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Compliance Concerns &Advanced E&M IssuesTodd Thomas, CCS-PWho is coming for you? Medicare Administrative Contractors (MACs) Recovery Audit Contractors (RACs) Medicaid Recovery Audit Contractors (MACs) Comprehensive Error Rate Testing (CERT) Zone Program Integrity Contractors (ZPICs) Private Payors Auto InsuranceTargeted Probe and Educate The CMS is expandingthe existing Targeted Probe and Educate (TPE)Pilot to include all MACs. The purpose of this expansion is to reduceappeals, decrease provider burden, and improve the medicalreview/education process. IMPLEMENTATIONDATE: October 1, 20171

Targeted Probe and Educate “CMS has seen very positiveresults from a currently running pilotfor this program as well as modifications to existing programs as aresult of lessons learned. CMS believesthat this strategy will continue to demonstratemeasurable reductions in the number of claims denied and thenumber and merit of appeals”.Targeted Probe and EducateStrategy / Key Elements Replace all currentmedical record reviews in the MAC’s ImproperPayment Reduction Strategy (IPRS) with up to three rounds of apre‐payment Targeted Probe & Educate process. If highdenial rates continue after three rounds refer to CMS foradditional action, ie extrapolation, referral to the (ZPIC) or (UPIC),referral to the RAC, 100% pre‐pay review, etc.Targeted Probe and EducateStrategy / Key Elements The MAC, rather than CMS, will select the topics for review (based onexisting data analysis procedures) The MAC can target the strategy on the providers most likely to besubmitting non‐compliant claims, rather than reviewing 100% of theproviders Limit the sample for each probe “round” to a minimum of twenty (20)and a maximum of forty (40) claims.2

Targeted Probe and EducateBe on alert Knowwho your local MAC, RAC, ZPIC, CERT, Etc contractors are Billing staff should know how to recognize records requests andinquiries from local contractors.What do to Respond as directed ASAP!!(per CMS “Non‐responses countas an error when considering a provider's or supplier's errorrate”. ) Review the documentation and coding and prepare a rebuttalin the event of a negative outcome. Appeal downcoding with supporting documentation andjustification of coding.3

Know the rules Know the coding guidelines and policies for your payers. Some payers have unique rules for E&M components. ROS Exam MDMReview the payer websites regularly for updates to policies.Willful ignorance in not a defense. After Missing Alerts on Sedation Billing, New York AnesthesiologyMedical Specialties agreed to pay 1.94 million to settle false claimsallegations that it overbilled for moderate sedation services. NYAMS billed Medicare for moderate sedation when the physiciandidn’t spend at least 16 minutes face to face with the patient and/or themedical record did not document that there had been at least 16minutes of face‐to‐face time from Jan. 1, 2012, to Jan. 5, 2016,Willful ignorance in not a defense. “The informationneeded to bill this code properly was available,but the mechanisms were not in place to obtain and process thatinformation.” ‐ Assistant U.S. Attorney Michael Gadarian Oct 2011 – CPT Asst publishes Guidelines for Time‐Based Codes “NYAMS did not subscribe to or otherwise receive the CPT Assistantpublication,” the settlement said.4

Willful ignorance in not a defense. In February 2012, National Government Services, the MAC for New York, postedan alert on its listserv explaining that providers had to perform and document 16minutes of face‐to‐face time to bill under 99144, consistent with CPT Assistant,according to the settlement. NGS kept the notice on its website for about oneyear. “No one at NYAMS subscribed to the NGS listserv,” the settlement states. Staff members at the billing service for NYAMS did receive NGS listservnotification but failed to inform NYAMS.Willful ignorance in not a defense. In January 2015, a commercial payer denied payment for moderate sedationbilled by NYAMS. Internal communication at billing service indicates staff did not appeal findingdue to 16‐minute rule to bill code wasn’t met. Five months later, additional MCS claims were denied “did not finddocumentation to support that the procedure lasted more than 16 minutes,” thesettlement states. NYAMS denies being notified of this by the billing company.5

Allergies as ROS "No known drug allergies or allergies in general are notconsidered part of the ROS. AMA/CPT publications havealways indicated that these are elements of PFSH."Allergies as ROS Q 14. Can an allergy be part of the ROS rather than the past history? For example,patient has allergy to penicillin; it causes hives? A 14. No, questions and responses concerning any past allergies and the resultingreactions are part of the Past, Family, and Social History (PFSH). They are not part of theReview of Systems (ROS).WPS ROS Q9. The 1995 and 1997 DGs indicate "all other systems are negative" is acceptablefor a comprehensive level of the Review of Systems. Does WPS accept this? A9. Yes. For a comprehensive ROS, the physician must document the review of at least10 organ systems. The physician must document both the positive and the problempertinent negative responses relating to the chief complaint. Indicating the individualsystems leaves no room for doubt as to the number of systems reviewed, but "allother systems negative" is acceptable.6

PMH as ROS Question: If the past medical section states a chronic or current illness (that the provider is nottreating), can it be used in the Review of Systems (ROS)? If the past medical section listsseveral conditions and there is no mention of controlled or uncontrolled, could this be used inthe ROS? Answer: No, per both the 1995 and 1997 Evaluation and Management (E & M) DocumentationGuidelines, "a Review of Systems is an inventory of body systems obtained through a series ofquestions seeking to identify signs or symptoms that the patient may be experiencing or hasexperienced."A past medical history would not contain a patient's pertinent positive and/or negativeresponses as related to the problems identified in the patient's history of the present illness.ExamNumericalInterpretation1995 E&M DGProblemFocused a limited examination of the affectedbody area or organ system 1 Body Area or Organ SystemExpandedProblemFocused a limited examination of the affectedbody area or organ system and othersymptomatic or related organ system(s). 2-4 Body areas or systems an extended examination of the affectedbody area(s) and other symptomatic orrelated organ system(s). 5-7 Body areas or systems a general multi-system examination orcomplete examination of a single organsystem. - The medical record for a generalmulti-system examination should includefindings about 8 or more of the 12 organsystems. 8 or more Organ systemsDetailedComprehensiveExamination The 2‐4, 5‐7 breakdownoriginated with thenHCFA Medical Director, Bart McCann at the CPTEditorial Panel Advisory Committee meeting inNovember of 1995. Indicatedthat a new version of the DGs were tobe released in 1996 that would reflect the 2‐4, 5‐7 to more clearly refine the exam requirements.7

Examination Many sourceschanged their version of the DGs to reflect theexpected update that was never made official. Still sources,including many of the Medicare carriers, that usethe numerical breakdown to assign a level to the exam.NHIC ExaminationExamination NGS‐ Audit Tool8

Examination Novitas ‐ Audit ToolExamination Palmetto ‐ Audit ToolCIGNA E&M Tips Understand the difference between "Expanded Problem‐Focused (EPF)"and "Limited" examination under 1995 guidelines. The difference is not the number of systems examined. Two to sevensystems are required for both examinations. The difference is the detail in which the examined systems aredescribed.9

Novitas 4x4 Rule Underthe 1995 guidelines both the expanded problem focusedexamination and the detailed examination provide for theexamination of "up to 7 systems" or 7 body areas. This has led to variabilityin reviews utilizing the '95 guidelines,and required an interpretation for proper and consistentimplementation of the E/M guidelines.Novitas 4x4 Rule By providing a tool (4 elements examined in 4 body areas or 4 organsystems satisfies a detailed examination) our reviewers and the physicianshave a clinically derived tool to assist in implementing the E/M guidelinesand decreasing one area of ambiguity. This is a tool that is consistent with the way medicine is practiced, asconfirmed in Documentation Coding & Billing by Laxmaiah Manchikanti, M.D, and A Guide to Physical Examination by Barbara Bates, M D. And, it is atool to reduce reviewer variability.Confirm information before setting policy How many vital signs do you require for a 1995 Constitutional exam? Any one vital sign or general appearance counts for a 1995 Constitutional exam.For “HEENT Normal”, how many body areas/organ systems would you give credit? Documentation of “HEENT Normal” would result in 1 Body area and 2 Organsystems as shown below: Head 1 Body area Eyes 1 Organ system ENT 1 Organ system10

Confirm information before setting policy Relating to HPI: Can one element be used more than one time to determinethe level of HPI? Example: If a patient comes in with complaints of ankle painand wrist pain, can location be counted twice? Yes, one elementcan be used more than one time. Evaluation and Managementguidelines for the documentation of the HPI must be followed.MDM Controversies Additional work‐up planned 2 Points for interps and/or 93010 Check box for “Old records reviewed” Discussion w/ another “health care provider”MDM variables MarshfieldMDM scoring11

Marshfield Scoring- Number ofDiagnoses / Treatment OptionsNew Problem, no add’l work‐up planned3 pointsNew Problem, add’l work‐up planned4 pointsA.2 common definitionsAdditional diagnostic work‐up after the current E&M service is completed.B.Diagnostic work‐up during the current E&M service.Additional work-up plannedPer Noridian: Q3. Please clarify if "new problem to provider, additional workup" means that the additionalworkup must be done beyond that encounter at that time. For example, if a physician sees a patient in his office and needs to send that patient on forfurther testing, that would be additional workup. The physician needs to obtain moreinformation for his medical decision making. Or, does additional work‐up consist of anydiagnostic testing, laboratory testing, etc. that can be performed during the visit. A3. There is no specific indication that "further workup needed" must be completed at afuture date.Additional work-up planned12

Additional work-up planned An example of Additional Work‐up Planned, is if the physician schedules testinghim/herself or communicates directly with the patient’s primary physician orrepresentative the need for testing which is to be done after discharge from the ED,and the appropriate documentation has been recorded. Credit for “Additional Work‐up” Planned is granted (4 points assigned). Credit is not given for the work up if it occurs during the ER Encounter. Patients admitted to the hospital under the care of a physician other than the ERphysician may have testing done as part of the admitting physician’s care for thatpatient. The ER physician will not receive credit for the Additional Work‐up Planneddone under the care of the admitting physician.Novitas Add’l W/U What constitutes additional workup in the Amount and Complexity of Data grid forMedical Decision Making? Additional workup is anything done beyond that encounter at that time. For example,if a physician sees a patient in his office and needs to send that patient on for furthertesting, that would be additional workup. The physician needs to obtain moreinformation for his medical decision‐making.Novitas Add’l W/U Is the physician doing additional workup? Additional workup will require the physician to review the results/make decisions ona day other than the day of the patient encounter.13

WPS MDMQ6. My question centers on the number of diagnosis or management options in theMDM of the E/M service. When coding an Emergency department encounter, would allpresenting problems fall under the "new problem“ category (either with or withoutadditional workup)?WPS MDMA6. The 1995 and the 1997 DGs have a table the provider can use indetermining the level of MDM. There is no specific "new problem"category.The number of possible diagnosis and/or the number of managementoptions your provider considers is based on the number and types ofproblems addressed during the encounter, the complexity of establishing adiagnosis and the management decisions that are made by the physician.The highest level of risk in any one category determines the overall risk.WPS MDM Q2. Define self‐limited or minor problem in the medical decision making grid underminimal level of risk. At times, it is difficult to determine whether a problem is self‐limited or minor or whether it is a new problem with no additional work‐upplanned. A2. The 1995 and 1997 DGs indicate the determination of risk is complex and notreadily quantifiable and includes some examples in each of the categories. The DGs donot address a new problem with no additional work up planned. Therefore, you canuse the examples provided in the DGs to determine the level of the presentingproblem.14

Noridian MDMMedical necessity cannot be quantified using a points system. Determining the medically necessary level of service(LOS) involves many factors and is not the same from patient to p patient and day to day. Medical necessity isdetermined through a culmination of vital factors, including, but not limited to: Clinical judgment Standards of practice Why the patient needs to be seen (chief complaint), Any acute exacerbations/onsets of medical conditions or injuries, The stability/acuity of the patient, Multiple medical co‐morbidities, And the management of the patient for that specific DOS.MDM ControversiesEMR MDMMedical Decision MakingDiscussion of test results with the performing providers: yesDecide to obtain previous medical records: yesObtain history from someone other than the patient: noReview and summarize previous medical records: yesDiscuss the patient with another provider: yesIndependent visualization of image, tracing, or specimen: yes15

Auditor response “These statements provide no clinical insight as to what happened in theED or how these steps impacted the diagnosis or treatment of the patient.Documentation that is aimed to meet the guidelines for payment but isclinically irrelevant to the patient presenting problem will not increase thelevel assigned to that visit.”EKG Pay vs Points The ordering of the EKG would be part of the Medical DecisionMaking (MDM) under the Risk category under DiagnosticProcedures Ordered. The interpretation of the ordered EKG is considered part of theEKG reimbursement, and as such is not part of the Amount and/orComplexity of Data to be Reviewed category under the MDMportion of the E/M service. Counting both a review of the ordered EKG and billing for theinterpretation and report of the same EKG is incorrect.Independent visualization of image,tracing or specimen itself If I personally review a film, e.g. x‐ray, electrocardiogram (EKG) in my office, will Ireceive 2 points on the E/M score sheet? Yes, you may get two points for independent visualization of an image, tracing orspecimen on the E/M score sheet in the Amount and/or Complexity of Data Reviewedsection under the Medical Decision Making key component. The medical record documentation must clearly indicate that the physician/qualifiedNPP personally (independently) visualized and performed the interpretation of theimage; tracing or specimen and that he/she did not simply read/review a report fromanother physician/qualified NPP.16

Automated Down codingAutomated Down codingAutomated Down coding17

Automated Down codingCentene (operates in 26 states, include Medicaid MCO plans, exchange plansand Medicare/Medicaid plans)Policy Overview To encourage providers to direct patients to more appropriate caresettings, the health plan has adopted a payment strategy that will providelower levels of reimbursement for services indicating lower levels ofcomplexity or severity rendered in the emergency room. The purpose of this policy is to define payment criteria for emergencyroom services to be used in making payment decisions and administeringbenefits. Automated Down codingReimbursement When a hospital,free‐standing emergency center or physicianbills a level 4 (99284) or level 5 (99285) emergency roomservice, with a diagnosis indicating a lower level of complexity orseverity, the health plan will reimburse the provider at a level 3(99283) reimbursement rate.Automated Down codingAnthem Blue Cross and Blue Shield of IndianaProvider information for avoidable emergency room visits The below clinical areas and respective codes will be reviewed if they are theemergency room discharge diagnosis. Prudent layperson language (law) was takeninto consideration in development of these clinical areas. The members presentingsymptoms in conjunction with prudent layperson language may allow approval of theER visit. The program is effective for Indiana commercial local accounts on01/01/2018.18

AutomatedDowncodingAutomated Down codingRemoved from the emergent diagnosis code listing as of R10.8176/30/18. These codes are no longer considered emergent R11.0by IME. Claim will only pay at 50% if these codes are in R11.11the 1st position.GENERALIZED ABDOMINAL TENDERNESSNAUSEAVOMITING WITHOUT NAUSEAWHEEZING R19.7DIARRHEA, UNSPECIFIEDR07.1CHEST PAIN ON BREATHING R31.9HEMATURIA, UNSPECIFIEDR07.89OTHER CHEST PAIN R50.9FEVER, UNSPECIFIED R07.9CHEST PAIN, UNSPECIFIED R51HEADACHE R10.12LEFT UPPER QUADRANT PAIN R53.1WEAKNESS R10.13EPIGASTRIC PAIN Plus dozens of Fracture, Sprains, Contusions, etc R10.815PERIUMBILIC ABDOMINAL TENDERNESS R10.816EPIGASTRIC ABDOMINAL TENDERNESS R06.2 19

Automated ReviewsAutomated review finding 36 claims listed on letter. 21 re: 10061vs 10060 Filed appeals for 35 of the claims w/ 100%success. 1 claim was not appealed due inconsistent documentation oflaceration length.CERT Audit20

CERT AuditCERT AuditCERT Audit21

CERT AuditCERT AuditCERT Audit22

CERT AuditCERT AuditCERT Audit23

CERT AuditCERT Audit 44 charts reviewed. CMS agreed with client on 16 charts 20 were 1 level downcodes 4 were 2 level downcodes 4 denied as billed by wrong provider Consultantagreed with CMS on 20 of the 24 downcodedcharts.Utilization Audit24

UtilizationAuditQui Tam / Whistleblowing qui tampro domino rege quam pro se ipso in hac partesequitur, meaning "he who sues in this matter for the king aswell as for himself.“ The False Claims Act allowspeople who are not affiliated withthe government to file actions claiming fraud against thegovernmentWhistleblower #125

Whistleblower #1Whistleblower #1Whistleblower #226

Whistleblower #2Whistleblower #3Whistleblower #327

AnMed Health Agrees to Pay 7 Millionto Settle False Claims Act Allegations The settlementalso resolves allegations that AnMedHealth systematically billed a minor care clinic as if it wasan Emergency Department, and billed EmergencyDepartment services as if they were provided by aphysician when, in fact, the services were rendered bymid‐level providers. Each of these billing practicesresulted in higher reimbursements to AnMed Health.AnMed Health Agrees to Pay 7 Millionto Settle False Claims Act Allegations arose froma lawsuit filed by a whistleblower formerlyemployed by AnMed Health under the whistleblower provisionsof the False Claims Act. Whistleblower will receive 1,202,500 of the United States’ FalseClaims Act recovery. will also receive 850,136.50 from AnMed Health to resolvewrongful termination claims under the False Claims Act.Appeal, Appeal, Appeal Always file at least one appeal of any findings that lowerthe assigned E&M code or decrease the reimbursementfor services rendered.28

Key Hot Spots in ED E&M 99283vs 99284 99284vs 99285 Medical necessity No longeris the key.a numbers game of counting elements.Todd Thomas(405) [email protected]

Nov 18, 2018 · Novitas‐Audit Tool Examination Palmetto ‐Audit Tool CIGNA E&M Tips Understand the difference between "Expanded Problem‐Focused (EPF)" and "Limited" examination under 1995 guidelines. The difference is not the number of systems examined.