Medicare Audits Continue…Reason for Visit is Frequent Target

by Dr. Charles Brownlow

Medicare contracted auditors are picking up the pace of their audits, often finding errors in the codes that are used to report patient visits. The codes are chosen based on the content of each records, measured against the definitions for the services in Current Procedural Terminology (CPT, American Medical Association), and, in the case of the 99000 series office visits, the Documentation Guidelines for the Evaluations and Management Services.

Accurate choices of visit codes is a straightforward process, as is reflected in the fact that most electronic health care software will automatically choose office visit codes, based purely upon the content of each record. Unfortunately, possibly partially due to the ease of recording data in EHR, Medicare is seeing a rising number of higher level 99000 codes billed. It is the increase in the frequency of the high level codes that was partially responsible for the current round of audits.

By doing hundreds of ‘friendly audits’ for eye doctors over the past fifteen years through PMI “Chart Review” service, we’ve known for a long time that doctors tend to under code visits, possibly due to a fear of audits or uncertainty as to how to accurately choose codes. EHR codes correctly, which often means higher than the same doctor coded prior to using EHR.

Sadly, the accuracy of code choice may be pretty good yet the audit may still be pretty bad. The auditors are focusing upon the appropriateness of care in addition to the accuracy of the code itself. For example, a medical record may “earn” a high level of code due to an expansive case history and a physical examination filled with lots of tests and yet be rejected by an auditor because the reason for visit did not support the need for all those questions in the history and all those tests in the examination.

Again, the importance of good records and accurate coding comes to light but most important, the auditors are emphasizing the very basic premise of all health care; that it should be focused on the needs of each patient and upon the needs of the doctor providing services to that patient during that particular visit. In short, if you have redone a thorough case history on a patient that was in the office 48 hours earlier, it may have been due to habit or internal office protocol, rather than the needs of the patient or doctor. If that’s the case, it is important to grade the visit based only upon the elements of the record that were germane to the visit and necessary for care of the patient.

If your records all look the same, regardless of the unique needs of each patient and doctor at each visit, you can expect to have problems in an audit. This trend should result in a “wake up call” or all health care providers and their educational institutions that we need to return to a clear focus upon the needs of the patient at each visit, customizing the components of each visit to those needs. It is the way health care was provided in the years before insurance or Medicare and it is the way health care must be provided in the new millennium.

AOA Gets “Answer” Regarding Rejections of Ophthalmological Visit Codes

A programing glitch that has resulted in the improper rejection of numerous Medicare claims with ophthalmological established patient exam codes 92012 and 92014 will be fixed system-wide by October 1, according to the U.S. Centers for Medicare & Medicaid Services (CMS).

The programing error has resulted in the rejection of 92012 and 92014 claims with modifiers –24, –25 and –59. Eye care practitioners began noticing the improper claim rejections in early July, according to the AOA Advocacy Group. The Medicare claims are being rejected due to computer system issues associated with new National Correct Coding Initiative (NCCI) edits.

At least one Medicare administrative contractor, Noridian Healthcare Solutions, LLC, has implemented a temporary fix in its computer system to address the issue. To be safe, practitioners will have to resubmit the improperly rejected claims after October 1 in order to receive payment, according to CMS officials. Medicare administrative contractors will not automatically reprocess the claims, they emphasized.

The AOA Advocacy Group suggests practitioners hold any new Medicare claims with the 92012 or 92014 exams codes and the –24, –25, or –59 modifiers until after October 1.

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