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Lisa Eramo, MA, is a contributing author for Medical Economics.
It’s every physician’s worst nightmare: Receive payment for services rendered, but then a payer identifies an aberrant pattern in claims data, audits the records, decides it has overpaid the practice, and recoups those funds. That money you already allocated for overhead, staff salaries, bonuses, or new medical equipment? Gone. The good news is, physicians can take steps to focus on accurate billing and avoid costly recoupments.
It’s every physician’s worst nightmare: Receive payment for services rendered, but then a payer identifies an aberrant pattern in claims data, audits the records, decides it has overpaid the practice, and recoups those funds. That money you already allocated for overhead, staff salaries, bonuses, or new medical equipment? Gone. With one post-payment audit, you now owe thousands of dollars or more. The good news is, physicians can take steps to focus on accurate billing and avoid costly recoupments. This article explores five billing vulnerabilities
and provides tips to maintain compliance.
E/M coding: Four tips to select the correct level
Payers don’t usually deny evaluation and management (E/M) codes on the front end, says Toni Elhoms, CCS, CPC, a provider coding and education consultant in Denver. It isn’t until they look at the totality of the data retrospectively-long after physicians are paid-that financial penalties ensue, she adds.
“Payers are like the IRS,” says Elhoms. “You don’t want them on your back because recoupments are insidious. They come out of nowhere.”
Consider the difference in reimbursement for established patient office visits levels 2 versus 3 (i.e., CPT codes 99212 and 99213)-approximately $29. Let’s say 10 to 20 times per week over a year, a physician bills 99213 when their documentation only supports 99212. They’ll be paid initially, but likely have a $15,000-$30,000 recoupment on their hands if a payer uncovers the error during a post-payment audit.
Here are four tips to help physicians avoid denials due to incorrect E/M levels:
1. Ensure the E/M code supports
the specific patient encounter.
Not every patient with asthma, for example, will justify reporting CPT code 99213, says Elhoms. Some cases may be exacerbated and/or require medication management and referrals to specialists while others may be relatively straightforward and controlled.
2. Refer to the E/M guidelines
Assigning an E/M code is not a subjective process. Instead, physicians should refer to the 1995 or ‘97 E/M guidelines that include specific requirements for time-based billing as well as billing based on the three key components: history, exam, and medical decision-making, says Elhoms. She says the most common mistake physicians make when applying these guidelines is under-documenting E/M level 4 and 5 visits for new patients. More specifically, they omit one or more systems in the requisite general multi-system exam or they omit a complete past family and social history.
3. Use copy and paste
functionality with caution.
Copy and paste can save time, but it can also cause serious compliance problems, says Elhoms. That’s because when physicians automatically bring historical information from a previous encounter forward into their current note, they may inadvertently inflate the E/M level. Best practice is to validate any information copied forward to ensure it’s accurate and relevant to the current encounter-or turn off the functionality altogether, she adds.
4. Watch out for pre-populated EHR templates.
Pre-populated templates not only lead to upcoding (e.g., if certain body systems are always indicated as having been reviewed even when they’re not relevant to the current encounter), they can also lead to contradictions that raise red flags with payers, says Elhoms. For example, a physician diagnoses a patient with strep throat. If the template defaults to a normal exam for ear, nose, and throat, this could open the door for a post-payment audit. Physicians should ensure their documentation is aligned with the patient’s diagnosis even if it means manually unchecking certain boxes in the template.
Three tips to avoid recoupments
Time-based billing for E/M services is appropriate only when the physician meets face-to-face with the patient and/or family and spends more than 50 percent of the encounter counseling and/or coordinating care, says Elhoms. It’s not appropriate when the counseling and/or coordination of care is rendered over the phone or via email, she adds. To avoid denials, consider these tips:
1. Know how much time is typically associated with each E/M level as well as the amount of time a physician must spend counseling and/or coordinating care to bill solely based on time rather than the three key components (i.e., history, exam, and medical decision-making).
Consider doing the following:
2. Document the total time spent face-to-face with the patient as well as the total time spent counseling and/or coordinating care.
3. Explain what the counseling and/or coordination of care entailed (e.g., answered questions regarding the treatment plan or extensively discussed treatment options.) Note that counseling and coordination of care does not include administrative tasks such as documenting in the EHR, dictating, refilling prescriptions, completing workers’ compensation applications, communicating with other professionals, or reviewing records and tests before or after the face-to-face visit.
When physicians report prolonged services (i.e., CPT codes 99354 [first hour of the prolonged service] and 99355 [each additional 30 minutes]), they signal to payers that they spent face-to-face time above and beyond what’s typically associated with an evaluation and management service. CPT code 99354 yields approximately $132, and CPT code 99355 yields approximately $101.
Physicians frequently provide prolonged services for new patients who are medically complex as well as established patients presenting with new and complex problems, says Sonal Patel, CPMA, CPC, a healthcare coder and compliance consultant with Nexsen Pruet LLC, a business law firm in Charleston, S.C.
“Internists are the first line of defense for some of these patients, and they can easily talk for two hours, for example, with a patient who has diabetes before they refer them out to a specialist,” she adds. The same is true for patients requiring a cardiology workup.
It’s important to document why this additional time was necessary, says Patel. More specifically, documentation should include the following:
Total duration of the face-to-face visit
1. Always report a prolonged service code with an E/M code. Prolonged services cannot be billed alone because they are ‘add-on’ codes.
2. Know how much time is required before billing a prolonged service is permitted. Consider the following:
3. Use the EHR to help calculate time spent on the prolonged service. Some EHRs enable physicians to use a timer when documenting, making it easier to track how much time was spent on the prolonged service and whether that service is separately billable.
Modifiers -25, -26, and -59: Expert advice to mitigate risk
When appended to a CPT code, modifiers provide additional information about how payers should reimburse certain services. Consider the following:
Physicians need to ensure they send the right message to payers so that message doesn’t come back to haunt them in the form of a recoupment, says Joette Derricks, healthcare compliance and revenue integrity consultant in Baltimore. “Many commercial payers have also tightened their reimbursement edits to deny modifier -25 claims upfront,” she says. It’s important to check with each payer to determine whether it has published any guidance before establishing a policy within the practice for reporting modifiers, she adds.
Dorothy Steed, CCS, CDIP, a revenue cycle consultant in Atlanta agrees. “A lack of knowledge doesn’t typically work well as a defense,” says Steed, adding that physicians should study these modifiers and, if financially feasible, hire a certified coder to validate claims before submission. “If physicians don’t protect their financial resources, they’ll be in trouble and possibly out of business,” she adds.
Consider the following tips to help maintain compliance:
Apply this modifier to the E/M code-not the code for the procedure.
Document why the additional E/M service was necessary and why it went above and beyond what’s typically required for the procedure. For example, a patient falls and suffers a laceration that requires stitches. If deemed necessary, the physician may perform a workup to determine whether the patient suffered a concussion during the fall. The physician could report a separate E/M service with modifier -25 for the workup if they document why they felt the patient was at risk for a concussion and what the workup entailed. The same is true for an annual wellness visit and separate problem (e.g., heart arrhythmia) that requires additional cardiology workup.
Use this modifier with caution when performing pre-scheduled and/or repetitive procedures (e.g. skin tag removals or pain injections). The E/M service associated with these procedures (e.g. checking the patient’s heart, lungs, and blood pressure) is not usually significant and separately identifiable. Other services may be separately billable, depending on the circumstances.
Apply this modifier to a global procedure code (i.e., one that includes the interpretation and test itself) when a more specific code is unavailable. For example, apply modifier -26 to CPT code 71045 (single-view chest x-ray) when the physician performs the interpretation only. If the physician owns the equipment and performs the test, modifier -26 isn’t necessary, and reporting it can actually result in an underpayment.
Know when a more specific code is available. Consider this scenario: A physician performs the interpretation and report of a routine electrocardiogram (EKG), but doesn’t perform the tracing. In this case, report CPT code 93010 (interpretation and report only)-not CPT 93000 (EKG with tracing, interpretation, and report) with modifier -26.
Ensure compliance when using an outsource coding vendor. Derricks says she provided consulting services to an internal medicine practice that owed several thousand dollars back to the payer because its coding vendor failed to apply modifier -26. The vendor wrongly assumed the physician performed various radiology procedures in addition to the interpretation, resulting in a significant overpayment.
Only apply this modifier when appropriate to non-E/M codes with a Correct Coding Modifier Indicator of ‘1’ (modifier allowed). To view modifier indicators for each code, visit https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html. Most practice management systems also include this information.
Think of this modifier as a ‘last resort.’ If another modifier is more appropriate, use that modifier instead. Consider these other options first: -RT (right), -LT (left), or -50 (bilateral procedure). Payers may also accept modifiers -XE (separate encounter), -XS (separate organ or structure), -XU (unusual non-overlapping service), or -XP (separate practitioner).
Know the criteria. Medicare recently published Medlearn Matters article SE1418 that includes clinical scenarios and guidelines for proper use of modifier -59.
Incident-to billing: Know the requirements to ensure compliance
Incident-to billing enables non-physician providers to bill services under a supervising physician’s National Provider Identifier (NPI) rather than their own NPI so the practice can collect 100 percent of the Medicare physician fee schedule amount, rather than 85 percent. However, incident-to billing has several requirements that, if unmet, can cause costly recoupments during post-payment audits, says Jamie Claypool, CPC, CPMA, practice management consultant at J. Claypool Associates Inc. in Spicewood, Texas.
Following are several common reasons for denials and how to avoid them:
Reason for denial: Incident-to services are billed for a new patient visit.
How to avoid it: Schedule all new patients with a physician who can establish a plan of care. Then schedule all follow-up appointments for the same problem with the non-physician provider, and bill those appointments incident-to the physician, says Joette Derricks, healthcare compliance and revenue integrity consultant in Baltimore.
Reason for denial: Incident-to services are billed for an established patient with a new problem.
How to avoid it: Ask the supervising physician to talk briefly with the patient and establish a plan of care for the new problem. The physician must then document their assessment of the problem, including any relevant history, exam, and medication decision-making as well as the plan of care itself. If a physician isn’t available to do this, bill the visit under the non-physician provider’s NPI, assuming they are credentialed with the payer, says Derricks.
Reason for denial: Incident-to services for new problems do not meet supervision requirements.
How to avoid it: Ensure a supervising physician is always in the office suite and immediately available. Note that the supervising physician doesn’t need to be the same person who established the initial care plan, says Claypool. It simply needs to be a physician employed by the practice, she adds.
Payers will go so far as to request access to daily schedules to determine whether the physician under whom the incident-to service was billed was in the office and immediately available (e.g., whether they too saw patients in the office during the same timeframes), says Claypool.
Nursing home visits can be tricky. If the non-physician provider sees patients in a nursing home, they can’t bill incident-to a physician unless that physician has an office in the nursing home, sees patients in that office, and is immediately available, says Derricks. A non-physician provider could also bill incident-to if the physician is in the room during the visit, but this doesn’t happen often because it’s counterproductive to tie up both providers with the same patient, she adds.
Reason for denial: Commercial payer requires -SA modifier to denote incident-to services.
How to avoid it: Know whether the payer requires it and for what types of providers, says Derricks. For example, some Medicaid programs such as California Medi-Cal and Texas BCBS require physicians to apply modifier -SA to all nurse practitioner services submitted under the physician’s NPI. Texas also requires it for physician assistants, and Tufts health plan in Massachusetts requires it only for nurse practitioners.