claims require only one diagnosis code: V76.51 (Special screening for malignant neoplasms; colon). “If the chart shows a diagnosis such as colitis, you shouldn’t be reporting a screening,” says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA’s CPT Advisory Panel.

Error averted: The chart notes and the procedure diagnosis should be consistent. “This is something the OIG and RAC auditors are scrutinizing,” Weinstein says.

Change Your Coding for Recent Sigmoidoscopy

The frequency rules differ depending on whether other related colorectal cancer tests were performed previously. If a patient has had a routine flexible sigmoidoscopy screening (G0104, Colorectal cancer screening; flexible sigmoidoscopy), he is not entitled to a screening colonoscopy for at least 48 months.

Example: An average-risk established Medicare patient reports to the gastroenterologist for a screening colonoscopy on March 18, 2010. The patient’s medical record indicates that he had a flexible sigmoidoscopy screening on April 7, 2007.

This patient is not now eligible under Medicare guidelines for a screening colonoscopy because it has been only three years since his sigmoidoscopy. Therefore, you cannot report G0121 for the March 2010 procedure and expect payment from Medicare.

Alter the Rules for High-Risk Patients

A patient who is considered at high risk for colorectal cancer might be entitled to a screening colonoscopy as frequently as once every 24 months. You’ll list a V code (such as V10.05, Personal history of malignant neoplasm; large intestine, or V12.72, Personal history of certain other diseases; diseases of digestive system; colonic polyps) as the primary diagnosis for these tests — most of the time.

Exception: If a patient has a condition that automatically puts him at high risk for colorectal cancer, then you would list that condition as the primary diagnosis (for instance, Crohn’s disease or ulcerative colitis; check your local coverage determination [LCD] for your payer’s specific list).

Example: A 69-year-old established Medicare patient with a personal history of colonic polyps reports to the gastroenterologist for a colonoscopy screening on March 1, 2010. The patient record indicates that the patient’s last colonoscopy screening was Feb. 4, 2008. On the claim, report G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) with V12.72 appended.

Beware Private Payer Screening Differences

Some private payers will reimburse for colonoscopy screenings — their coding practices for these services, however, can differ from Medicare. Many U.S. states have passed legislation similar to the Medicare regulations requiring all health insurance companies to cover routine colorectal cancer screening starting at age 50. Most non-Medicare payers accept 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing; with or without colon decompression [separate procedure]) for a screening colonoscopy. Before coding these services, check the payer’s frequency and diagnosis guidelines. Each payer reimburses for screenings according to the patient’s policy.

G codes possible: Other private payers might want you to code the same way as Medicare. For instance, Blue Cross Blue Shield of Michigan accepts the G codes nd follows most of the same diagnosis guidelines as Medicare, says Rumisek.

Best bet: Check with your private payers before coding any screening colonoscopy services.

@ Gastroenterology Coding Alert, Editor: Caroline Harris

Want to know more? Order the CD or transcript of Jill M. Young’s Things You Shouldn’t Have to Swallow in Gastroenterology Billing.

Be a hero. Sign up at Supercoder.com.