Preparing for E/M Coding Audits Proactive Compliance

1. Preparing for E/M Coding AuditsProactive Compliance Robert Jagielski, JD Chief Compliance Officer Robert.Jagielski@Practicemax.com

2. Today’s ever-changing, complex healthcare landscape presents a unique challenge for modern physician practices. Apart from basic compliance with existing licensure, coding, and billing requirements, physicians need to proactively focus on pending legislation, emerging reimbursement trends and future paradigm shifts to ensure that their practices are prepared for the forthcoming industry changes. PracticeMax’s services are designed to optimize reimbursement and minimize costs through short and long term strategic planning and project implementation. Our services are grounded in a unique multi-disciplinary approach that integrates regulatory, financial, and operational analysis into provide a well-balanced, global perspective. http://www.practicemax.com/ Corporate Philosophy

3. I’ve been asked to speak about currentgovernment initiatives regarding fraud and abuse with a particular focus on ED Physician Billing. • The primary catalyst for most current initiatives is a 2012 OIG report entitled “Coding Trends of Medicare Evaluation And Management Services” Introduction

4. Accordingly, to properly understand the current focus of government audits, including who is being audited and why, we need to understand what was stated in the OIG Report and what was not. Introduction

5. I will then discuss current initiatives, which include: • OIG 2013 Work Plan Audit; • A service-specific prepay audit for Outpatient E/M services (99205 and 99215) initiated by NGS on Oct 1, 2013 (Impacts IL, MN, and WI). • A service specific prepay audit for E/M visits (99285) initiated by Noridian on October 29, 2013 (Impacts Arizona, along with AK, AZ, MT, ND, OR, SD, UT, WA and WY) Introduction

6. Finally, I will conclude with a brief discussion of my own recent experience with a private payer audit and discuss the key factors that led to our successful appeal of the issues raised. Introduction

7. 2012 Coding Trend Report Insight and Analysis

8. In May of 2012, the OIG released a study entitled “Coding Trends of Medicare Evaluation And Management Services”. The most widely reported statistic was: • Part B payments for E/M services increased from $22.7 billion to $33.5 billion (a 48 percent increase) during a ten year period (2001-2010). The alarming statistic is pulled from the second sentence of the executive summary. OIG Coding Trend Report

9. Note the first sentence of the report reads: • Between 2001 and 2010, Medicare payments for Part B goods and services increased by 43 percent, from $77 billion to $110 billion. Accordingly, the 48 percent payment increase for E/M services does not seem so alarming as it is only 5% higher then the payment increase for Part B goods and services in general. OIG Coding Trend Report

10. The OIG noted that several factors contributed to the E/M Payment increases. Specifically: • The number of E/M services billed increased by 13 percent, from 346 million to 392 million. • Additionally, the average Medicare payment amount per E/M service increased by 31 percent, from approximately $65 to $85 Each of the above are significant causal factors for the increase. Contributing Factors

11. Accordingly, changes in physicians’ billing of E/M codes, were just one of three factors that contributed to the payment increase. Contributing Factors

12. Specific Findings

13. With respect to the findings specific to coding trends, the OIG found that: • Physicians increased their billing of higher level codes in all 15 visit types allowed by CPT Coding. * • Overall, physicians who billed for E/M services represented 66 specialties, with most specializing in internal medicine, family practice, and emergency medicine. * From 2001 to 2009, there were 15 visit types for E/M services. In 2010, inpatient and outpatient consultations were no longer permitted by CMS for payment, resulting in 13 visit types. Specific Findings

14. To illustrate the shift in physician billing, the OIG provided details on three visit types: • Established Patient Office Visit • Subsequent Inpatient Hospital Care, and • Emergency Department Visits. Specific Findings

15. Emergency Department Visits represented the fifth-largest amount of Medicare payments for E/M services in 2010 and constituted 7.4% of total payment. • In 10 years, physicians’ billing of the highest level code (99285) rose 21 percent, increasing from 27 to 48 percent. • During the same time, physicians’ billing of all other codes decreased. Emergency Department

16. Emergency Department

17. Emergency Department The level five increases occured incrementally at rates of 2 to 3 percent each year. Many commentators, including CMS, consider this to be normal growth in light of various circumstances that had a causal impact.

18. The OIG did not discuss or analyze specific reasons why the increase occurred. • Nor did it determine whether physicians who billed higher level E/M codes billed inappropriately. Scope of Review

19. The OIG clarified that subsequent evaluations will determine: • the appropriateness of Medicare payments; and • the extent of documentation vulnerabilities in E/M services. One of the primary purposes of this study was merely to identify the key outliers for the subsequent review. Scope of Review

20. In 2010, nearly 370 million E/M services were provided by approximately 442,000 physicians nationwide. • Of that population, 3,008 had an average E/M code level in the top 1 percent of their specialties. 2010: Top Outliers

21. After identifying the top one percent, the OIG then focused on the physicians who billed the 2 highest level E/M codes within a visit at least 95 percent of the time. • The OIG identified 1,669 physicians that fit this category • These physicians represented less than 1 percent of all physicians who performed E/M services in 2010. 2010: Top Outliers

22. 2010: Top Outliers

23. On average, the physicians who billed the two highest level E/M codes did so 98 percent of the time, compared to others who billed these codes 53 percent of the time. • Of the top outliers, roughly half (55% / 916) billed the two highest level codes 100 percent of the time 2010: Top Outliers

24. Physicians who consistently billed higher level E/M codes: • Practiced in nearly all States • Represented similar specialties • Treated beneficiaries of similar ages • Treated beneficiaries with similar diagnoses 2010: Top Outliers

25. However, some States had a greater percentage of these physicians: • For example, California had 17% of the physicians • New York and Florida had 11.3% and 9.6% respectively • Arizona had 4.3% 2010: Top Outliers

26. 2010: Top Outliers

27. The OIG found that among physicians who consistently billed higher-level E/M codes: • 19.8% were internists • 12.2 % were family physicians • 9.9 % were in emergency medicine Accordingly, of the 1669 physicians identified, approximately 170 physicians were in emergency medicine, and 4.3% lived in Arizona. 2010: Top Outliers

28. Potential Factors for Increase

29. Increase in sicker patients seeking care in emergency rooms • More accurate billing • Increased utilization of clinics and urgent care • Nurse practitioners and physician assistants are treating less sick patients who in the past would have been treated by doctors Potential Factors for Increase

30. Increased utilization of EHRs has also been suggested as a possible reason for the increase. • Those who make this assertion suggest that templates, drop boxes and cloned records are making it easier to “game the system”. Potential Factors for Increase

31. The AMA addressed the impact of EHRs in depth at aMay 3, 2013 teleconference and in subsequent testimony to a congressional review board. • They noted that to overcome inefficiencies, various shortcuts and tools are used in the EHR (templates, macros, and cut & paste) • The emphasized that none of these shortcuts are inherently bad, but each of them can be misapplied, accidentally or intentionally. EHR: AMA

32. Alarmingly, some Medicare carriers have already disseminated rules that if charts look too much alike they will deny payment. • In this instance, even when EHRs are properly used, physicians are accused of inappropriate behavior and are being economically penalized. • The AHA and others have strongly opposed these rules as being overly broad and negatively impacting the intended economic benefit of EHRs. EHR: AMA Testimony

33. The OIG is currently reviewing EHRs to determine how cloned records are being used and if they are associated with potentially improper payments. • This issue will clearly continue to be debated 2013 OIG Work Plan

34. OIG Recommendations

35. The OIG made three recommendations ….. OIG Recommendations

36. First, CMS should continue to educate physicians on proper billing for E/M services. • CMS concurred and implemented. • CMS updated E/M educational products and is seeking new ways of educating providers on proper billing for E/M services, such as exploring the use of Web-based learning tools OIG Recommendations

37. Second, CMS Contractors should review physicians’ billing • CMC Concurred and Implemented • CMS issued a comparative billing report aimed at 5,000 physicians identified as top billers (included the 1669 identified by OIG) • The report was not intended to be punitive or to be an indication of fraud • The report was intended to help providers identify potential errors in billing practices and help prevent improper billing and payment in the future. OIG Recommendations

38. The third recommendation was to review the top billers for possible punitive action. • CMS Partially Concurred and Partially Implemented • CMS forwarded the names of the 1,669 physicians to MACs. • However, they directed each MAC to limit its review to the top 10 high billers in its jurisdiction. OIG Recommendations

39. Why the partial implementation of the recommended MAC review? • CMS stated that it and its contractors must weigh the cost and benefit of E/M reviews against reviews of more costly Part B services. • Although initially indicating it would take a limited review of the issue, recent prepayment audits announced by MACs indicate a shift in prioritization and focus. CMS Partial Implementation

40. Current Audits and Review

41. OIG will determine the extent to which CMS made potentially inappropriate payments for E/M services in 2010 and the consistency of E/M medical review determinations. • This is the key follow-up to the 2012 report. 1 OIG 2013 Work Plan

42. On October 1st, 2013, NGS initiated a service-specific prepay audit for Outpatient E/M codes 99205 and 99215. • National CERT data indicated that the selected codes are in the top 15 codes identified for improper payment rates. • Impacts IL, MN, and WI. 1 Outpatient E/M Prepay Audit

43. On October 29th, 2013, Noridian initiated a service-specific prepay audit for ED E/M code 99285 (level 5). • The news release did not provide any indication of why the audit was initiated; however, presumably it is related to trending reports or issues identified during the initial MAC review. • Impacts Arizona, along with AK, AZ, ID, MT, ND, OR, SD, UT, WA and WY. 1 ED E/M Prepay Audit

44. Service specific reviews are based upon the general populations use of a particular CPT code; whereas in a complex review, the focus is on a particular provider. • Claims suspended for medical review are chosen at random from current claim submissions. • There is little direct provider contact with this type of review since the review is based on the general billing of a particular CPT code, and not the billing of a particular provider. 1 Service-Specific Prepay Audits

45. You will be notified by letter if your claims are selected for review. • You will then have 30 days from the receipt to submit supporting documentation . • If Noridian does not receive the documentation within 30 days, the claim will be denied. • Denials may result in future provider specific complex reviews. 1 Noridian Process

46. A determination will be made within 60 days of receipt of claim documentation. • Noridian will post a high-level summary on its website at the end of each quarter and at the end of the review. • Providers will not receive an individual notice detailing why claim(s) were denied and/or paid at a different level of service. • Providers will only receive a standard Remittance Advice. Determinations can be appealed per the standard process. 1 Noridian Process

47. Audit notices will be sent directly to the practices administrative office. • Please advise all front office staff to pay special attention for any notices coming from Noridian in the near future. • Please make sure notices received are date stamped and immediately sent to your practice management firm. 1 Noridian Process

48. Please do not be alarmed if you receive a prepayment review letter. • Claims are randomly selected. • There is no analysis of specific provider coding patterns. • It is not an indication that your practice has been flagged. 1 Noridian Process

49. Surviving an Audit

50. Recently a large private insurer audited one of our ED clients. • The trending of this practice has been relatively stable and consistent with industry practices. No outliers. • Of the 14 claims selected for review, 11 were determined to be over-coded to levels 4 and 5. • They requested an immediate plan of correction and a refund of the alleged overpayments. Surviving an Audit