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Submission Support
Physicians receive requests for documentation on a daily basis. Insurer requests need particular attention, as they can be directly related to reimbursement. If the documentation supports the service, payment is rendered (pre-payment request) or maintained (post-payment request). If the documentation is not supportive, payment is denied (pre-payment request) or refunded (post-payment request).
The two most common reasons submitted documentation is not supportive: It lacks information or only a portion of the documentation was submitted.
Not Enough Documentation
“Insufficient documentation” can take many forms. Each visit category (e.g., initial hospital care or subsequent hospital care) and level of service (e.g., 99221-99233) has corresponding documentation requirements. A full list of requirements is available on the Centers for Medicare and Medicaid Services Web site (www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf). Selecting an evaluation and management (E/M) level is focused on either upon the content of three key components: history, exam, and decision-making; time can also be a consideration but only when counseling or coordination of care dominate more than 50% of the physician’s total visit time.1 Failure to document any essential element in a given visit level (e.g., family history required but missing for 99222 and 99223) might result in a reviewer down-coding or denying the service.
Dates and signatures are vital to each encounter. The reviewer must be able to identify each individual who performs, documents, and bills for a service, as well as when the service occurred. Notes that lack dates or signatures are not considered in support of a billed service. Notes that contain an illegible signature are equally problematic. If the legibility of a signature prevents the reviewer from correctly identifying the rendering physician, the service can be denied.
It is advisable for the physician to print their name alongside the signature on the encounter note, or include a separate signature sheet with the requested documentation to assist the reviewer in deciphering the physician’s scrawl. Keep in mind that stamped signatures are not acceptable. Medicare accepts handwritten signatures, electronic signatures, or facsimiles of original written or electronic signatures.2
A service is questioned when two different sets of handwriting appear on a note and only one signature is provided. Because the reviewer cannot confirm the credentials of the unidentified individual and cannot be sure which portion belongs to the identified individual, the entire note is disregarded.
Incomplete Submission
Many times, an encounter note does not contain the cumulative information representing the reported service. For example, other pieces of pertinent information might be included in the data section or order section of the chart. If the individual responsible for gathering the requested documentation does not review the information before submitting it, those other important entries could be missed, and the complexity of the billed service might not be justified.
To avoid this, have the designated individual review the note for specific references to information housed in different areas of the chart. The provider should submit any entry with the same date as the requested documentation: labs, diagnostic testing, physician orders, patient instructions, nursing notes, resident notes, notes by other physicians in the same group, discharge summaries, etc.
Legibility is crucial when the documentation is sent for review. Note that the reviewer will not contact the provider if the information is not readable. Most reviewers seek another reviewer’s assistance in translating the handwriting, but they are not obligated to do this. If the note is deemed incomprehensible, the service is denied.
Electronic health records (EHR) are assisting physicians and other providers with legibility issues, and can help take the guesswork out of the note’s content. If a physician is still writing notes by hand, a transcription could be sent along with the documentation to prevent unnecessary denials. It is not advisable to do this for all requests, but only for requests involving providers who have particularly problematic handwriting.
Timeliness of Response
Once the documentation request is received, the physician has a small window of opportunity to review the request, collect the information, and issue a response. A lack of physician response always results in a service denial or a refund request. Once denied, the physician must go through the proper channels of appeal (with a different insurer reviewing department). Requests for refunds are more difficult to overturn. It is difficult to “open” a case that has been “closed.” Denials resulting from a failure to respond to a pre-payment request are a bit easier to resolve because the resulting denial is typically the payor’s initial determination of the claim. The physician usually is allowed an appeal of the payor’s initial determination. However, it is not a cost-effective process to handle prepayment requests in this manner. Always attempt to respond to the initial request within the designated time frame. TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is also on the faculty of SHM’s inpatient coding course.
References
- Pohlig, C. Documentation and Coding Evaluation and Management Services. In: Coding for Chest Medicine 2009. Northbrook, Ill.: American College of Chest Physicians, 2008;79-109.
- Centers for Medicare and Medicaid Services: CR 5971 Clarification-Signature Requirements. Medicare Learning Network Web site. Available at: www.cms.hhs.gov/MLNMattersArticles/downloads/SE0829.pdf. Accessed Sept. 1, 2009.
- Pohlig C. Evaluation and Management Services: An Overview. In: Coding for Chest Medicine 2009. Northbrook, Ill.: American College of Chest Physicians, 2008; 65-78.
Physicians receive requests for documentation on a daily basis. Insurer requests need particular attention, as they can be directly related to reimbursement. If the documentation supports the service, payment is rendered (pre-payment request) or maintained (post-payment request). If the documentation is not supportive, payment is denied (pre-payment request) or refunded (post-payment request).
The two most common reasons submitted documentation is not supportive: It lacks information or only a portion of the documentation was submitted.
Not Enough Documentation
“Insufficient documentation” can take many forms. Each visit category (e.g., initial hospital care or subsequent hospital care) and level of service (e.g., 99221-99233) has corresponding documentation requirements. A full list of requirements is available on the Centers for Medicare and Medicaid Services Web site (www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf). Selecting an evaluation and management (E/M) level is focused on either upon the content of three key components: history, exam, and decision-making; time can also be a consideration but only when counseling or coordination of care dominate more than 50% of the physician’s total visit time.1 Failure to document any essential element in a given visit level (e.g., family history required but missing for 99222 and 99223) might result in a reviewer down-coding or denying the service.
Dates and signatures are vital to each encounter. The reviewer must be able to identify each individual who performs, documents, and bills for a service, as well as when the service occurred. Notes that lack dates or signatures are not considered in support of a billed service. Notes that contain an illegible signature are equally problematic. If the legibility of a signature prevents the reviewer from correctly identifying the rendering physician, the service can be denied.
It is advisable for the physician to print their name alongside the signature on the encounter note, or include a separate signature sheet with the requested documentation to assist the reviewer in deciphering the physician’s scrawl. Keep in mind that stamped signatures are not acceptable. Medicare accepts handwritten signatures, electronic signatures, or facsimiles of original written or electronic signatures.2
A service is questioned when two different sets of handwriting appear on a note and only one signature is provided. Because the reviewer cannot confirm the credentials of the unidentified individual and cannot be sure which portion belongs to the identified individual, the entire note is disregarded.
Incomplete Submission
Many times, an encounter note does not contain the cumulative information representing the reported service. For example, other pieces of pertinent information might be included in the data section or order section of the chart. If the individual responsible for gathering the requested documentation does not review the information before submitting it, those other important entries could be missed, and the complexity of the billed service might not be justified.
To avoid this, have the designated individual review the note for specific references to information housed in different areas of the chart. The provider should submit any entry with the same date as the requested documentation: labs, diagnostic testing, physician orders, patient instructions, nursing notes, resident notes, notes by other physicians in the same group, discharge summaries, etc.
Legibility is crucial when the documentation is sent for review. Note that the reviewer will not contact the provider if the information is not readable. Most reviewers seek another reviewer’s assistance in translating the handwriting, but they are not obligated to do this. If the note is deemed incomprehensible, the service is denied.
Electronic health records (EHR) are assisting physicians and other providers with legibility issues, and can help take the guesswork out of the note’s content. If a physician is still writing notes by hand, a transcription could be sent along with the documentation to prevent unnecessary denials. It is not advisable to do this for all requests, but only for requests involving providers who have particularly problematic handwriting.
Timeliness of Response
Once the documentation request is received, the physician has a small window of opportunity to review the request, collect the information, and issue a response. A lack of physician response always results in a service denial or a refund request. Once denied, the physician must go through the proper channels of appeal (with a different insurer reviewing department). Requests for refunds are more difficult to overturn. It is difficult to “open” a case that has been “closed.” Denials resulting from a failure to respond to a pre-payment request are a bit easier to resolve because the resulting denial is typically the payor’s initial determination of the claim. The physician usually is allowed an appeal of the payor’s initial determination. However, it is not a cost-effective process to handle prepayment requests in this manner. Always attempt to respond to the initial request within the designated time frame. TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is also on the faculty of SHM’s inpatient coding course.
References
- Pohlig, C. Documentation and Coding Evaluation and Management Services. In: Coding for Chest Medicine 2009. Northbrook, Ill.: American College of Chest Physicians, 2008;79-109.
- Centers for Medicare and Medicaid Services: CR 5971 Clarification-Signature Requirements. Medicare Learning Network Web site. Available at: www.cms.hhs.gov/MLNMattersArticles/downloads/SE0829.pdf. Accessed Sept. 1, 2009.
- Pohlig C. Evaluation and Management Services: An Overview. In: Coding for Chest Medicine 2009. Northbrook, Ill.: American College of Chest Physicians, 2008; 65-78.
Physicians receive requests for documentation on a daily basis. Insurer requests need particular attention, as they can be directly related to reimbursement. If the documentation supports the service, payment is rendered (pre-payment request) or maintained (post-payment request). If the documentation is not supportive, payment is denied (pre-payment request) or refunded (post-payment request).
The two most common reasons submitted documentation is not supportive: It lacks information or only a portion of the documentation was submitted.
Not Enough Documentation
“Insufficient documentation” can take many forms. Each visit category (e.g., initial hospital care or subsequent hospital care) and level of service (e.g., 99221-99233) has corresponding documentation requirements. A full list of requirements is available on the Centers for Medicare and Medicaid Services Web site (www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf). Selecting an evaluation and management (E/M) level is focused on either upon the content of three key components: history, exam, and decision-making; time can also be a consideration but only when counseling or coordination of care dominate more than 50% of the physician’s total visit time.1 Failure to document any essential element in a given visit level (e.g., family history required but missing for 99222 and 99223) might result in a reviewer down-coding or denying the service.
Dates and signatures are vital to each encounter. The reviewer must be able to identify each individual who performs, documents, and bills for a service, as well as when the service occurred. Notes that lack dates or signatures are not considered in support of a billed service. Notes that contain an illegible signature are equally problematic. If the legibility of a signature prevents the reviewer from correctly identifying the rendering physician, the service can be denied.
It is advisable for the physician to print their name alongside the signature on the encounter note, or include a separate signature sheet with the requested documentation to assist the reviewer in deciphering the physician’s scrawl. Keep in mind that stamped signatures are not acceptable. Medicare accepts handwritten signatures, electronic signatures, or facsimiles of original written or electronic signatures.2
A service is questioned when two different sets of handwriting appear on a note and only one signature is provided. Because the reviewer cannot confirm the credentials of the unidentified individual and cannot be sure which portion belongs to the identified individual, the entire note is disregarded.
Incomplete Submission
Many times, an encounter note does not contain the cumulative information representing the reported service. For example, other pieces of pertinent information might be included in the data section or order section of the chart. If the individual responsible for gathering the requested documentation does not review the information before submitting it, those other important entries could be missed, and the complexity of the billed service might not be justified.
To avoid this, have the designated individual review the note for specific references to information housed in different areas of the chart. The provider should submit any entry with the same date as the requested documentation: labs, diagnostic testing, physician orders, patient instructions, nursing notes, resident notes, notes by other physicians in the same group, discharge summaries, etc.
Legibility is crucial when the documentation is sent for review. Note that the reviewer will not contact the provider if the information is not readable. Most reviewers seek another reviewer’s assistance in translating the handwriting, but they are not obligated to do this. If the note is deemed incomprehensible, the service is denied.
Electronic health records (EHR) are assisting physicians and other providers with legibility issues, and can help take the guesswork out of the note’s content. If a physician is still writing notes by hand, a transcription could be sent along with the documentation to prevent unnecessary denials. It is not advisable to do this for all requests, but only for requests involving providers who have particularly problematic handwriting.
Timeliness of Response
Once the documentation request is received, the physician has a small window of opportunity to review the request, collect the information, and issue a response. A lack of physician response always results in a service denial or a refund request. Once denied, the physician must go through the proper channels of appeal (with a different insurer reviewing department). Requests for refunds are more difficult to overturn. It is difficult to “open” a case that has been “closed.” Denials resulting from a failure to respond to a pre-payment request are a bit easier to resolve because the resulting denial is typically the payor’s initial determination of the claim. The physician usually is allowed an appeal of the payor’s initial determination. However, it is not a cost-effective process to handle prepayment requests in this manner. Always attempt to respond to the initial request within the designated time frame. TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is also on the faculty of SHM’s inpatient coding course.
References
- Pohlig, C. Documentation and Coding Evaluation and Management Services. In: Coding for Chest Medicine 2009. Northbrook, Ill.: American College of Chest Physicians, 2008;79-109.
- Centers for Medicare and Medicaid Services: CR 5971 Clarification-Signature Requirements. Medicare Learning Network Web site. Available at: www.cms.hhs.gov/MLNMattersArticles/downloads/SE0829.pdf. Accessed Sept. 1, 2009.
- Pohlig C. Evaluation and Management Services: An Overview. In: Coding for Chest Medicine 2009. Northbrook, Ill.: American College of Chest Physicians, 2008; 65-78.
Are You Red Flag Ready?
Senate Refuses To Consider Bill to Fix SGR
Legislation that would have provided a 10-year replacement of Medicare's sustainable growth rate formula was blocked when senators voted 53–47 against bringing the bill to the floor.
The sustainable growth rate (SGR) has dictated how Medicare pays physicians. For the last 7 years, the formula has required a reduction in physician fees, but each of those years, Congress has voted to reverse the cuts.
Eleven Democrats voted against cloture, a procedural motion that precedes a legislative vote: Evan Bayh (Ind.), Robert Byrd (W.Va.), Kent Conrad (N.D.), Byron Dorgan (N.D.), Russ Feingold (Wisc.), Herbert Kohl (Wisc.), Bill Nelson (Fla.), Jon Tester (Mont.), Mark Warner (Va.), James Webb (Va.), and Ron Wyden (Ore.). Independent Joseph Lieberman (Conn.) also voted no. No Republicans voted yes.
In a statement, American Medical Association President James Rohack said, “The AMA is deeply disappointed that the Senate today blocked consideration of S. 1776, legislation to preserve access to health care for America's seniors, baby boomers and military families.”
Sen. Debbie Stabenow (D-Mich.), the legislation's sponsor, and her Democratic colleagues did not offer any way to pay for the fix, which would have cost an estimated $250 billion over the 10 years.
Republicans—and some Democrats—leapt on the bill's lack of funding, especially since President Obama has said he would not sign a health bill that added to the deficit. The SGR fix was presented by Sen. Stabenow and her supporters—including the AMA—as something entirely separate from health reform, thus possibly exempt from that promise.
“Although many will claim that their vote against cloture was a vote for fiscal responsibility, there is nothing fiscally responsible about pretending that Medicare will save money from cuts that Congress has no intention to let go into effect,” said Dr. Joseph W. Stubbs, president of the American College of Physicians.
The House is not expected to act on any physician fee fix until after it considers health reform.
To respond to this column, e-mail Dr. Eastern at sknews@elsevier.com
Legislation that would have provided a 10-year replacement of Medicare's sustainable growth rate formula was blocked when senators voted 53–47 against bringing the bill to the floor.
The sustainable growth rate (SGR) has dictated how Medicare pays physicians. For the last 7 years, the formula has required a reduction in physician fees, but each of those years, Congress has voted to reverse the cuts.
Eleven Democrats voted against cloture, a procedural motion that precedes a legislative vote: Evan Bayh (Ind.), Robert Byrd (W.Va.), Kent Conrad (N.D.), Byron Dorgan (N.D.), Russ Feingold (Wisc.), Herbert Kohl (Wisc.), Bill Nelson (Fla.), Jon Tester (Mont.), Mark Warner (Va.), James Webb (Va.), and Ron Wyden (Ore.). Independent Joseph Lieberman (Conn.) also voted no. No Republicans voted yes.
In a statement, American Medical Association President James Rohack said, “The AMA is deeply disappointed that the Senate today blocked consideration of S. 1776, legislation to preserve access to health care for America's seniors, baby boomers and military families.”
Sen. Debbie Stabenow (D-Mich.), the legislation's sponsor, and her Democratic colleagues did not offer any way to pay for the fix, which would have cost an estimated $250 billion over the 10 years.
Republicans—and some Democrats—leapt on the bill's lack of funding, especially since President Obama has said he would not sign a health bill that added to the deficit. The SGR fix was presented by Sen. Stabenow and her supporters—including the AMA—as something entirely separate from health reform, thus possibly exempt from that promise.
“Although many will claim that their vote against cloture was a vote for fiscal responsibility, there is nothing fiscally responsible about pretending that Medicare will save money from cuts that Congress has no intention to let go into effect,” said Dr. Joseph W. Stubbs, president of the American College of Physicians.
The House is not expected to act on any physician fee fix until after it considers health reform.
To respond to this column, e-mail Dr. Eastern at sknews@elsevier.com
Legislation that would have provided a 10-year replacement of Medicare's sustainable growth rate formula was blocked when senators voted 53–47 against bringing the bill to the floor.
The sustainable growth rate (SGR) has dictated how Medicare pays physicians. For the last 7 years, the formula has required a reduction in physician fees, but each of those years, Congress has voted to reverse the cuts.
Eleven Democrats voted against cloture, a procedural motion that precedes a legislative vote: Evan Bayh (Ind.), Robert Byrd (W.Va.), Kent Conrad (N.D.), Byron Dorgan (N.D.), Russ Feingold (Wisc.), Herbert Kohl (Wisc.), Bill Nelson (Fla.), Jon Tester (Mont.), Mark Warner (Va.), James Webb (Va.), and Ron Wyden (Ore.). Independent Joseph Lieberman (Conn.) also voted no. No Republicans voted yes.
In a statement, American Medical Association President James Rohack said, “The AMA is deeply disappointed that the Senate today blocked consideration of S. 1776, legislation to preserve access to health care for America's seniors, baby boomers and military families.”
Sen. Debbie Stabenow (D-Mich.), the legislation's sponsor, and her Democratic colleagues did not offer any way to pay for the fix, which would have cost an estimated $250 billion over the 10 years.
Republicans—and some Democrats—leapt on the bill's lack of funding, especially since President Obama has said he would not sign a health bill that added to the deficit. The SGR fix was presented by Sen. Stabenow and her supporters—including the AMA—as something entirely separate from health reform, thus possibly exempt from that promise.
“Although many will claim that their vote against cloture was a vote for fiscal responsibility, there is nothing fiscally responsible about pretending that Medicare will save money from cuts that Congress has no intention to let go into effect,” said Dr. Joseph W. Stubbs, president of the American College of Physicians.
The House is not expected to act on any physician fee fix until after it considers health reform.
To respond to this column, e-mail Dr. Eastern at sknews@elsevier.com
Send Texters a Message
A dermatologist recently sought my input regarding his two-physician private practice on the West Coast. They were struggling with an increasing problem, he said, of employees sending personal text messages and surfing the Internet during office hours.
“We added a page to our office manual prohibiting these activities, but there has been no improvement. If anything, it's getting worse,” he added.
It always surprises me when physicians think that the solution to any employee issue is an unannounced new page in the office manual. How often do you suppose your employees peruse your manual, looking for new entries?
Ignorance of the rules is seldom a viable excuse, but if an employee charges you with unreasonable termination, arbitrators may be sympathetic to the contention that policies were established essentially in secret, and no effort was made to make the employee aware of the policy he or she was accused of violating.
Anytime a policy change is made in my office, I call a staff meeting to explain it and answer questions about it. If the change is significant, I also have my manager sit down with each staff member individually and review the new policy in detail, (all of this is documented, of course) making certain everyone fully understands the new policy and the consequences of violating it.
We then have each staffer sign a written copy of the new policy and we post a copy on the bulletin board in our lunch room. Call it overkill if you wish, but no one can plausibly claim they weren't told the rules had changed.
As to the specific problem on the West Coast, the issue clearly is neither local nor trivial. Nor is it medicine specific. When I shop with my wife, I'm increasingly amazed at how many salespeople we see texting or chatting on cell phones, often oblivious of waiting customers.
This is especially true of younger workers. Surveys have shown that most Americans in their teens and twenties find nothing inappropriate or rude about using this technology in any conceivable situation, including the workplace. Without firm policies in place, some staffers will inevitably abuse this technology.
And the damage can be significant. A typical text message, according to one study, takes about 1 minute to send or receive, so an employee who sends and receives 30 messages a day squanders an hour of office time. For a full-time employee that's about 20 hours a month.
How many additional patients could you see in that 240 hours? How much less liability risk would there be if that one employee were paying attention instead of texting? Add a second texter, and a couple of Web surfers, and suddenly you have a major problem.
If you have yet to establish a formal policy on this issue, I recommend that you put one in place immediately. When you call a staff meeting to explain it, speak plainly: Using office time for personal texting and Web surfing is theft, pure and simple. They are stealing your time. Make this crystal clear.
As with any policy, the keys are diligence and consistency. Always enforce this and every other rule, and follow through with consequences when necessary—even if it means penalizing a key employee, or even terminating someone. Firings should always be a last resort, but nothing will make it clearer that you are serious, nor send a stronger message that it is never permissible to steal any office property—least of all your most marketable commodity, office time.
To respond to this column, e-mail Dr. Eastern at sknews@elsevier.com
A dermatologist recently sought my input regarding his two-physician private practice on the West Coast. They were struggling with an increasing problem, he said, of employees sending personal text messages and surfing the Internet during office hours.
“We added a page to our office manual prohibiting these activities, but there has been no improvement. If anything, it's getting worse,” he added.
It always surprises me when physicians think that the solution to any employee issue is an unannounced new page in the office manual. How often do you suppose your employees peruse your manual, looking for new entries?
Ignorance of the rules is seldom a viable excuse, but if an employee charges you with unreasonable termination, arbitrators may be sympathetic to the contention that policies were established essentially in secret, and no effort was made to make the employee aware of the policy he or she was accused of violating.
Anytime a policy change is made in my office, I call a staff meeting to explain it and answer questions about it. If the change is significant, I also have my manager sit down with each staff member individually and review the new policy in detail, (all of this is documented, of course) making certain everyone fully understands the new policy and the consequences of violating it.
We then have each staffer sign a written copy of the new policy and we post a copy on the bulletin board in our lunch room. Call it overkill if you wish, but no one can plausibly claim they weren't told the rules had changed.
As to the specific problem on the West Coast, the issue clearly is neither local nor trivial. Nor is it medicine specific. When I shop with my wife, I'm increasingly amazed at how many salespeople we see texting or chatting on cell phones, often oblivious of waiting customers.
This is especially true of younger workers. Surveys have shown that most Americans in their teens and twenties find nothing inappropriate or rude about using this technology in any conceivable situation, including the workplace. Without firm policies in place, some staffers will inevitably abuse this technology.
And the damage can be significant. A typical text message, according to one study, takes about 1 minute to send or receive, so an employee who sends and receives 30 messages a day squanders an hour of office time. For a full-time employee that's about 20 hours a month.
How many additional patients could you see in that 240 hours? How much less liability risk would there be if that one employee were paying attention instead of texting? Add a second texter, and a couple of Web surfers, and suddenly you have a major problem.
If you have yet to establish a formal policy on this issue, I recommend that you put one in place immediately. When you call a staff meeting to explain it, speak plainly: Using office time for personal texting and Web surfing is theft, pure and simple. They are stealing your time. Make this crystal clear.
As with any policy, the keys are diligence and consistency. Always enforce this and every other rule, and follow through with consequences when necessary—even if it means penalizing a key employee, or even terminating someone. Firings should always be a last resort, but nothing will make it clearer that you are serious, nor send a stronger message that it is never permissible to steal any office property—least of all your most marketable commodity, office time.
To respond to this column, e-mail Dr. Eastern at sknews@elsevier.com
A dermatologist recently sought my input regarding his two-physician private practice on the West Coast. They were struggling with an increasing problem, he said, of employees sending personal text messages and surfing the Internet during office hours.
“We added a page to our office manual prohibiting these activities, but there has been no improvement. If anything, it's getting worse,” he added.
It always surprises me when physicians think that the solution to any employee issue is an unannounced new page in the office manual. How often do you suppose your employees peruse your manual, looking for new entries?
Ignorance of the rules is seldom a viable excuse, but if an employee charges you with unreasonable termination, arbitrators may be sympathetic to the contention that policies were established essentially in secret, and no effort was made to make the employee aware of the policy he or she was accused of violating.
Anytime a policy change is made in my office, I call a staff meeting to explain it and answer questions about it. If the change is significant, I also have my manager sit down with each staff member individually and review the new policy in detail, (all of this is documented, of course) making certain everyone fully understands the new policy and the consequences of violating it.
We then have each staffer sign a written copy of the new policy and we post a copy on the bulletin board in our lunch room. Call it overkill if you wish, but no one can plausibly claim they weren't told the rules had changed.
As to the specific problem on the West Coast, the issue clearly is neither local nor trivial. Nor is it medicine specific. When I shop with my wife, I'm increasingly amazed at how many salespeople we see texting or chatting on cell phones, often oblivious of waiting customers.
This is especially true of younger workers. Surveys have shown that most Americans in their teens and twenties find nothing inappropriate or rude about using this technology in any conceivable situation, including the workplace. Without firm policies in place, some staffers will inevitably abuse this technology.
And the damage can be significant. A typical text message, according to one study, takes about 1 minute to send or receive, so an employee who sends and receives 30 messages a day squanders an hour of office time. For a full-time employee that's about 20 hours a month.
How many additional patients could you see in that 240 hours? How much less liability risk would there be if that one employee were paying attention instead of texting? Add a second texter, and a couple of Web surfers, and suddenly you have a major problem.
If you have yet to establish a formal policy on this issue, I recommend that you put one in place immediately. When you call a staff meeting to explain it, speak plainly: Using office time for personal texting and Web surfing is theft, pure and simple. They are stealing your time. Make this crystal clear.
As with any policy, the keys are diligence and consistency. Always enforce this and every other rule, and follow through with consequences when necessary—even if it means penalizing a key employee, or even terminating someone. Firings should always be a last resort, but nothing will make it clearer that you are serious, nor send a stronger message that it is never permissible to steal any office property—least of all your most marketable commodity, office time.
To respond to this column, e-mail Dr. Eastern at sknews@elsevier.com
RAC Audits Go Nationwide
The Centers for Medicare and Medicaid Services thinks it is overpaying you. That probably comes as no surprise, nor will the news that CMS has devised yet another scheme for taking back money that it has already paid to you.
The new reel-in is called a recovery audit contractor (RAC) audit, and if this is the first you've heard of it, you probably don't practice in California, Florida, New York, Massachusetts, or South Carolina.
Those states were the sites of a pilot program conducted over the last 3 years to test the RAC system. The total amount recovered so pleased CMS that it has now authorized a nationwide rollout.
Here's how it works: CMS has divided the country into four regions and put an RAC in charge of each one. Region A (Northeast states) is covered by Diversified Collection Services; Region B (the Midwest) by CGI Technologies and Solutions; Region C (the South) by Connolly Consulting Associates; and Region D (the West and Southwest plus Alaska and Hawaii) by HealthData Insights.
Each RAC has its own unique procedures and criteria for audits. You can learn more about your RAC's idiosyncrasies, and confirm which region includes your state, at the CMS Web site: www.cms.hhs.gov/RAC/
RACs are paid a percentage of any overpayments they can identify and collect from providers. They are supposed to identify underpayments too, but in the pilot program that amounted to less than $38 million, compared with over $900 million in overpayments.
They will mostly be looking for only four basic transgressions:
▸ Incorrect payment amounts (either too much or too little).
▸ Noncovered services, including those that are not considered “reasonable and necessary.”
▸ Incorrect coding.
▸ Duplicate payments.
The RACs are required to have good cause to audit your claims. They cannot randomly select claims or focus only on high-paying claims. And they can only look back a maximum of 3 years—and no earlier than Oct. 1, 2007. That's a relatively short period of time requiring your review, and a relatively small number of transgressions to look for.
So now is the time for your staff to start getting out Medicare EOBs (explanation of benefits) and determine where you might be vulnerable on the past 2 years' claims. And once you identify any vulnerabilities, you can take steps to audit-proof future claims.
So far, the RACs have mostly targeted hospitals, nursing homes, home health care organizations, and medical equipment companies, but anyone who bills Medicare is fair game.
If an RAC wants to look at your records, they must make the request in writing and they must tell you what they are looking for. They are limited by law to auditing no more than 10% of the average number of Medicare claims you file each month. The law states they must pay the costs of copying records, both paper and electronic.
The law provides you 45 days to respond to an RAC's request for patient records. It also specifies a “discussion period,” so if your records are requested, don't rush to send them. Call the RAC and discuss!
If a repayment is demanded, you have 120 days to appeal that determination, in the same way (and by essentially the same process) that conventional Medicare audit determinations are appealed.
In case you're wondering, RAC audits will not replace regular Medicare audits. However, the RACs will not be permitted to audit claims that have already been audited conventionally.
The Centers for Medicare and Medicaid Services thinks it is overpaying you. That probably comes as no surprise, nor will the news that CMS has devised yet another scheme for taking back money that it has already paid to you.
The new reel-in is called a recovery audit contractor (RAC) audit, and if this is the first you've heard of it, you probably don't practice in California, Florida, New York, Massachusetts, or South Carolina.
Those states were the sites of a pilot program conducted over the last 3 years to test the RAC system. The total amount recovered so pleased CMS that it has now authorized a nationwide rollout.
Here's how it works: CMS has divided the country into four regions and put an RAC in charge of each one. Region A (Northeast states) is covered by Diversified Collection Services; Region B (the Midwest) by CGI Technologies and Solutions; Region C (the South) by Connolly Consulting Associates; and Region D (the West and Southwest plus Alaska and Hawaii) by HealthData Insights.
Each RAC has its own unique procedures and criteria for audits. You can learn more about your RAC's idiosyncrasies, and confirm which region includes your state, at the CMS Web site: www.cms.hhs.gov/RAC/
RACs are paid a percentage of any overpayments they can identify and collect from providers. They are supposed to identify underpayments too, but in the pilot program that amounted to less than $38 million, compared with over $900 million in overpayments.
They will mostly be looking for only four basic transgressions:
▸ Incorrect payment amounts (either too much or too little).
▸ Noncovered services, including those that are not considered “reasonable and necessary.”
▸ Incorrect coding.
▸ Duplicate payments.
The RACs are required to have good cause to audit your claims. They cannot randomly select claims or focus only on high-paying claims. And they can only look back a maximum of 3 years—and no earlier than Oct. 1, 2007. That's a relatively short period of time requiring your review, and a relatively small number of transgressions to look for.
So now is the time for your staff to start getting out Medicare EOBs (explanation of benefits) and determine where you might be vulnerable on the past 2 years' claims. And once you identify any vulnerabilities, you can take steps to audit-proof future claims.
So far, the RACs have mostly targeted hospitals, nursing homes, home health care organizations, and medical equipment companies, but anyone who bills Medicare is fair game.
If an RAC wants to look at your records, they must make the request in writing and they must tell you what they are looking for. They are limited by law to auditing no more than 10% of the average number of Medicare claims you file each month. The law states they must pay the costs of copying records, both paper and electronic.
The law provides you 45 days to respond to an RAC's request for patient records. It also specifies a “discussion period,” so if your records are requested, don't rush to send them. Call the RAC and discuss!
If a repayment is demanded, you have 120 days to appeal that determination, in the same way (and by essentially the same process) that conventional Medicare audit determinations are appealed.
In case you're wondering, RAC audits will not replace regular Medicare audits. However, the RACs will not be permitted to audit claims that have already been audited conventionally.
The Centers for Medicare and Medicaid Services thinks it is overpaying you. That probably comes as no surprise, nor will the news that CMS has devised yet another scheme for taking back money that it has already paid to you.
The new reel-in is called a recovery audit contractor (RAC) audit, and if this is the first you've heard of it, you probably don't practice in California, Florida, New York, Massachusetts, or South Carolina.
Those states were the sites of a pilot program conducted over the last 3 years to test the RAC system. The total amount recovered so pleased CMS that it has now authorized a nationwide rollout.
Here's how it works: CMS has divided the country into four regions and put an RAC in charge of each one. Region A (Northeast states) is covered by Diversified Collection Services; Region B (the Midwest) by CGI Technologies and Solutions; Region C (the South) by Connolly Consulting Associates; and Region D (the West and Southwest plus Alaska and Hawaii) by HealthData Insights.
Each RAC has its own unique procedures and criteria for audits. You can learn more about your RAC's idiosyncrasies, and confirm which region includes your state, at the CMS Web site: www.cms.hhs.gov/RAC/
RACs are paid a percentage of any overpayments they can identify and collect from providers. They are supposed to identify underpayments too, but in the pilot program that amounted to less than $38 million, compared with over $900 million in overpayments.
They will mostly be looking for only four basic transgressions:
▸ Incorrect payment amounts (either too much or too little).
▸ Noncovered services, including those that are not considered “reasonable and necessary.”
▸ Incorrect coding.
▸ Duplicate payments.
The RACs are required to have good cause to audit your claims. They cannot randomly select claims or focus only on high-paying claims. And they can only look back a maximum of 3 years—and no earlier than Oct. 1, 2007. That's a relatively short period of time requiring your review, and a relatively small number of transgressions to look for.
So now is the time for your staff to start getting out Medicare EOBs (explanation of benefits) and determine where you might be vulnerable on the past 2 years' claims. And once you identify any vulnerabilities, you can take steps to audit-proof future claims.
So far, the RACs have mostly targeted hospitals, nursing homes, home health care organizations, and medical equipment companies, but anyone who bills Medicare is fair game.
If an RAC wants to look at your records, they must make the request in writing and they must tell you what they are looking for. They are limited by law to auditing no more than 10% of the average number of Medicare claims you file each month. The law states they must pay the costs of copying records, both paper and electronic.
The law provides you 45 days to respond to an RAC's request for patient records. It also specifies a “discussion period,” so if your records are requested, don't rush to send them. Call the RAC and discuss!
If a repayment is demanded, you have 120 days to appeal that determination, in the same way (and by essentially the same process) that conventional Medicare audit determinations are appealed.
In case you're wondering, RAC audits will not replace regular Medicare audits. However, the RACs will not be permitted to audit claims that have already been audited conventionally.
Document Inspection
One constant in all the modifications to billing and reimbursement guidelines for evaluation and management (E/M) services provided by hospitalists is that a face-to-face patient encounter by the billing provider is required. Exceptions do occur (e.g., telehealth services, care plan oversight, home health certification) but are infrequently reported by hospitalist teams. Do not get caught misreporting the following services due to the absence of a physician presence.
Discharge Day Management
Hospital discharge day management (CPT 99238-99239) is a face-to-face E/M service between the attending physician and the patient. Document the date of the actual physician visit even if the patient is discharged from the facility on a different date.1 Documentation must substantiate this personal patient encounter.
A hospitalist can choose to record the face-to-face encounter in a handwritten progress note or make note of it in the formal discharge summary. When relying solely upon the dictated summary, physicians often fail to identify personal contact with the patient. Although an examination need only be performed “as appropriate” on the day of discharge, it is the best indicator of a face-to-face encounter. Such statements as “Upon discharge, the patient appeared well, vital signs stable, lungs clear” or “Patient seen and examined by me on discharge day” clearly illustrate this service.
It is important to note that only the attending physician of record reports the discharge day management service. Physicians or qualified non-physician practitioners (NPPs), other than the attending physician, who have been managing concurrent healthcare problems not primarily managed by the attending physician and who are not acting on behalf of the attending physician should use subsequent hospital care codes (99231-99233) for a final visit.2
Death pronouncement can be reported with discharge day management codes (99238-99239), but only when this service involves a physician-patient encounter. Physicians should report the most appropriate discharge code on the actual day of pronouncement.
Shared/Split Services
Shared/split Medicare services occur when two providers from the same specialty and group practice perform a portion of a facility-based (outpatient hospital, inpatient hospital, or ED) patient encounter on the same day. One provider must be a physician; the other must be a qualified and certified NPP (e.g., nurse practitioner, physician assistant, clinical nurse specialist, certified nurse midwife).
The culmination of the two portions of service must fulfill the requirements of a single E/M service (consultations, critical care, and other time-based services excluded). The physician has the option to report the shared/split service to Medicare under their name for 100% of the allowable reimbursement rate, or under the NPP’s name for 85% of the allowable reimbursement rate.
In order to utilize this billing model, the physician and the NPP must provide a face-to-face encounter on the same day. If there is no face-to-face encounter between the patient and the physician, then the service can only be billed under the NPP’s name at 85% of the allowable reimbursement rate.3
Documentation must clearly identify each provider involved in the shared/split service, along with the presence and the portion of each individual’s service. The NPP and the physician should each indicate the extent of their involvement (e.g., “Patient seen and examined by me … ”) in the patient’s care and sign their portion of the note. If the NPP and physician each write a separate note, each note should refer to the other provider. That way, the supporting documentation for the service rendered encompasses the summation of both notes.4
Teaching Physician Services
A different type of shared service can occur under the teaching physician rules, whereby an attending physician and a “resident” are involved in the same patient encounter. The term “resident” also includes interns and fellows in recognized graduate medical education (GME) programs, as approved for purposes of direct GME payments made by the fiscal intermediary.5 As with services shared with NPPs, the attending physician must provide a face-to-face encounter and participate in a key portion of the service.
The attending physician can perform their portion of the service concurrently or independent of the resident but is allowed to discuss the case (teaching service) with the resident, as appropriate. If the attending physician does not physically see the patient, the service cannot be reported. Payment is made only for the teaching physician’s involvement in the patient’s care.
Instead of detailing the entire encounter, the teaching physician should write a short, legible linking or tethering statement specifically referencing the resident’s note. Physicians must demonstrate their physical presence (e.g., “Patient seen and examined by me. Agree with note by Dr. Jones”) and comment on the patient’s evaluation and their active involvement in the care plan.6 TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is faculty for SHM’s inpatient coding course.
References
- Medicare Claims Processing Manual: Chapter 12, Section 30.6.15.1C. Centers for Medicare and Medicaid Services (CMS) Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
- Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.2B. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
- Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
- Pohlig, C. Nonphysician Providers in Your Practice. In: Coding for Chest Medicine 2009. Northbrook, IL: American College of Chest Physicians, 2008;265-271.
- Medicare Claims Processing Manual: Chapter 12, Section 100. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
- Manaker, S. Teaching Physician Regulations. In: Coding for Chest Medicine 2009. Northbrook, IL: American College of Chest Physicians, 2008;299-305.
- Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.1D. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
- Beebe M, Dalton J, Espronceda M, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2008.
One constant in all the modifications to billing and reimbursement guidelines for evaluation and management (E/M) services provided by hospitalists is that a face-to-face patient encounter by the billing provider is required. Exceptions do occur (e.g., telehealth services, care plan oversight, home health certification) but are infrequently reported by hospitalist teams. Do not get caught misreporting the following services due to the absence of a physician presence.
Discharge Day Management
Hospital discharge day management (CPT 99238-99239) is a face-to-face E/M service between the attending physician and the patient. Document the date of the actual physician visit even if the patient is discharged from the facility on a different date.1 Documentation must substantiate this personal patient encounter.
A hospitalist can choose to record the face-to-face encounter in a handwritten progress note or make note of it in the formal discharge summary. When relying solely upon the dictated summary, physicians often fail to identify personal contact with the patient. Although an examination need only be performed “as appropriate” on the day of discharge, it is the best indicator of a face-to-face encounter. Such statements as “Upon discharge, the patient appeared well, vital signs stable, lungs clear” or “Patient seen and examined by me on discharge day” clearly illustrate this service.
It is important to note that only the attending physician of record reports the discharge day management service. Physicians or qualified non-physician practitioners (NPPs), other than the attending physician, who have been managing concurrent healthcare problems not primarily managed by the attending physician and who are not acting on behalf of the attending physician should use subsequent hospital care codes (99231-99233) for a final visit.2
Death pronouncement can be reported with discharge day management codes (99238-99239), but only when this service involves a physician-patient encounter. Physicians should report the most appropriate discharge code on the actual day of pronouncement.
Shared/Split Services
Shared/split Medicare services occur when two providers from the same specialty and group practice perform a portion of a facility-based (outpatient hospital, inpatient hospital, or ED) patient encounter on the same day. One provider must be a physician; the other must be a qualified and certified NPP (e.g., nurse practitioner, physician assistant, clinical nurse specialist, certified nurse midwife).
The culmination of the two portions of service must fulfill the requirements of a single E/M service (consultations, critical care, and other time-based services excluded). The physician has the option to report the shared/split service to Medicare under their name for 100% of the allowable reimbursement rate, or under the NPP’s name for 85% of the allowable reimbursement rate.
In order to utilize this billing model, the physician and the NPP must provide a face-to-face encounter on the same day. If there is no face-to-face encounter between the patient and the physician, then the service can only be billed under the NPP’s name at 85% of the allowable reimbursement rate.3
Documentation must clearly identify each provider involved in the shared/split service, along with the presence and the portion of each individual’s service. The NPP and the physician should each indicate the extent of their involvement (e.g., “Patient seen and examined by me … ”) in the patient’s care and sign their portion of the note. If the NPP and physician each write a separate note, each note should refer to the other provider. That way, the supporting documentation for the service rendered encompasses the summation of both notes.4
Teaching Physician Services
A different type of shared service can occur under the teaching physician rules, whereby an attending physician and a “resident” are involved in the same patient encounter. The term “resident” also includes interns and fellows in recognized graduate medical education (GME) programs, as approved for purposes of direct GME payments made by the fiscal intermediary.5 As with services shared with NPPs, the attending physician must provide a face-to-face encounter and participate in a key portion of the service.
The attending physician can perform their portion of the service concurrently or independent of the resident but is allowed to discuss the case (teaching service) with the resident, as appropriate. If the attending physician does not physically see the patient, the service cannot be reported. Payment is made only for the teaching physician’s involvement in the patient’s care.
Instead of detailing the entire encounter, the teaching physician should write a short, legible linking or tethering statement specifically referencing the resident’s note. Physicians must demonstrate their physical presence (e.g., “Patient seen and examined by me. Agree with note by Dr. Jones”) and comment on the patient’s evaluation and their active involvement in the care plan.6 TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is faculty for SHM’s inpatient coding course.
References
- Medicare Claims Processing Manual: Chapter 12, Section 30.6.15.1C. Centers for Medicare and Medicaid Services (CMS) Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
- Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.2B. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
- Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
- Pohlig, C. Nonphysician Providers in Your Practice. In: Coding for Chest Medicine 2009. Northbrook, IL: American College of Chest Physicians, 2008;265-271.
- Medicare Claims Processing Manual: Chapter 12, Section 100. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
- Manaker, S. Teaching Physician Regulations. In: Coding for Chest Medicine 2009. Northbrook, IL: American College of Chest Physicians, 2008;299-305.
- Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.1D. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
- Beebe M, Dalton J, Espronceda M, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2008.
One constant in all the modifications to billing and reimbursement guidelines for evaluation and management (E/M) services provided by hospitalists is that a face-to-face patient encounter by the billing provider is required. Exceptions do occur (e.g., telehealth services, care plan oversight, home health certification) but are infrequently reported by hospitalist teams. Do not get caught misreporting the following services due to the absence of a physician presence.
Discharge Day Management
Hospital discharge day management (CPT 99238-99239) is a face-to-face E/M service between the attending physician and the patient. Document the date of the actual physician visit even if the patient is discharged from the facility on a different date.1 Documentation must substantiate this personal patient encounter.
A hospitalist can choose to record the face-to-face encounter in a handwritten progress note or make note of it in the formal discharge summary. When relying solely upon the dictated summary, physicians often fail to identify personal contact with the patient. Although an examination need only be performed “as appropriate” on the day of discharge, it is the best indicator of a face-to-face encounter. Such statements as “Upon discharge, the patient appeared well, vital signs stable, lungs clear” or “Patient seen and examined by me on discharge day” clearly illustrate this service.
It is important to note that only the attending physician of record reports the discharge day management service. Physicians or qualified non-physician practitioners (NPPs), other than the attending physician, who have been managing concurrent healthcare problems not primarily managed by the attending physician and who are not acting on behalf of the attending physician should use subsequent hospital care codes (99231-99233) for a final visit.2
Death pronouncement can be reported with discharge day management codes (99238-99239), but only when this service involves a physician-patient encounter. Physicians should report the most appropriate discharge code on the actual day of pronouncement.
Shared/Split Services
Shared/split Medicare services occur when two providers from the same specialty and group practice perform a portion of a facility-based (outpatient hospital, inpatient hospital, or ED) patient encounter on the same day. One provider must be a physician; the other must be a qualified and certified NPP (e.g., nurse practitioner, physician assistant, clinical nurse specialist, certified nurse midwife).
The culmination of the two portions of service must fulfill the requirements of a single E/M service (consultations, critical care, and other time-based services excluded). The physician has the option to report the shared/split service to Medicare under their name for 100% of the allowable reimbursement rate, or under the NPP’s name for 85% of the allowable reimbursement rate.
In order to utilize this billing model, the physician and the NPP must provide a face-to-face encounter on the same day. If there is no face-to-face encounter between the patient and the physician, then the service can only be billed under the NPP’s name at 85% of the allowable reimbursement rate.3
Documentation must clearly identify each provider involved in the shared/split service, along with the presence and the portion of each individual’s service. The NPP and the physician should each indicate the extent of their involvement (e.g., “Patient seen and examined by me … ”) in the patient’s care and sign their portion of the note. If the NPP and physician each write a separate note, each note should refer to the other provider. That way, the supporting documentation for the service rendered encompasses the summation of both notes.4
Teaching Physician Services
A different type of shared service can occur under the teaching physician rules, whereby an attending physician and a “resident” are involved in the same patient encounter. The term “resident” also includes interns and fellows in recognized graduate medical education (GME) programs, as approved for purposes of direct GME payments made by the fiscal intermediary.5 As with services shared with NPPs, the attending physician must provide a face-to-face encounter and participate in a key portion of the service.
The attending physician can perform their portion of the service concurrently or independent of the resident but is allowed to discuss the case (teaching service) with the resident, as appropriate. If the attending physician does not physically see the patient, the service cannot be reported. Payment is made only for the teaching physician’s involvement in the patient’s care.
Instead of detailing the entire encounter, the teaching physician should write a short, legible linking or tethering statement specifically referencing the resident’s note. Physicians must demonstrate their physical presence (e.g., “Patient seen and examined by me. Agree with note by Dr. Jones”) and comment on the patient’s evaluation and their active involvement in the care plan.6 TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is faculty for SHM’s inpatient coding course.
References
- Medicare Claims Processing Manual: Chapter 12, Section 30.6.15.1C. Centers for Medicare and Medicaid Services (CMS) Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
- Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.2B. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
- Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
- Pohlig, C. Nonphysician Providers in Your Practice. In: Coding for Chest Medicine 2009. Northbrook, IL: American College of Chest Physicians, 2008;265-271.
- Medicare Claims Processing Manual: Chapter 12, Section 100. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
- Manaker, S. Teaching Physician Regulations. In: Coding for Chest Medicine 2009. Northbrook, IL: American College of Chest Physicians, 2008;299-305.
- Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.1D. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
- Beebe M, Dalton J, Espronceda M, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2008.
Parties settle for $11 million after uterine rupture … Radiologist: It’s Ca. Gyns: No, it is not. Patient dies—of Ca. … $23 million for failure to test breast lump
Parties settle for $11 million after uterine rupture
A PREGNANT WOMAN REPORTED to her local hospital complaining of uterine contractions. Under the supervision of an attending physician, a resident started oxytocin to initiate vaginal delivery. Decelerations in the fetal heart rate were observed, but the plan of delivery did not change. When decelerations became severe, however, cesarean delivery was performed, and uterine rupture was discovered. The infant was later given a diagnosis of cerebral palsy and cognitive and visual impairment. Tube feeding is necessary.
PATIENT’S CLAIM Contractions were weak when she first presented to the hospital, and labor questionable, so oxytocin should not have been administered. Also, the physicians failed to recognize the likelihood of uterine rupture and performed the cesarean too late to prevent it.
PHYSICIANS’ DEFENSE Not reported.
VERDICT $11 million Illinois settlement.
Radiologist: It’s Ca. Gyns: No, it is not. Patient dies—of Ca.
A 65-YEAR-OLD WOMAN with postmenopausal bleeding underwent pelvic ultrasonography (US). The radiologist reported abnormal findings and a primary diagnostic consideration of endometrial cancer. Dr. A, the patient’s gynecologist, performed an office biopsy after informing her of concern about abnormal tissue and cancer but never mentioned the US results. The patient was then referred to Dr. B, a gynecologic oncologist, for a hysteroscopy and dilation and curettage (D & C). Dr. A and Dr. B agreed that all results were negative for cancer, and Dr. B told the patient she did not have cancer.
Six months later, she returned to Dr. A because of postcoital bleeding, and topical estrogen was recommended for vaginal dryness. On vacation the following year, the woman experienced heavy bleeding. Dr. C, another gynecologist, found abnormal tissue and sent her back to her own physicians. Dr. B performed an immediate hysterectomy and gave her a diagnosis of stage 2 endometrial cancer that had spread to the lymph nodes. Nine months later, after two courses of chemotherapy and radiation therapy, the patient died.
CLAIM ON BEHALF OF PATIENT’S ESTATE She should have been informed of the radiologist’s concern about endometrial cancer and offered the option of a hysterectomy. If a hysterectomy had been performed within the next year, she would have had a 90% chance of survival. Also, the tissue samples obtained in the office biopsy and the D & C were too small to rule out cancer, and not all the tissue was analyzed.
PHYSICIANS’ DEFENSE They had informed the patient about the possibility of cancer and then obtained the negative test results; she did not need to be told specific details of the radiologist’s report. Also, the cancer was aggressive and developed more than a year after her first visit for bleeding.
VERDICT $1,137,444 Pennsylvania verdict.
$23 million for failure to test breast lump
A 23-YEAR-OLD WOMAN called her ObGyn in July 2003 to report a lump in her breast and asked to be seen immediately. The physician asked her to wait until her next appointment, which was 2 weeks away. At that time, the patient had to remind the physician to examine the lump. The physician diagnosed the mass as a cyst, without testing, and told the patient it was nothing to worry about. She did not document the lump in the chart or schedule any follow-up for it.
The patient became pregnant and was seen by the ObGyn for prenatal care on 16 occasions, without further evaluation of the lump. After delivery, 2 years after the lump was first reported, the patient complained that it was growing in size. She was seen by her ObGyn’s partner, who ordered a mammogram and ultrasonography that revealed a 4-cm mass. A biopsy confirmed breast cancer. Additional imaging revealed metastasis to the liver. The patient underwent chemotherapy, lumpectomy, total hysterectomy, and radiation therapy, but was told a cure was unlikely.
PATIENT’S CLAIM The first ObGyn should have ordered testing when the lump was first reported.
PHYSICIAN’S DEFENSE The lump diagnosed as cancer in 2005 was not the lump present in 2003. Even if it were the same lump, it likely had already metastasized, rendering the delay in treatment irrelevant.
VERDICT $23.6 million Tennessee verdict.
These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
Parties settle for $11 million after uterine rupture
A PREGNANT WOMAN REPORTED to her local hospital complaining of uterine contractions. Under the supervision of an attending physician, a resident started oxytocin to initiate vaginal delivery. Decelerations in the fetal heart rate were observed, but the plan of delivery did not change. When decelerations became severe, however, cesarean delivery was performed, and uterine rupture was discovered. The infant was later given a diagnosis of cerebral palsy and cognitive and visual impairment. Tube feeding is necessary.
PATIENT’S CLAIM Contractions were weak when she first presented to the hospital, and labor questionable, so oxytocin should not have been administered. Also, the physicians failed to recognize the likelihood of uterine rupture and performed the cesarean too late to prevent it.
PHYSICIANS’ DEFENSE Not reported.
VERDICT $11 million Illinois settlement.
Radiologist: It’s Ca. Gyns: No, it is not. Patient dies—of Ca.
A 65-YEAR-OLD WOMAN with postmenopausal bleeding underwent pelvic ultrasonography (US). The radiologist reported abnormal findings and a primary diagnostic consideration of endometrial cancer. Dr. A, the patient’s gynecologist, performed an office biopsy after informing her of concern about abnormal tissue and cancer but never mentioned the US results. The patient was then referred to Dr. B, a gynecologic oncologist, for a hysteroscopy and dilation and curettage (D & C). Dr. A and Dr. B agreed that all results were negative for cancer, and Dr. B told the patient she did not have cancer.
Six months later, she returned to Dr. A because of postcoital bleeding, and topical estrogen was recommended for vaginal dryness. On vacation the following year, the woman experienced heavy bleeding. Dr. C, another gynecologist, found abnormal tissue and sent her back to her own physicians. Dr. B performed an immediate hysterectomy and gave her a diagnosis of stage 2 endometrial cancer that had spread to the lymph nodes. Nine months later, after two courses of chemotherapy and radiation therapy, the patient died.
CLAIM ON BEHALF OF PATIENT’S ESTATE She should have been informed of the radiologist’s concern about endometrial cancer and offered the option of a hysterectomy. If a hysterectomy had been performed within the next year, she would have had a 90% chance of survival. Also, the tissue samples obtained in the office biopsy and the D & C were too small to rule out cancer, and not all the tissue was analyzed.
PHYSICIANS’ DEFENSE They had informed the patient about the possibility of cancer and then obtained the negative test results; she did not need to be told specific details of the radiologist’s report. Also, the cancer was aggressive and developed more than a year after her first visit for bleeding.
VERDICT $1,137,444 Pennsylvania verdict.
$23 million for failure to test breast lump
A 23-YEAR-OLD WOMAN called her ObGyn in July 2003 to report a lump in her breast and asked to be seen immediately. The physician asked her to wait until her next appointment, which was 2 weeks away. At that time, the patient had to remind the physician to examine the lump. The physician diagnosed the mass as a cyst, without testing, and told the patient it was nothing to worry about. She did not document the lump in the chart or schedule any follow-up for it.
The patient became pregnant and was seen by the ObGyn for prenatal care on 16 occasions, without further evaluation of the lump. After delivery, 2 years after the lump was first reported, the patient complained that it was growing in size. She was seen by her ObGyn’s partner, who ordered a mammogram and ultrasonography that revealed a 4-cm mass. A biopsy confirmed breast cancer. Additional imaging revealed metastasis to the liver. The patient underwent chemotherapy, lumpectomy, total hysterectomy, and radiation therapy, but was told a cure was unlikely.
PATIENT’S CLAIM The first ObGyn should have ordered testing when the lump was first reported.
PHYSICIAN’S DEFENSE The lump diagnosed as cancer in 2005 was not the lump present in 2003. Even if it were the same lump, it likely had already metastasized, rendering the delay in treatment irrelevant.
VERDICT $23.6 million Tennessee verdict.
Parties settle for $11 million after uterine rupture
A PREGNANT WOMAN REPORTED to her local hospital complaining of uterine contractions. Under the supervision of an attending physician, a resident started oxytocin to initiate vaginal delivery. Decelerations in the fetal heart rate were observed, but the plan of delivery did not change. When decelerations became severe, however, cesarean delivery was performed, and uterine rupture was discovered. The infant was later given a diagnosis of cerebral palsy and cognitive and visual impairment. Tube feeding is necessary.
PATIENT’S CLAIM Contractions were weak when she first presented to the hospital, and labor questionable, so oxytocin should not have been administered. Also, the physicians failed to recognize the likelihood of uterine rupture and performed the cesarean too late to prevent it.
PHYSICIANS’ DEFENSE Not reported.
VERDICT $11 million Illinois settlement.
Radiologist: It’s Ca. Gyns: No, it is not. Patient dies—of Ca.
A 65-YEAR-OLD WOMAN with postmenopausal bleeding underwent pelvic ultrasonography (US). The radiologist reported abnormal findings and a primary diagnostic consideration of endometrial cancer. Dr. A, the patient’s gynecologist, performed an office biopsy after informing her of concern about abnormal tissue and cancer but never mentioned the US results. The patient was then referred to Dr. B, a gynecologic oncologist, for a hysteroscopy and dilation and curettage (D & C). Dr. A and Dr. B agreed that all results were negative for cancer, and Dr. B told the patient she did not have cancer.
Six months later, she returned to Dr. A because of postcoital bleeding, and topical estrogen was recommended for vaginal dryness. On vacation the following year, the woman experienced heavy bleeding. Dr. C, another gynecologist, found abnormal tissue and sent her back to her own physicians. Dr. B performed an immediate hysterectomy and gave her a diagnosis of stage 2 endometrial cancer that had spread to the lymph nodes. Nine months later, after two courses of chemotherapy and radiation therapy, the patient died.
CLAIM ON BEHALF OF PATIENT’S ESTATE She should have been informed of the radiologist’s concern about endometrial cancer and offered the option of a hysterectomy. If a hysterectomy had been performed within the next year, she would have had a 90% chance of survival. Also, the tissue samples obtained in the office biopsy and the D & C were too small to rule out cancer, and not all the tissue was analyzed.
PHYSICIANS’ DEFENSE They had informed the patient about the possibility of cancer and then obtained the negative test results; she did not need to be told specific details of the radiologist’s report. Also, the cancer was aggressive and developed more than a year after her first visit for bleeding.
VERDICT $1,137,444 Pennsylvania verdict.
$23 million for failure to test breast lump
A 23-YEAR-OLD WOMAN called her ObGyn in July 2003 to report a lump in her breast and asked to be seen immediately. The physician asked her to wait until her next appointment, which was 2 weeks away. At that time, the patient had to remind the physician to examine the lump. The physician diagnosed the mass as a cyst, without testing, and told the patient it was nothing to worry about. She did not document the lump in the chart or schedule any follow-up for it.
The patient became pregnant and was seen by the ObGyn for prenatal care on 16 occasions, without further evaluation of the lump. After delivery, 2 years after the lump was first reported, the patient complained that it was growing in size. She was seen by her ObGyn’s partner, who ordered a mammogram and ultrasonography that revealed a 4-cm mass. A biopsy confirmed breast cancer. Additional imaging revealed metastasis to the liver. The patient underwent chemotherapy, lumpectomy, total hysterectomy, and radiation therapy, but was told a cure was unlikely.
PATIENT’S CLAIM The first ObGyn should have ordered testing when the lump was first reported.
PHYSICIAN’S DEFENSE The lump diagnosed as cancer in 2005 was not the lump present in 2003. Even if it were the same lump, it likely had already metastasized, rendering the delay in treatment irrelevant.
VERDICT $23.6 million Tennessee verdict.
These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
RAC Audits Go Nationwide
The Centers for Medicare and Medicaid Services thinks it is overpaying you. That probably comes as no surprise, nor will the news that CMS has devised yet another scheme for taking back money that they have already paid to you.
The new reel-in is called a recovery audit contractor (RAC) audit, and if this is the first you've heard of it, you probably don't practice in California, Florida, New York, Massachusetts, or South Carolina.
Those states were the sites of a pilot program conducted over the last 3 years to test the RAC system. The total amount that was recovered so pleased CMS that it has now authorized a nationwide rollout.
So RAC audits could be in your future no matter where you practice. And now is the time to examine your Medicare claims to determine where you may be vulnerable in the event of an RAC audit of past claims and to minimize your risk of audit on future claims. Limitations on scope and look-back period should make that process relatively painless.
Here's how the program works: CMS has divided the country into four regions and put an RAC in charge of each one. Region A (Northeast states) is covered by Diversified Collection Services; Region B (the Midwest) by CGI Technologies and Solutions; Region C (the South) by Connolly Consulting Associates; and Region D (the West and Southwest plus Alaska and Hawaii) by HealthData Insights.
Each RAC has its own unique procedures and criteria for audits. You can learn more about your RAC's idiosyncrasies, and confirm which region includes your state, at the CMS Web site: www.cms.hhs.gov/RAC/
RACs are paid a percentage of any overpayments they can identify and collect from providers.
They are supposed to identify underpayments too, but in the pilot program that amounted to less than $38 million, compared with over $900 million in overpayments.
Although most audits are automatic, meaning an analysis of computer data only to identify administrative errors, the RACs are also authorized to undertake “complex” audits in which patient records are examined.
They will mostly be looking for only four basic transgressions:
▸ Incorrect payment amounts (either too much or too little).
▸ Noncovered services, including those that are not considered “reasonable and necessary.”
▸ Incorrect coding.
▸ Duplicate payments.
The RACs are required to have good cause to audit your claims. They cannot randomly select claims or focus only on high-paying claims. And they can only look back a maximum of 3 years—and no earlier than Oct. 1, 2007. That is a relatively short period of time requiring your review, and a relatively small number of transgressions that you need to look for.
So now is the time for your staff to start getting out Medicare EOBs (explanation of benefits) and determine where you might be vulnerable on the past 2 years' claims. And once you identify any vulnerabilities, you can take steps to audit-proof future claims.
So far, the RACs have mostly targeted hospitals, nursing homes, home health care organizations, and medical equipment companies, but anyone who bills Medicare is fair game. And it's only a matter of time before state-run Medicaid programs become targets as well.
CMS has hinted that a majority of audits will take place in California, New York, and Florida, because 25% of all Medicare payments are made to those three states alone.
If a RAC wants to look at your records, they must make the request in writing and they must tell you what they are looking for. They are limited by law to auditing no more than 10% of the average number of Medicare claims you file each month. The law states they must pay the costs of copying records, both paper and electronic.
The law provides you 45 days to respond to a RAC's request for patient records. It also specifies a “discussion period,” so if your records are requested, don't rush to send them. Call the RAC and discuss! The RAC's medical director is “required to be actively involved in examining all evidence used to make determinations,” and you have a right to speak to him or her if you wish.
If a repayment is demanded, you have 120 days to appeal that determination, in the same way (and by essentially the same process) that conventional Medicare audit determinations are appealed.
In case you're wondering, RAC audits will not replace regular Medicare audits, which I discussed in my June 2004 column.
To respond to this column, e-mail Dr. Eastern at sknews@elsevier.com
The Centers for Medicare and Medicaid Services thinks it is overpaying you. That probably comes as no surprise, nor will the news that CMS has devised yet another scheme for taking back money that they have already paid to you.
The new reel-in is called a recovery audit contractor (RAC) audit, and if this is the first you've heard of it, you probably don't practice in California, Florida, New York, Massachusetts, or South Carolina.
Those states were the sites of a pilot program conducted over the last 3 years to test the RAC system. The total amount that was recovered so pleased CMS that it has now authorized a nationwide rollout.
So RAC audits could be in your future no matter where you practice. And now is the time to examine your Medicare claims to determine where you may be vulnerable in the event of an RAC audit of past claims and to minimize your risk of audit on future claims. Limitations on scope and look-back period should make that process relatively painless.
Here's how the program works: CMS has divided the country into four regions and put an RAC in charge of each one. Region A (Northeast states) is covered by Diversified Collection Services; Region B (the Midwest) by CGI Technologies and Solutions; Region C (the South) by Connolly Consulting Associates; and Region D (the West and Southwest plus Alaska and Hawaii) by HealthData Insights.
Each RAC has its own unique procedures and criteria for audits. You can learn more about your RAC's idiosyncrasies, and confirm which region includes your state, at the CMS Web site: www.cms.hhs.gov/RAC/
RACs are paid a percentage of any overpayments they can identify and collect from providers.
They are supposed to identify underpayments too, but in the pilot program that amounted to less than $38 million, compared with over $900 million in overpayments.
Although most audits are automatic, meaning an analysis of computer data only to identify administrative errors, the RACs are also authorized to undertake “complex” audits in which patient records are examined.
They will mostly be looking for only four basic transgressions:
▸ Incorrect payment amounts (either too much or too little).
▸ Noncovered services, including those that are not considered “reasonable and necessary.”
▸ Incorrect coding.
▸ Duplicate payments.
The RACs are required to have good cause to audit your claims. They cannot randomly select claims or focus only on high-paying claims. And they can only look back a maximum of 3 years—and no earlier than Oct. 1, 2007. That is a relatively short period of time requiring your review, and a relatively small number of transgressions that you need to look for.
So now is the time for your staff to start getting out Medicare EOBs (explanation of benefits) and determine where you might be vulnerable on the past 2 years' claims. And once you identify any vulnerabilities, you can take steps to audit-proof future claims.
So far, the RACs have mostly targeted hospitals, nursing homes, home health care organizations, and medical equipment companies, but anyone who bills Medicare is fair game. And it's only a matter of time before state-run Medicaid programs become targets as well.
CMS has hinted that a majority of audits will take place in California, New York, and Florida, because 25% of all Medicare payments are made to those three states alone.
If a RAC wants to look at your records, they must make the request in writing and they must tell you what they are looking for. They are limited by law to auditing no more than 10% of the average number of Medicare claims you file each month. The law states they must pay the costs of copying records, both paper and electronic.
The law provides you 45 days to respond to a RAC's request for patient records. It also specifies a “discussion period,” so if your records are requested, don't rush to send them. Call the RAC and discuss! The RAC's medical director is “required to be actively involved in examining all evidence used to make determinations,” and you have a right to speak to him or her if you wish.
If a repayment is demanded, you have 120 days to appeal that determination, in the same way (and by essentially the same process) that conventional Medicare audit determinations are appealed.
In case you're wondering, RAC audits will not replace regular Medicare audits, which I discussed in my June 2004 column.
To respond to this column, e-mail Dr. Eastern at sknews@elsevier.com
The Centers for Medicare and Medicaid Services thinks it is overpaying you. That probably comes as no surprise, nor will the news that CMS has devised yet another scheme for taking back money that they have already paid to you.
The new reel-in is called a recovery audit contractor (RAC) audit, and if this is the first you've heard of it, you probably don't practice in California, Florida, New York, Massachusetts, or South Carolina.
Those states were the sites of a pilot program conducted over the last 3 years to test the RAC system. The total amount that was recovered so pleased CMS that it has now authorized a nationwide rollout.
So RAC audits could be in your future no matter where you practice. And now is the time to examine your Medicare claims to determine where you may be vulnerable in the event of an RAC audit of past claims and to minimize your risk of audit on future claims. Limitations on scope and look-back period should make that process relatively painless.
Here's how the program works: CMS has divided the country into four regions and put an RAC in charge of each one. Region A (Northeast states) is covered by Diversified Collection Services; Region B (the Midwest) by CGI Technologies and Solutions; Region C (the South) by Connolly Consulting Associates; and Region D (the West and Southwest plus Alaska and Hawaii) by HealthData Insights.
Each RAC has its own unique procedures and criteria for audits. You can learn more about your RAC's idiosyncrasies, and confirm which region includes your state, at the CMS Web site: www.cms.hhs.gov/RAC/
RACs are paid a percentage of any overpayments they can identify and collect from providers.
They are supposed to identify underpayments too, but in the pilot program that amounted to less than $38 million, compared with over $900 million in overpayments.
Although most audits are automatic, meaning an analysis of computer data only to identify administrative errors, the RACs are also authorized to undertake “complex” audits in which patient records are examined.
They will mostly be looking for only four basic transgressions:
▸ Incorrect payment amounts (either too much or too little).
▸ Noncovered services, including those that are not considered “reasonable and necessary.”
▸ Incorrect coding.
▸ Duplicate payments.
The RACs are required to have good cause to audit your claims. They cannot randomly select claims or focus only on high-paying claims. And they can only look back a maximum of 3 years—and no earlier than Oct. 1, 2007. That is a relatively short period of time requiring your review, and a relatively small number of transgressions that you need to look for.
So now is the time for your staff to start getting out Medicare EOBs (explanation of benefits) and determine where you might be vulnerable on the past 2 years' claims. And once you identify any vulnerabilities, you can take steps to audit-proof future claims.
So far, the RACs have mostly targeted hospitals, nursing homes, home health care organizations, and medical equipment companies, but anyone who bills Medicare is fair game. And it's only a matter of time before state-run Medicaid programs become targets as well.
CMS has hinted that a majority of audits will take place in California, New York, and Florida, because 25% of all Medicare payments are made to those three states alone.
If a RAC wants to look at your records, they must make the request in writing and they must tell you what they are looking for. They are limited by law to auditing no more than 10% of the average number of Medicare claims you file each month. The law states they must pay the costs of copying records, both paper and electronic.
The law provides you 45 days to respond to a RAC's request for patient records. It also specifies a “discussion period,” so if your records are requested, don't rush to send them. Call the RAC and discuss! The RAC's medical director is “required to be actively involved in examining all evidence used to make determinations,” and you have a right to speak to him or her if you wish.
If a repayment is demanded, you have 120 days to appeal that determination, in the same way (and by essentially the same process) that conventional Medicare audit determinations are appealed.
In case you're wondering, RAC audits will not replace regular Medicare audits, which I discussed in my June 2004 column.
To respond to this column, e-mail Dr. Eastern at sknews@elsevier.com
Putting the Web to Use in Practice
I am a strong believer in using the resources we have so readily at hand to inform ourselves of the latest medical information and guidelines and to inform our patients. Every exam room in our practice is wired with access to the Web and I refer to it during nearly every patient visit. Here's a quick look at sites that I'm currently using:
▸ Social Bookmarking: With the explosion of social networking sites in the past year, there has been a corresponding increase in sites, such as delicious.com
▸ Patient Education: If a patient needs information, I turn to sites vetted by government agencies or medical organizations such as the American Academy of Family Physicians. The AAFP's site, www.familydoctor.org
The National Library of Medicine (http://medlineplus.gov
The Mayo Clinic's site (www.mayoclinic.com
Despite the fact that 54% of our residency program clinic patients are on Medicaid, a large number have access to a computer to look at these sites.
▸ Physician Education: When I'm searching for information for my own purposes, I use the same rule of thumb: Well-worn paths are best. When I'm looking for a high-level overview or when I can't remember a specific fact, I'll go to www.fpnotebook.comwww.emedicine.com
Through our hospital and residency program affiliate, I have access to www.uptodate.com
The 600-pound gorilla for drug information, of course, is www.epocrates.com
The Agency for Healthcare Research and Quality's electronic Preventive Services Selector (www.epss.ahrq.gov
For guidelines on any topic, go to www.guidelines.govwww.nhlbi.gov
To some degree I worry about physicians who aren't checking Web resources. As Dr. Larry Weed, the pioneer visionary of the information age in health care, once suggested: If you want to go on a trip, you don't go to a travel agent who has memorized all of the flight boarding times, you go to someone who knows how to utilize resources to pick the best trip for you.
Our memory of what we learned in medical school is imperfect. And what was true back then, has probably changed.
I am a strong believer in using the resources we have so readily at hand to inform ourselves of the latest medical information and guidelines and to inform our patients. Every exam room in our practice is wired with access to the Web and I refer to it during nearly every patient visit. Here's a quick look at sites that I'm currently using:
▸ Social Bookmarking: With the explosion of social networking sites in the past year, there has been a corresponding increase in sites, such as delicious.com
▸ Patient Education: If a patient needs information, I turn to sites vetted by government agencies or medical organizations such as the American Academy of Family Physicians. The AAFP's site, www.familydoctor.org
The National Library of Medicine (http://medlineplus.gov
The Mayo Clinic's site (www.mayoclinic.com
Despite the fact that 54% of our residency program clinic patients are on Medicaid, a large number have access to a computer to look at these sites.
▸ Physician Education: When I'm searching for information for my own purposes, I use the same rule of thumb: Well-worn paths are best. When I'm looking for a high-level overview or when I can't remember a specific fact, I'll go to www.fpnotebook.comwww.emedicine.com
Through our hospital and residency program affiliate, I have access to www.uptodate.com
The 600-pound gorilla for drug information, of course, is www.epocrates.com
The Agency for Healthcare Research and Quality's electronic Preventive Services Selector (www.epss.ahrq.gov
For guidelines on any topic, go to www.guidelines.govwww.nhlbi.gov
To some degree I worry about physicians who aren't checking Web resources. As Dr. Larry Weed, the pioneer visionary of the information age in health care, once suggested: If you want to go on a trip, you don't go to a travel agent who has memorized all of the flight boarding times, you go to someone who knows how to utilize resources to pick the best trip for you.
Our memory of what we learned in medical school is imperfect. And what was true back then, has probably changed.
I am a strong believer in using the resources we have so readily at hand to inform ourselves of the latest medical information and guidelines and to inform our patients. Every exam room in our practice is wired with access to the Web and I refer to it during nearly every patient visit. Here's a quick look at sites that I'm currently using:
▸ Social Bookmarking: With the explosion of social networking sites in the past year, there has been a corresponding increase in sites, such as delicious.com
▸ Patient Education: If a patient needs information, I turn to sites vetted by government agencies or medical organizations such as the American Academy of Family Physicians. The AAFP's site, www.familydoctor.org
The National Library of Medicine (http://medlineplus.gov
The Mayo Clinic's site (www.mayoclinic.com
Despite the fact that 54% of our residency program clinic patients are on Medicaid, a large number have access to a computer to look at these sites.
▸ Physician Education: When I'm searching for information for my own purposes, I use the same rule of thumb: Well-worn paths are best. When I'm looking for a high-level overview or when I can't remember a specific fact, I'll go to www.fpnotebook.comwww.emedicine.com
Through our hospital and residency program affiliate, I have access to www.uptodate.com
The 600-pound gorilla for drug information, of course, is www.epocrates.com
The Agency for Healthcare Research and Quality's electronic Preventive Services Selector (www.epss.ahrq.gov
For guidelines on any topic, go to www.guidelines.govwww.nhlbi.gov
To some degree I worry about physicians who aren't checking Web resources. As Dr. Larry Weed, the pioneer visionary of the information age in health care, once suggested: If you want to go on a trip, you don't go to a travel agent who has memorized all of the flight boarding times, you go to someone who knows how to utilize resources to pick the best trip for you.
Our memory of what we learned in medical school is imperfect. And what was true back then, has probably changed.
Revenue Essentials
As physicians take on more extensive roles outside of patient care (e.g., administrative, academic, and billing compliance), involvement in the revenue cycle might diminish or even fail to commence. It is crucial for physicians to keep abreast of revenue cycle issues, but more often than not, they go unnoticed until a physician’s bottom line is affected.
The risk of inappropriately billed claims and corresponding reimbursement is increased until the problem is identified and resolved. In an effort to prevent this from occurring, physicians should get involved with or oversee their billing service or staff. Some of the revenue cycle essentials that require physician attention are:1
- Periodic reports of claims billed on the physician’s behalf and data regarding payments;
- Changes in procedure codes, diagnosis codes, or other information furnished by the physician without the physician’s knowledge and consent; and
- Information received from Medicare and other payors.
Feedback
One of the most common billing-related physician complaints involves the lack of feedback. Most physicians want to receive information regarding their quarterly billings: the volume and frequency of specific reported services, and corresponding payments or denials. Physicians prefer to know how they rank as individuals and as a group. Although they might not be experts in coding and documentation, this information offers physicians a feeling of security, as it permits them to identify typical billing patterns or highlight outlier patterns.
Establish communication with the manager/coder/biller to better assist with feedback. Appoint a physician leader to spearhead this effort; ensure feedback is provided quarterly, at a minimum. If the coders/billers feel that they have an approachable contact, they’re more likely to offer feedback before formal reports are generated. A quick resolution of potential problems lessens the financial burden on the HM group, as well as the resource-intensive education process that ensues.
Discrepancy Notation
Physicians should be notified whenever coding changes take place. Discrepancies occur when the physician employs coders to select the service or diagnosis codes, and the selected codes differ from the physician-intended codes. Discrepancies also occur when billers change the original physician-selected codes to codes that are considered covered or medically necessary by the pay0r. Physicians need to instruct coders to only report codes that are supported by the documentation.
Physicians must be aware that delegating any portion of the billing to an employee or a billing company does not alleviate physicians’ personal responsibility for erroneously submitted claims or receipt of overpayments. Physicians should regularly review information submitted by the designated employee or billing service to ensure consistency with their own records, and also keep complete administrative records for the claims a billing service files on their behalf.1 Physicians also should meet with staff to resolve discrepancies and reinforce the billing education process. If biller/coder performance becomes a recurring problem, the physician should question the competency of the employee or company with whom the billing is entrusted.
Accounts Receivable
Physicians do not necessarily recognize the need for involvement in the accounts receivable (A/R) component of the revenue cycle. Physicians should be aware of denials, and the reasons for the denials. Some services are denied because of issues that can be easily corrected (e.g., truncated diagnoses, two physicians of the same specialty billing on the same date, missing modifiers). These denial types might require physician assistance in changing the codes originally submitted. If the denied services can be corrected with the appropriate information and resubmitted electronically, payment might be recovered quickly. Other types of denials require submission of the documentation to support the service billed.
Billers should know the difference between the types of denials and the required action for each denial type. Physicians should feel confident that such denials will be handled in the correct manner. Be mindful of billing staff that accepts denials and surrenders the reimbursement efforts without hesitation. As a physician, do not default to the idea that “no news is good news.” Do not assume the billing manager (physician employee or outsourced firm) will let the group know if there is a problem. Develop a standard that requires monthly feedback of denials.
Only a short window of time exists for the appeals process to occur. Do not lose the potential to recover monies because the information was not provided to the physician in a timely manner. TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is also on the faculty of SHM’s inpatient coding course.
References
- Centers for Medicare and Medicaid Services. Protecting Your Practice. CMS Web site. Available at: www.cms.hhs.gov/MLNProducts/downloads/Protectingpracbroch508-09.pdf. Accessed Aug. 2, 2009.
- Office of Inspector General. Work Plan Health Care Financing Administration Projects Fiscal Year 1999. Physicians: Billing Service Companies. Available at: http://oig.hhs.gov/publications/docs/workplan/1999/99hcfawp.pdf. Accessed Aug. 2, 2009.
- Office of Inspector General. OIG Compliance Program Guidance for Third-Party Medical Billing Companies in Federal Register, December 1998, Vol. 63; pages 70138-70152. Available at: http://oig.hhs.gov/fraud/docs/complianceguidance/thirdparty.pdf. Accessed Aug. 2, 2009.
As physicians take on more extensive roles outside of patient care (e.g., administrative, academic, and billing compliance), involvement in the revenue cycle might diminish or even fail to commence. It is crucial for physicians to keep abreast of revenue cycle issues, but more often than not, they go unnoticed until a physician’s bottom line is affected.
The risk of inappropriately billed claims and corresponding reimbursement is increased until the problem is identified and resolved. In an effort to prevent this from occurring, physicians should get involved with or oversee their billing service or staff. Some of the revenue cycle essentials that require physician attention are:1
- Periodic reports of claims billed on the physician’s behalf and data regarding payments;
- Changes in procedure codes, diagnosis codes, or other information furnished by the physician without the physician’s knowledge and consent; and
- Information received from Medicare and other payors.
Feedback
One of the most common billing-related physician complaints involves the lack of feedback. Most physicians want to receive information regarding their quarterly billings: the volume and frequency of specific reported services, and corresponding payments or denials. Physicians prefer to know how they rank as individuals and as a group. Although they might not be experts in coding and documentation, this information offers physicians a feeling of security, as it permits them to identify typical billing patterns or highlight outlier patterns.
Establish communication with the manager/coder/biller to better assist with feedback. Appoint a physician leader to spearhead this effort; ensure feedback is provided quarterly, at a minimum. If the coders/billers feel that they have an approachable contact, they’re more likely to offer feedback before formal reports are generated. A quick resolution of potential problems lessens the financial burden on the HM group, as well as the resource-intensive education process that ensues.
Discrepancy Notation
Physicians should be notified whenever coding changes take place. Discrepancies occur when the physician employs coders to select the service or diagnosis codes, and the selected codes differ from the physician-intended codes. Discrepancies also occur when billers change the original physician-selected codes to codes that are considered covered or medically necessary by the pay0r. Physicians need to instruct coders to only report codes that are supported by the documentation.
Physicians must be aware that delegating any portion of the billing to an employee or a billing company does not alleviate physicians’ personal responsibility for erroneously submitted claims or receipt of overpayments. Physicians should regularly review information submitted by the designated employee or billing service to ensure consistency with their own records, and also keep complete administrative records for the claims a billing service files on their behalf.1 Physicians also should meet with staff to resolve discrepancies and reinforce the billing education process. If biller/coder performance becomes a recurring problem, the physician should question the competency of the employee or company with whom the billing is entrusted.
Accounts Receivable
Physicians do not necessarily recognize the need for involvement in the accounts receivable (A/R) component of the revenue cycle. Physicians should be aware of denials, and the reasons for the denials. Some services are denied because of issues that can be easily corrected (e.g., truncated diagnoses, two physicians of the same specialty billing on the same date, missing modifiers). These denial types might require physician assistance in changing the codes originally submitted. If the denied services can be corrected with the appropriate information and resubmitted electronically, payment might be recovered quickly. Other types of denials require submission of the documentation to support the service billed.
Billers should know the difference between the types of denials and the required action for each denial type. Physicians should feel confident that such denials will be handled in the correct manner. Be mindful of billing staff that accepts denials and surrenders the reimbursement efforts without hesitation. As a physician, do not default to the idea that “no news is good news.” Do not assume the billing manager (physician employee or outsourced firm) will let the group know if there is a problem. Develop a standard that requires monthly feedback of denials.
Only a short window of time exists for the appeals process to occur. Do not lose the potential to recover monies because the information was not provided to the physician in a timely manner. TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is also on the faculty of SHM’s inpatient coding course.
References
- Centers for Medicare and Medicaid Services. Protecting Your Practice. CMS Web site. Available at: www.cms.hhs.gov/MLNProducts/downloads/Protectingpracbroch508-09.pdf. Accessed Aug. 2, 2009.
- Office of Inspector General. Work Plan Health Care Financing Administration Projects Fiscal Year 1999. Physicians: Billing Service Companies. Available at: http://oig.hhs.gov/publications/docs/workplan/1999/99hcfawp.pdf. Accessed Aug. 2, 2009.
- Office of Inspector General. OIG Compliance Program Guidance for Third-Party Medical Billing Companies in Federal Register, December 1998, Vol. 63; pages 70138-70152. Available at: http://oig.hhs.gov/fraud/docs/complianceguidance/thirdparty.pdf. Accessed Aug. 2, 2009.
As physicians take on more extensive roles outside of patient care (e.g., administrative, academic, and billing compliance), involvement in the revenue cycle might diminish or even fail to commence. It is crucial for physicians to keep abreast of revenue cycle issues, but more often than not, they go unnoticed until a physician’s bottom line is affected.
The risk of inappropriately billed claims and corresponding reimbursement is increased until the problem is identified and resolved. In an effort to prevent this from occurring, physicians should get involved with or oversee their billing service or staff. Some of the revenue cycle essentials that require physician attention are:1
- Periodic reports of claims billed on the physician’s behalf and data regarding payments;
- Changes in procedure codes, diagnosis codes, or other information furnished by the physician without the physician’s knowledge and consent; and
- Information received from Medicare and other payors.
Feedback
One of the most common billing-related physician complaints involves the lack of feedback. Most physicians want to receive information regarding their quarterly billings: the volume and frequency of specific reported services, and corresponding payments or denials. Physicians prefer to know how they rank as individuals and as a group. Although they might not be experts in coding and documentation, this information offers physicians a feeling of security, as it permits them to identify typical billing patterns or highlight outlier patterns.
Establish communication with the manager/coder/biller to better assist with feedback. Appoint a physician leader to spearhead this effort; ensure feedback is provided quarterly, at a minimum. If the coders/billers feel that they have an approachable contact, they’re more likely to offer feedback before formal reports are generated. A quick resolution of potential problems lessens the financial burden on the HM group, as well as the resource-intensive education process that ensues.
Discrepancy Notation
Physicians should be notified whenever coding changes take place. Discrepancies occur when the physician employs coders to select the service or diagnosis codes, and the selected codes differ from the physician-intended codes. Discrepancies also occur when billers change the original physician-selected codes to codes that are considered covered or medically necessary by the pay0r. Physicians need to instruct coders to only report codes that are supported by the documentation.
Physicians must be aware that delegating any portion of the billing to an employee or a billing company does not alleviate physicians’ personal responsibility for erroneously submitted claims or receipt of overpayments. Physicians should regularly review information submitted by the designated employee or billing service to ensure consistency with their own records, and also keep complete administrative records for the claims a billing service files on their behalf.1 Physicians also should meet with staff to resolve discrepancies and reinforce the billing education process. If biller/coder performance becomes a recurring problem, the physician should question the competency of the employee or company with whom the billing is entrusted.
Accounts Receivable
Physicians do not necessarily recognize the need for involvement in the accounts receivable (A/R) component of the revenue cycle. Physicians should be aware of denials, and the reasons for the denials. Some services are denied because of issues that can be easily corrected (e.g., truncated diagnoses, two physicians of the same specialty billing on the same date, missing modifiers). These denial types might require physician assistance in changing the codes originally submitted. If the denied services can be corrected with the appropriate information and resubmitted electronically, payment might be recovered quickly. Other types of denials require submission of the documentation to support the service billed.
Billers should know the difference between the types of denials and the required action for each denial type. Physicians should feel confident that such denials will be handled in the correct manner. Be mindful of billing staff that accepts denials and surrenders the reimbursement efforts without hesitation. As a physician, do not default to the idea that “no news is good news.” Do not assume the billing manager (physician employee or outsourced firm) will let the group know if there is a problem. Develop a standard that requires monthly feedback of denials.
Only a short window of time exists for the appeals process to occur. Do not lose the potential to recover monies because the information was not provided to the physician in a timely manner. TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is also on the faculty of SHM’s inpatient coding course.
References
- Centers for Medicare and Medicaid Services. Protecting Your Practice. CMS Web site. Available at: www.cms.hhs.gov/MLNProducts/downloads/Protectingpracbroch508-09.pdf. Accessed Aug. 2, 2009.
- Office of Inspector General. Work Plan Health Care Financing Administration Projects Fiscal Year 1999. Physicians: Billing Service Companies. Available at: http://oig.hhs.gov/publications/docs/workplan/1999/99hcfawp.pdf. Accessed Aug. 2, 2009.
- Office of Inspector General. OIG Compliance Program Guidance for Third-Party Medical Billing Companies in Federal Register, December 1998, Vol. 63; pages 70138-70152. Available at: http://oig.hhs.gov/fraud/docs/complianceguidance/thirdparty.pdf. Accessed Aug. 2, 2009.