Medicare CERT Audits: The Physician’s Perspective

1. Brian S. Parsley, MD 2nd Vice President AAHKS Clinical Associate Professor Baylor College of Medicine Houston, Texas Medicare CERT Audits: The Physician’s Perspective

2. Who Do We Serve? • The PATIENT • We Want to Get It Right • Outline the Rules and We Will Follow Them! • We Want to Maintain Access to Care for Our Patients. • We are in this Together!

3. Medicare Claims Data Medicare receives over 1.2 Billion claims per year. This equates to: • • 4.6 million claims per work day, or • •575,000 claims per hour • •9,580 claims per minute • •160 claims per second

4. Why Are Audits Beneficial???

5. Error Rates and Improper Payments

6. Improper Payments vs. Fraud • ALL FRAUDULENT CLAIMS ARE IMPROPER PAYMENTS BUT ALL IMPROPER PAYMENTS ARE NOT FRAUDULENT CLAIMS!!!!! • MOST ARE DUE TO IMPROPER DOCUMENTATION!

7. Is This AHospital Problem? • You bettcha! • It can affect the cost of borrowing • It raises the costs to hospital • It increases the cost of care • Purchase of new equipment • Maintenance of facility/ equipment • Staffing ratios and salaries to attract good staff • Marketing (information in the public domain)

8. Is This Just a Hospital Problem? • No! • Physician payments are now coming under review. • If the hospital services are denied then you will be denied! • Physicians are now being audited directly

9. DOCUMENTATION, DOCUMENTATION,DOCUMENTATION • CMS Wants to know what YOUare thinking • Accurate and complete documentation in the physician records as well as the hospital records is the key • A medical evaluation must be performed. The evaluation should include: • clear documentation of the patient’s functional status • documentation of the patient’s mobility and pain. • evaluation may be done all or in part by the surgeon. • the surgeon must sign off on the report and incorporate it into their records.

10. What Is My Hospital Requiring Now? • Pre certification and approval of DRG 470 patients prior to posting on surgery schedule • Screening for sufficient data to justify surgery • This effects both Medicare and commercial insurance patients

14. Advanced DJD Must Be Demonstrated By • pain or functional disability from injury due to trauma or arthritis of the joint and • non-surgical medical management must have been tried and failed and such management must be clearly addressed in the pre-procedure medical record • non-surgical medical management have been tried for a sufficient period (usually three months) to assess effectiveness. Treatment should include one of more of the following: • anti-inflammatory medications • analgesics • flexibility and muscle strengthening exercises • supervised PT (DATE OF TREATMENTS???) (COST OF TREATMENT?) • activity restrictions as is reasonable • assistive devices (canes, braces, etc.) • weight reduction as appropriate • therapeutic injections into the joint as appropriate • radiographic supported evidence (X-ray) or MRI supported evidence

15. How Can I Help?

16. Clear Documentation Improves Likelihood of Payment • Chief Complaint: End stage osteoarthritis, right knee, for knee replacement. • History: Patient has had bilateral osteoarthritis, gradually progressive over 10-15 years. Most recent X-ray (7/22/11), right knee shows joint space near obliteration along with marginal osteophytes and subchondral sclerosis. Has been treated as follows: Ibuprofen 400 mg QID since January; PT 3 x week from 3/15/11 to 6/30/11. Patient started using a cane in May. Right knee pain is continuous at level 3/10 with 6/10 on ambulation. Sometimes pain keeps him up at night. No longer able to climb the five steps to his front door. Knee pain and stiffness limit walking to less than 25 yards without resting. • Physical Exam: Bilateral knee deformity consistent with severe osteoarthritis. Right knee reduced to less than 90 degrees. Unable to rise from a chair unassisted. • Impression: Worsening pain, deteriorating range of motion and significant interference with function. Current therapy ineffective. Total Knee Replacement is only option for pain control and functional restoration. • Orders: Admit to inpatient care for right TKR.

17. Operative Report • MUST be dictated for transcription within 24 hours • Operative findings should support the diagnoses; describe pathology observed in detail. • For your and the surgical assistant’s benefit, describe the need for any surgical assistance. • Include type of metal or ceramic surface of prostheses, orthopedic devices, use of cement and rationale for biological products. Include every item used in this description. • Describe any complications and how handled intraoperatively.

18. Discharge Summary Report • RECOMMEND dictating within 24 hours of discharge for optimal coding. • This intended to be more than a recap of the surgery performed. • If complication occurs, THEN DOCUMENT IT IN THE D/C • OP patients discharged the day of surgery also must have pertinent information filled in the form.

19. Tips to Avoid Denial of Claims: Properly Documenting Medical Necessity

20. Tips to Avoid Denial of Claims: Properly Documenting Medical Necessity • MR should contain enough information to support the determination that the total joint procedure was reasonable and necessary =presence of advanced DJD • Currently, audits show medical records commonly lack documentation that justifies the need for payment. • Not Fraud and Abuse but lack of Documentation!

21. Do You Have EHR? Then USE IT! • Set up templates to ask the questions that you need to include and allow for comment sections so that you can explain yourself • Describe the treatment plans and include as many dates as possible • Add X-ray detail check-offs • Instruct your office personnel on the importance

25. If Your Hospital Has NOT Been Audited……………It Will Be !!! • Take this information and educate your Hospital and Colleagues on Medicare Audits • Work with your hospital NOW to begin to screen and review all cases for compliance with criterion and educate them prior to review • Recommend and Implement changes in your office process and EHR to ensure documentation

26. An Ounce of Prevention is Worth a Pound of Cure

27. What Do I Do If My Record Is Audited? • DO NOT TAKE THIS LIGHTLY!!!!!!!! • Work with Your Hospital • Spend the time to pull all your data together • Contact your patients for additional data to submit for your appeal. This includes requesting information from prior orthopaedic and primary care records. • The more information provided at first appeal, the higher the success on Appeal!

28. YOUR FEE IS NEXT!!!!!!!!!!!!

29. Knee Case Audit Example No discussion of level of knee pain, degree of limitation, ambulation status, need for assistive devices

30. Knee Case Audit Example No Discussion regarding function, ambulation, assistive aids, crepitus, pain with ROM X-ray reports somewhat limited

31. Lessons Learned When Initial Audit Request Received • 1. Review all documentation prior to submitting to MAC on the initial request. Try to submit a complete package that addresses the criteria as completely as possible. • 2. If any criteria point was not done, state in the record why it was not done. List all contraindications to the interventions that were not appropriate for the patient. • 3. Strictly adhere to the time frames for submission and appeal, the MAC certainly will. • 4. Appeal every denial.

32. Lessons Learned When Initial Audit Request Received • A physician advisor is invaluable to the process, especially as you move to the higher levels of appeal. • We consulted an audit advisory consultant MedManagement who was recommended thru our Coding Oversight Consultant • Engage them on all appeals at the time of the initial request for information. This is the most successful timeframe.

33. Knee Case Audit Report

34. Knee Case Audit Response Example Payment Approved on Appeal!

35. Hip Case Audit Example • Short H&P Form no longer allowed at the hospital

36. Hip Case Audit Example Documentation does not support evidence of end stage osteoarthritis that warrants Hip replacement surgery. Inadequate documentation of conservative management. NO EXAM! X-ray report inadequate

37. Hip Case Audit Clawback

38. Hip Case Level I Audit Appeal • Submitted Pre-op management screening sheet • Included additional detailed data • Reviewed past records • Contacted patient • Revised the H&P and resubmitted

39. Hip Case Level I Audit Appeal More Detailed information provided regarding the treatment history and failure of the conservative management and degree of difficulties.

40. Hip Case Level I Audit Appeal X-ray details provided outlining key elements required Plan summarizes the thought process leading up to the recommendation for surgery.

41. Again DENIED!!!

42. Level II Audit Appeal • Must be submitted within 180 days of the initial denial • Med Management, a Medicare Audit Consulting Group • The MAC will provide a detailed response outlining reasons for denial

43. Reasons for Denial Outlined

44. Hip Case Level II Appeal • A more detailed response was made to CMS on Second Appeal • Point by point rebuttal in the response letter • The Second Appeal was approved by Maximus

45. Second Appeal Payment Approved!

46. If You Follow These Steps……….. You Can Show Me The Money! Thank You