AMERICAN OSTEOPATHIC ASSOCIATION

AMERICAN OSTEOPATHIC ASSOCIATION DIVISION OF SOCIOECONOMIC AFFAIRS Presents: Medicare Updates, Documentation, Auditing and Incident To” Physician Billing December 3, 2011

Socioeconomic Affairs Staff • Yolanda Doss, MJ, RHIA, Director, Division of Socioeconomic Affairs • Sandra Peters, MHA Assistant Director, Clinical Practice Outreach • Michele Campbell, CPC, Coding & Reimbursement Specialist • Kavin Williams, CPC, CCP Health Reimbursement Policy Specialist

Yolanda Doss, MJ, RHIA Responsibilities include: • Helping to secure reimbursement for osteopathic services • Securing the acceptance of osteopathic credentials • Addressing Medicare issues • HIPAA compliance • Fraud and Abuse

Sandra Peters, MHA Responsibilities include: • Develop educational material on physician advocacy, manage care, quality and performance measures impacting osteopathic medicine • Design and manage a set of member services to enhance their manage care interactions and to promote their opportunities to participate in manage care • Provide update to the AOA leadership on health care trends particularly in the areas of pay for performance and physician profiling

Michele Campbell, CPC Responsibilities include: • Assists AOA members with coding and billing questions • Assists AOA members with coding disputes with carriers • Medical record reviews in audit situations. • Coordinates AOA’s responses to AMA CPT coding requests • Provide physician education on coding and coding guidelines • Write monthly coding hints and participate in articles that effect the profession

Kavin T. Williams, CPC, CCP Responsibilities include: • Oversees and assists AOA members with payment disputes and health payment policies. • Oversees the AOA Coding and Reimbursement Advisory Panel. • Represents the AOA at national reimbursement policy meetings.

Contact Information • Yolanda Doss 1-312-202-8187 ydoss@osteopathic.org • Sandra Peters 1-312-202-8088 speters@osteopathic.org • Michele Campbell 1-312-202-8182 mcampbell@osteopathic.org • Kavin T. Williams, -312-202-8194 kwilliams@osteopathic.org

The Objective is to Provide Informationon the Following Topics: • Medicare 2012 Updates • Evaluation & Management • Medicare Audits • Recovery Audit Contractors (RAC) • “Incident To” Services

Medicare 2012 Updates • Physician Fee Schedule is facing a 30 percent reduction • Physician Quality Reporting Initiative (PQRI) Bonus Payment 2% • E-Prescribing Bonus Payment 2% • OMT Survey

Physician Documentation • This is critical to your reimbursement • If it was not documented it did not happen • Clear and Legible, words to document by • Chief complaint (this is the driver to most insurance auditors) • Familiarize yourself with your documentation style- is it 1995 guidelines that you follow or 1997?

Documentation Guidelines • The medical record should be complete and legible. • The documentation of each patient encounter should include: • reason for the encounter and relevant history, physical examination findings and prior diagnostic test results; • assessment, clinical impression or diagnosis; • plan for care

Documentation Guidelines [Cont.] • The patient’s progress, response to and changes in treatment, and revisions of diagnosis should be documented. • The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record. • Hospital visits should be included in the patient’s chart

Evaluation & Management (E/M) Coding • Coding for office visits • Modifier usage when billing an E/M with a procedure (OMT) • Time Based Coding

Chief Complaint (CC) • The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factors that is the reason for the encounter, usually stated in the “patient’s own” words. • Documentation Guidelines states that the medical record should clearly reflect the chief complaint

Medical Necessity • This area is not black/white • There are numerous definitions of medical necessity • Linking the appropriate diagnosis to the appropriate procedure to support the necessity of the procedure performed is critical. • Medicare defines medical necessity as services or items reasonable and necessary for the diagnosis or treatment of illness or injury to improve the functioning of a malformed body member.

Coding For Time • When is it appropriate to code for time? • What is the auditor looking for when they review a chart that was billed as time being the controlling factor?

Tips For Verbiage When Billing For Time Example of correct documentation of time: • In your note it should read “ I spent 45 minutes with the patient and over 50% of that time was spent discussing … Example of incorrect documentation of time: • “I spent 45 minutes with the patient, discussed surgical options versus medical management.

How Would Code This Date of Service

What Is An Audit? • An effective tool used by Medicare and other payors to recover monies lost to fraud and erroneous billings.

Why Audits Are Initiated? • Suspicion (Billing Pattern) • Outlier Physicians • The Senior Patrol • Whistleblowers • Procedure Codes

Who Are The Auditors? • The Office of the Inspector General (OIG) • Medicare • The Department of Justice (DOJ) • The Federal Bureau of Investigation (FBI) • Carriers

Types of Audits • Prepayment Audits • Post-Payment Audits • Statistical Sampling Method

What Auditors Look For? • Billing for services or supplies that were not provided. • Billing for non-allowable or non-covered services. • Altering claim forms to receive a higher payment amount. • Unbundling claims.

How To Respond To A Request For Documentation • Reply to the audit notice in a timely fashion. • Gather and submit Only the requested documentation. • Be cooperative. • You may want to conduct an internal audit.

How to Respond to the Audit Findings • If the findings are not favorable: • Attempt to discuss the findings with the reviewer. • If necessary request redetermination. • If necessary request a level one appeal.

Medicare Recovery AuditContractors (RACs) 26

RAC Legislation The RAC program was created by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 which pays incentive fees to third-party auditors that identify and correct improper payments paid to healthcare providers in fee-for-service Medicare. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 also requires permanent and nationwide RAC program by no later than 2010 27

The RAC Demonstration Project • The RAC demonstration project took place of New York, Florida, and California. • By 2010 the RAC covered all 50 states.

RAC Program Mission To detect and correct past improper payments, To implement actions that will preventfutureimproper payments. Providers can avoid submitting claims that don’t comply with Medicare rules CMS can lower its error rate Taxpayers & future Medicare beneficiaries are protected 29

The New RAC’s Are: • Diversified Collection Services, Inc. of Livermore, California, in Region A, initially working in Maine, New Hampshire, Vermont, Massachusetts, Rhode Island and New York. • CGI Technologies and Solutions, Inc. of Fairfax, Virginia, in Region B, initially working in Michigan, Indiana and Minnesota. • Connolly Consulting Associates, Inc. of Wilton, Connecticut, in Region C, initially working in South Carolina, Florida, Colorado and New Mexico. • HealthDataInsights, Inc. of Las Vegas, Nevada, in Region D, initially working in Montana, Wyoming, North Dakota, South Dakota, Utah and Arizona. Additional states will be added to each RAC region in 2009

Minimize Provider Burden Limit the RAC “look back period” to three years Maximum look back date is October 1, 2007 RACs will accept imaged medical records on CD/DVD Limit the number of medical record requests 31

Medical Record Limit Example Outpatient Hospital 360,000 Medicare paid services in 2007 Divided by 12 = average 30,000 Medicare paid services per month x .01 = 300 Limit = 200 records/45 days (hit the max) 32

Summary of Medical Record Limits (for FY 2009) Inpatient Hospital, IRF, SNF, Hospice 10% of the average monthly Medicare claims (max 200) per 45 days per NPI Other Part A Billers (HH) 1% of the average monthly Medicare episodes of care (max 200) per 45 days per NPI 33

Summary of Medical Record Limits (for FY 2009) Continued Physicians (including podiatrists, chiropractors) Sole Practitioner: 10 medical records per 45 days per NPI Partnership 2-5 individuals: 20 medical records per 45 days per NPI Group 6-15 individuals: 30 medical records per 45 days per NPI Large Group 16+ individuals: 50 medical records per 45 days per NPI Other Part B Billers (DME, Lab, Outpatient hospitals) 1% of the average monthly Medicare services (max 200) per NPI per 45 days 34

RAC Validation Contractor (RVC) • CMS has contracted with Provider Resources, Inc. of Erie, PA, to work as the Recovery Audit Contractor (RAC) Validation Contractor. • The RAC Validation Contractor (RVC) will work with CMS and the RAC to approve new issues the RACs want to pursue for improper payments, as well as perform accuracy reviews on a sample of randomly selected claims on which the RACs have already collected overpayment. • The RVC is another tool CMS will use to provide additional oversight and ensure that the RACs are making accurate claim determinations in the permanent program.

For Additional Information on RAC • http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6125.pdf • http://www.cms.hhs.gov/RAC/Downloads/RAC%20Evaluation%20Report.pdf • http://www.cms.hhs.gov/rac/

Medicare “Incident to” Physician Services The OIG reviews Medicare services that are “incident to” physicians services to determine the qualificationsand appropriateness of the staff whoperformed them.

Physician Defined The “physician” refers to physician or other practitioner (listed below), who are authorized to receive payment for services “incident to” his or her own services. • physician assistants • nurse practitioners • clinical nurse specialist • nurse midwife, and • clinical psychologist

Professional Service • A direct, personal, professional service which is rendered by the physician • To meet the “incident to” guidelines, the physician must initiate the course of treatment, and • Conduct subsequent physician services to show ongoing involvement

Coverage Requirements To be covered, service and supplies must be: • An integral, though incidental, part of the physician’s or on-physician practitioner’s professional services • Commonly furnished in a physician’s office or clinic • Furnished by the practitioner or auxiliary personnel under the physician’s direct supervision

Supervision Requirements Direct physician supervision of auxiliary personnel is required. Auxiliary personnel: • any individual (employee, leased employee, or independent contractor) who is acting under the supervision of a physician • Auxiliary personnel include nurses, medical assistants, technicians, etc.

Direct Supervision in the Office • Physician must be present in the office suite • Physician must be immediately available to assist if needed • Does not require that the physician be in the same room

Direct Supervision in the Office Continued Scenarios that do not meet the direct supervision requirement: • Availability of a physician by telephone • Physician presence somewhere in an institution

Documentation To support the use of the incident to provision, the documentation should clearly indicate: • Who performed the “Incident to” service • The physician’s presence in the office suite during the service/procedure

Division Website • Go to www.do-online.org and sign onto DO-Online. • First time users will need their AOA member number to sign up. • On DO-Online, click on Practice Management for the division website. • There is also a Division email address: practicemanagement@osteopathic.org.

Billing and Coding E/M documentation ICD-9-CM code updates OMT information Legal Litigation fund Updates on class action suits CMS/Medicare Links to local carrier information Information on each CPT code Enrollment information CMS Medlearn CCI link Fee schedules, new and prior What the DO-Online Practice Management Website has for You

Preventive health services Demonstration projects CERT- fraud and abuse information HIPPA Managed care Osteopathic Advocacy Resources What the DO-Online Practice Management Website has for You

Division CME Seminars • Conducted in conjunction with state associations and specialty colleges. • Seminars available include Medicare Compliance, HIPAA Privacy Compliance, and Documentation Guidelines and Coding Reimbursement. • Call Yolanda Doss, MJ, RHIA at 800-621-1773 ext. 8187 or ydoss@osteopathic.org for info.

Contact Information • Yolanda Doss 1-312-202-8187 ydoss@osteopathic.org • Sandra Peters 1-312-202-8088 speters@osteopathic.org • Michele Campbell 1-312-202-8182 mcampbell@osteopathic.org • Kavin T. Williams, -312-202-8194 kwilliams@osteopathic.org

AMERICAN OSTEOPATHIC ASSOCIATION