RPANEPHROLOGYCODINGRPANEPHROLOGYCODING ANDBILLINGSEMINARSANDBILLINGSEMINARS 20122012 1 CodingandBillingforCodingandBillingfor NephrologyPracticesNephrologyPractices DebraLawson,CPC,PCSDebraLawson,CPC,PCS NephrologyBilling&ManagementServices,LLC. Rogersville,Tennessee 2 BreakingNewsBreakingNews …….................. CRIMERATESRISECRIMERATESRISE PerpetratorscaughtPerpetratorscaught AccomplicesnamedAccomplicesnamed Detailsat11Detailsat11 3 ITCANITCAN ’’THAPPENTOME!THAPPENTOME! BeeninpracticeforyearsandeverytimeBeeninpracticeforyearsandeverytime theylookittheylookit ’’sbeenOKsbeenOK II’’llll ““flyundertheradarflyundertheradar ”” sotheywonsotheywon ’’tlookattlookat meme IthappenedtoDr.Joe,buteveryoneknowsIthappenedtoDr.Joe,buteveryoneknows hehe ’’sacrooksacrook II’’masmallfish,theywillgoafterthebigmasmallfish,theywillgoafterthebig guysguys 4 WHATMAKESYOUAWHATMAKESYOUA TARGET?TARGET? TimelapseingettingtothedocumentationTimelapseingettingtothedocumentation LackofdocumentationLackofdocumentation SloppydocumentationSloppydocumentation LackofknowledgeofthedocumentationrulesLackofknowledgeofthedocumentationrules ThinkingdocumentationisThinkingdocumentationis ““justforbillingjustforbilling ”” andand isnotimportantisnotimportant –– ithasnothingtodowithithasnothingtodowith medicalcaremedicalcare II’’maspecialistmaspecialist –– allmyservicesarehighlevelallmyservicesarehighlevel 5 WHOISLOOKING?WHOISLOOKING? TheAuditAlphabetSoupTheAuditAlphabetSoup –– CMSCMS –– CERTCERT –– RACRAC Isn’titamazing…..theycanlook –– OIGOIG atus,butwhoislookingatthem! –– MICMIC –– ZIPZIP 6 WHYWOULDTHEYLOOKATWHYWOULDTHEYLOOKAT ME?ME? BillingforservicesnotrenderedBillingforservicesnotrendered IntentionalupcodingordowncodingservicesIntentionalupcodingordowncodingservices BillingoneproviderunderanotherproviderBillingoneproviderunderanotherprovider ’’ss numbernumber BillingBilling ““incidenttoincidentto ”” serviceswhentheserviceswhenthe physicianisnotinthesuitephysicianisnotinthesuite ““MonotoneMonotone ”” billingbilling 7 WHOARETHETARGETS?WHOARETHETARGETS? LargepracticesLargepractices SmallpracticesSmallpractices HospitalownedpracticesHospitalownedpractices TeachingpracticesTeachingpractices JointventuresJointventures YOU!YOU! 8 WHOARETHEHIREDGUNS?WHOARETHEHIREDGUNS? RACRAC –– AsofMarch27,2008CMSreportedAsofMarch27,2008CMSreported thattheRAChadthattheRAChad ““succeededsucceeded ”” incorrectingincorrecting morethan$1billioninimproperpaymentsmorethan$1billioninimproperpayments fromMedicarefromMedicare –– 96%($992.7million)in96%($992.7million)in overpaymentsand4%(37.8million)inoverpaymentsand4%(37.8million)in underpaymentsreturnedtoprovidersunderpaymentsreturnedtoproviders – www.cms.hhs.gov/RAC/Downloads/RAC%20Evaluation%20Report.pdf 9 WHENWILLTHEYCOMEFORWHENWILLTHEYCOMEFOR YOU?YOU? TheTaxReliefandHealthCareActof2006TheTaxReliefandHealthCareActof2006 madetheRACpermanentandmandatedmadetheRACpermanentandmandated thatCMSexpandtheprogramtoall50thatCMSexpandtheprogramtoall50 statesby2010statesby2010 ThirdpartyauditorshiredbyCMSwillThirdpartyauditorshiredbyCMSwill conducttheauditsconducttheaudits TheywillkeepapercentageofwhatisTheywillkeepapercentageofwhatis collectedcollected 10 HOWDOTHEYIDENTIFYHOWDOTHEYIDENTIFY PROBLEMCLAIMS?PROBLEMCLAIMS? AutomatedreviewAutomatedreview –– conductedwithoutconductedwithout reviewofthemedicalrecordsupportingthereviewofthemedicalrecordsupportingthe claimclaim ComplexreviewComplexreview –– analyzesactualmedicalanalyzesactualmedical recordssupportingclaimsunderrecordssupportingclaimsunder investigationinvestigation CannotreviewanyclaimspriortoOct.2007CannotreviewanyclaimspriortoOct.2007 11 COMPLEXREVIEWSCOMPLEXREVIEWS OnOn --sitereviewslookattheprovidersitereviewslookattheprovider ’’ss recordsinpersonrecordsinperson MayrequestamailorsecuretransmissionMayrequestamailorsecuretransmission oftherecordstotheRACoftherecordstotheRAC Mayreview10recordsper45daysforsoloMayreview10recordsper45daysforsolo practitionerspractitioners Ifnotreceivedwithin45daysRACmayIfnotreceivedwithin45daysRACmay renderaoverpaymentdecisionwithoutrenderaoverpaymentdecisionwithout reviewreview 12 PROVIDERPROVIDER ’’SRIGHTSSRIGHTS MayrequestanextensiontosecureandMayrequestanextensiontosecureand forwardrecordstotheRACforwardrecordstotheRAC RACmustfollowMedicarepolicies,RACmustfollowMedicarepolicies, regulations,nationalandlocalcarrierregulations,nationalandlocalcarrier determinationsandmanualinstructionsdeterminationsandmanualinstructions MustfollowMedicarecoverage,codingandMustfollowMedicarecoverage,codingand billingpoliciesandmaynotapplytheirownbillingpoliciesandmaynotapplytheirown 13 APPEALOFARACDECISIONAPPEALOFARACDECISION RedeterminationRedetermination –– 120daysfromdenial120daysfromdenial ReconsiderationReconsideration –– 180daysfrom180daysfrom redeterminationbyQualifiedIndependentredeterminationbyQualifiedIndependent Contractor(QIC)Contractor(QIC) AdministrativeLawJudgehearing(60daysafterAdministrativeLawJudgehearing(60daysafter QIC)QIC) MedicareAppealsCouncil(MAC)hearing(60MedicareAppealsCouncil(MAC)hearing(60 daysafterALJ)daysafterALJ) FederalDistrictCourt(60daysafterMAC)FederalDistrictCourt(60daysafterMAC) 14 SUCCESSRATEINAPPEAL?SUCCESSRATEINAPPEAL? Providershavebeensuccessful34%oftheProvidershavebeensuccessful34%ofthe timetheclaimswerechallengedtimetheclaimswerechallenged ThismaybelowgiventhenumberofThismaybelowgiventhenumberof appealsstillpendingappealsstillpending BecauseoftheincentivegiventheRACtoBecauseoftheincentivegiventheRACto finderrors,providersshouldconsideranfinderrors,providersshouldconsideran appealiftheythinktheRACiserroneousappealiftheythinktheRACiserroneous 15 ARETHEYALWAYSRIGHT?ARETHEYALWAYSRIGHT? JustbecauseyouhavegotteninformationJustbecauseyouhavegotteninformation aboutaRACdetermination,donaboutaRACdetermination,don ’’talwaystalways assumeitisthecorrectdecisionassumeitisthecorrectdecision RecentlytherewasanerroneousdecisionRecentlytherewasanerroneousdecision byConnollyConsultingAssociates(RegionbyConnollyConsultingAssociates(Region ““CC”” RAC)thatinvolvednumerousprovidersRAC)thatinvolvednumerousproviders fromWestVirginiatoTexas.ThisdecisionfromWestVirginiatoTexas.Thisdecision wasinvolvinghospitaladmissionsduringawasinvolvinghospitaladmissionsduringa monththeMCPwasprovidedmonththeMCPwasprovided 16 HOWDOWEPREPAREFORHOWDOWEPREPAREFOR ANAUDIT?ANAUDIT? ““AnounceofpreventionisworthapoundofAnounceofpreventionisworthapoundof curecure ”” appliestoauditingasmuchastoappliestoauditingasmuchasto medicinemedicine LookathowthingsaredoneLookathowthingsaredone …….objectively.objectively notjustinhowisshouldbedonenotjustinhowisshouldbedone EducationEducation CorrectiveactionCorrectiveaction –– ifyouarenotgoingtoifyouarenotgoingto takethesteptakethestep ……dondon ’’tdotheaudittdotheaudit 17 DOCUMENTATIONDOCUMENTATION GUIDELINESGUIDELINES 18 ICD9ICD9 WhatisthepatientsproblemthatYOUareWhatisthepatientsproblemthatYOUare addressing?addressing? Isitasymptomoradiagnosedcondition?Isitasymptomoradiagnosedcondition? Isitsingularormultiple?Isitsingularormultiple? Istheclinicalpicturereflectedcomplete?Istheclinicalpicturereflectedcomplete? Howisitrecorded?Howisitrecorded? –– InthechartInthechart –– OnthebillOnthebill 19 CPTCPT WhatisthephysicianserviceWhatisthephysicianservice YOUYOU performed?performed? –– AretheelementsofdocumentationguidelinesAretheelementsofdocumentationguidelines reflected?reflected? –– Wheredidyoudoit?(siteofservice)Wheredidyoudoit?(siteofservice) –– Howisitcategorized?(screeningortreatment)Howisitcategorized?(screeningortreatment) –– Howisitrecorded?Howisitrecorded? Inthechart Onthebill 20 INTRODUCTIONINTRODUCTION ““TheproofisinthedetailTheproofisinthedetail ”” ThemedicalrecordisnotonlyadocumentThemedicalrecordisnotonlyadocument forbillingbutalsoachronologicalrecordofforbillingbutalsoachronologicalrecordof thecarethatisrenderedtothepatientthecarethatisrenderedtothepatient ThemedicalrecordprotectsboththepatientThemedicalrecordprotectsboththepatient andtheproviderintheeventofaandtheproviderintheeventofa malpracticecasemalpracticecase Inanaudit,themedicalrecordistheonlyInanaudit,themedicalrecordistheonly thinganauditorwillreviewthinganauditorwillreview 21 DOCUMENTATIONDOCUMENTATION GUIDELINESFORGUIDELINESFOR EVALUATIONANDEVALUATIONAND MANAGEMENTMANAGEMENT SERVICESSERVICES 22 DOCUMENTATIONDOCUMENTATION E/MSERVICESE/MSERVICES DescriptorsforthelevelsofE/MservicesDescriptorsforthelevelsofE/Mservices recognizesevencomponents:recognizesevencomponents: HistoryHistory ExamExam MedicalDecisionMakingMedicalDecisionMaking CounselingCounseling CoordinationofCareCoordinationofCare NatureofPresentingProblemNatureofPresentingProblem TimeTime 23 E/MDOCUMENTATIONE/MDOCUMENTATION HISTORYHISTORY HistoryincludessomeoralloftheHistoryincludessomeorallofthe followingelements:followingelements: ChiefComplaint(CC)ChiefComplaint(CC) HistoryofPresentIllness(HPI)HistoryofPresentIllness(HPI) ReviewofSystems(ROS)ReviewofSystems(ROS) Past,Familyand/orSocialHistoryPast,Familyand/orSocialHistory (PFSH)(PFSH) –– DG:TheCC,ROS,andPFSHmustDG:TheCC,ROS,andPFSHmust belistedasseparateelementsofbelistedasseparateelementsof history,ormaybeincludedinthehistory,ormaybeincludedinthe descriptionoftherecordedhistoryofdescriptionoftherecordedhistoryof thepresentillnessthepresentillness 24 E/MDOCUMENTATIONE/MDOCUMENTATION HISTORYHISTORY –– DG:AnearlierROSand/orPFSHneedDG:AnearlierROSand/orPFSHneed notberenotbere --recordedifevidenceshowsrecordedifevidenceshows update.Thereviewandupdatemaybeupdate.Thereviewandupdatemaybe documentedby:documentedby: