PwC. HCCA Compliance Institute. Evaluation/Management (E/M) Sampling Methodologies. April 19, 2005

Transcription

1 Evaluation/Management (E/M) Sampling Methodologies Georgette Gustin CPC, CCS-P, CHC Mary Ann Swann MBA, FACPME, CPC HCCA Compliance Institute April 19, 2005 PwC

2 Learning Objectives Review how using data mining can assist with developing an audit plan and sampling methodologies Review how to design profiles and establish metrics Discuss how to prepare reports and present results HCCA Compliance Institute Humana Focus review on outlier physicians for high intensity E/M claims effective October 1, Any physician whose high intensity E/M claims coding practice are above the 75% percentile for their specialty Review of the 8 specific high intensity E/M codes: New patient exams ( ) Established patient exams ( ) Consultations (99244 and 99245) Emergency Room Services ( ) Review bi-annually the list of participating and non participating physicians on the outlier list Source: HCCA Compliance Institute 1

3 Data Analysis CIGNA Medicare: Uses Focused Medical Review System (FMRS) software: to identify utilization of services for procedure codes by individual providers, groups and specialties to provide on-line access of Medicare providers practices for comparative analysis of individual performance to that of his/her peers Can compare procedure code utilization by specialty across states, regions and the nation Has direct access to CMS s data banks for information retrieval HCCA Compliance Institute CMS Public Data Medicare Utilization Data for Part B National Physician and Supplier Berenson and Eggers Type of Service (BETOS) Provides allowed services, charges and payment data Organized by Calendar Year Provides Top 200 Level I and Level II HCPCS Code utilization data across all specialty areas Includes Medicare Leading Part B CPT Procedure Codes based on allowed charges HCCA Compliance Institute 2

4 Supplemental Sources Data mining methodologies should take into consideration other relevant information Reports published by the OIG Improper Medicare Fee-for-Service Payments Reviewing the various clinical scenarios CERT reports Probe results published by Part B Carriers HCCA Compliance Institute Focused Medical Review (FMA) CIGNA Medicare Administration and the other Medicare Carriers have been doing a Focused Medical Review of the top thirty (30) CPT codes billed by specialty. The top thirty (30) codes are listed according to the Carrier allowed charges per 1,000 Medicare beneficiaries in the state. The state rankings are compared to national rankings for the same specialty along with comparing the Carrier and National allowed services per 1,000 beneficiaries. When large differences are found (i.e., one and one-half times more services or one and one-half times more allowed charges by the Carrier per 1,000 beneficiaries) when compared to National averages, the FMR team looks at their local medical review data base to determine what is causing the large difference (aberrancy) HCCA Compliance Institute 3

5 Data Mining Medicaid Fraud Control Units MFCUs will join with CMS to uncover billing anomalies by comparing Medicaid and Medicare bills to see if a provider billed both programs for the same service Pilot Medicare-Medicaid (Medi-Medi) data match to identify time bandits looking to identify providers who bill the programs for more than 24 hours a day Program was launched in CA in 2001 and it saved $58 million HCCA Compliance Institute CERT Report Findings Includes the Top 20 CMS Upcoding Errors - Carriers Note: Of the 20, the Top 5 were E/M services Service Billed to Carrier Paid Claims Error Rate Initial inpatient consult (99255) 19.7% Office/outpatient visit, est (99215) 18.6% Office/outpatient visit, new (99204) 18.5% Office consultation (99245) 17.5% Office/outpatient visit, new (99205) 15.5% Nursing facility care (99303) 15.2% Source: Improper Medicare Fee-for-Service Payments Report FY 2004, Supplementary Appendices HCCA Compliance Institute 4

6 Evaluation & Management (E/M) Services Hospital Daily Care Fiscal Year Analysis CPT Code Number of Services Reviewed Number of Services Questioned Percent of Services in Error % , % % % % % % Source: DHHS, 1/16/2003, Improper Fiscal Year 2002 Medicare Fee-for-Service Payments (A ) HCCA Compliance Institute Example: Part B Carrier Probe Wisconsin Physician s Service (WPS) Jurisdiction over Wisconsin, Illinois, Michigan and Minnesota Purpose to identify or confirm potential billing issues Performed on a prepayment basis allows review of current billing practices Reviewed100 randomly selected claims from each of the four states No more than 5 claims are selected from a single provider, which assures that at lease 20 providers claims will be in a state s sample After review, the state findings are compiled, identifying the main issues found Providers involved in the probe receive a general education letter listing the overall findings of the probe Focused probe on CPT codes (office/established patient) and (hospital/daily care) Source: (Pages 69 thru 76) HCCA Compliance Institute 5

7 WPS Probe Findings Michigan: Overall error rate for CPT code (99213) 22.10% Requested records not received: 18.15% Documentation does not support services billed: 1.04% Services not billed under appropriate procedure code: 1.04% Service not documented in medical record: 0.98% Documentation supports a lower level of care than service billed: 0.88% Minnesota: Overall error rate for CPT code (99232) 51.39% Requested records not received: 34.95% Services not documented in record: 14.06% Documentation supports a lower level of care than services billed: 2.38% Source: (Pages 69 thru 76) HCCA Compliance Institute Approaches to E/M Sampling Typical Sample Sizes 5-10 records per physician or department Frequency Monthly, Quarterly, Semi-annual, Annually or two-year cycle OIG Compliance Guidance for Individual and Small Group Physician Practices 5 or 10 records per Federal payer (ie, Medicare or Medicaid); or 5 to 10 medical records per physician Recent Corporate Integrity Agreements (CIA) requirements 6 per physician (3 inpatient and 3 outpatient) E/M and procedures HCCA Compliance Institute 6

8 Establishing Methodology to Select Sample Focus areas High volume/high-risk areas or specific unit of study Outliers (Utilization review, using the Bell Curve data) Government payors Random record selection Statistically valid record selection Targeted record selection (specific codes) Prospective/Retrospective Example of recent CIA requirements for conducting internal audits Pull list of all patients seen by provider for the past 1-3 months Divide the total number of patients seen by 6 Select sample by using 6 (T/6=N) Select every Nth encounter and randomly select encounters (4 of which must be from federal healthcare programs) Include cross section of outpatient and inpatient E/M and procedures HCCA Compliance Institute Using Data Mining for Sampling Internal data Utilization reports Payor, department, physician, location, code type, etc. Denial data as it relates to coding reason codes Service included in another procedure Deleted code Service location/cpt code mismatch External data CMS utilization data MGMA Physcape data Other sources HCCA Compliance Institute 7

9 Monitoring E/M Code Level Distributions 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% Outpatient Consultation E/M Bell Curve 0.00% Medicare Dr. A Dr. B Dr. C Dr. D HCCA Compliance Institute Evaluation and Management Services CMS FY 2002 Bell Curve Data - All Specialties New Patient Visits 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% HCCA Compliance Institute 8

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16 Summary Remarks Analyze the data objectively, frequently and aggregately Consider an annual or bi-annual independent external assessment Be flexible in developing the annual plan Seek others input into the process Don t get stuck in a rut year after year (same old, same old) Think outside of the box Be creative and open to change HCCA Compliance Institute Baylor College of Medicine Case Study From To Prospective review E/M documentation and coding Anesthesia, psychiatry and radiology documentation and coding Surgery documentation and coding Teaching physician issues Prospective and retrospective review 12 projects 4 stages More data analysis Increased randomness HCCA Compliance Institute 15

17 Expanded Review Strategy (12 Step Program) 1. Research billing for routine services 2. Modifier Physician extenders 4. Acuity & Medical Necessity in E/M Services 5. Modifiers GC and GE 6. Billing and Collection Process 7. Outlier Inpatient Services & Procedures 8. Outlier Outpatient Services & Procedures 9. EMR 10. Surgery and Anesthesia 11. Modifiers 22, 59, 80, 81, Targeted Medicare and Medicaid Payments HCCA Compliance Institute Expanded Review Strategy - Stage 1 Research billing for routine services Identify trials which include billing routine services Validate billing to correct funding source Modifier -25 Investigate use of -25, which allows billing E/M visit on same day as procedure Physician extenders Review scope of practice Monitor appropriateness of incident to billing HCCA Compliance Institute 16

18 Expanded Review Strategy - Stage 2 Acuity and medical necessity in targeted E/M services Target , , Identify acuity and frequency coding outliers Reconcile w/ medical necessity, chief complaint Modifiers -GC and -GE Monitor use of -GC to indicate resident involvement and -GE to indicate resident care in Primary Care Exception clinic Billing and collection process Review from registration through appeal Validate diagnoses used in appeals Identify process upsets and resolution steps HCCA Compliance Institute Expanded Review Strategy - Stage 3 Outlier inpatient services and procedures Monitor targeted service and procedure frequencies eg, critical care, high level admissions, high level rounding visits, cardiology interventions Validate coding, TP issues, medical necessity Outlier outpatient services and procedures Monitor targeted service and procedure frequencies eg, emergency services, cataract removal with IOL, venipuncture, lumbar puncture Validate coding, TP issues, medical necessity EMR Does EMR yield higher level coding? Validate coding, TP issues, medical necessity HCCA Compliance Institute 17

19 Expanded Review Strategy - Stage 4 Surgery and Anesthesia Identify frequency outlier cases Compare anesthesia records to operative reports Compare surgery schedules to clinic schedules Validate coding, TP issues, medical necessity Modifiers -59; -80, -81, -82; -22 Used to bypass NCCI edits for separately billable procedures; for assistants at surgery; and for unusual procedures Review medical records for correct usage Targeted Medicare and Medicaid payments Identify providers with highest payments Validate coding, TP issues, medical necessity HCCA Compliance Institute Process for each audit project State project objectives Determine key criteria Data mine to capture universe to audit Apply sampling strategy Design audit tool Identify metrics Consolidate findings Graphically report results HCCA Compliance Institute 18

20 Acuity & Medical Necessity in E/M Services Objective Identify acuity and frequency outliers for high level new and established outpatient/office visits & consultations Reconcile with medical necessity and chief complaint Process Data mine IDX to find departments with highest utilization of target codes; identify providers within these departments with highest utilization Chart bell curves for each provider; compare to industry curves Develop audit tool Collect sample; audit Develop metrics tracking format; enter findings Design graphic report format; report to participants and leaders HCCA Compliance Institute E/M Acuity Form Baylor College of Medicine Compliance Program Acuity Form Patient: DOS: Mcare/Caid Yes No EMR Yes No Provider Department: Division: Codes Billed: E/M Service: Yes No N/A Correct level chosen History meets level Exam meets level MDM meets level Upcoded? Downcoded? How many levels? Service cannot be billed due to lack of documentation Resident involved Link/TP documentation adequate Diagnosis correct Chief Complaint and severity of illness supports level billed Consult meets requirements Referring MD, request, opinion, written report Code changed Error in processing of charge document (see comments) Signature present Follow-up meeting with Provider necessary Date of meeting Comments Analyst Date HCCA Compliance Institute 19

21 Legend for Acuity Review SSL = Severity Supports Level Billed E/M CIC = E/M Coded Incorrectly LUC = Level Upcoded LDC = Level Do P = No Personal Documentation L = No Link to Resident Note S = No Signature CCC = CPT Cod No CC = No Chief Compliant CRNM = Consult Requirements not Met PCIC = Procedure Coded Incorrectly LOD Lack of Do YU = Upcoded Procedure UB = Unbundled Procedure or E/M DX = Diagnosis Incorrect CIF = Comment PI = Process Issue R = Refund to Medicare or Medicaid Dept T MCM C HCH D RES EMR IP OP OV SSL E/M CIC UH UE UM L U C D L D C P L S CCC No CC CRN M PCI C LO D YU UB A B C D E F G Totals Percent 39% 16% 24% 35% 0% 59% 41% 69% 42% 34% 20% 23% 1% 3% 4% 3% 7% 2% 5% 1% 2% 1% 0% SSL Accuracy by Department A 58% Total Providers 262 Records B 67% Total Records 1555 cpc1 407 C 67% Percent of Upcoding 42% cpc2 239 D 36% Percent of Downcoding 1% cpc3 251 E 75% cpc4 5 F 66% cpc5 255 G 75% cpc6 398 Total All Departments 69% 1555 Providers HCCA Compliance Institute Acuity & Medical Necessity in E/M 7 Departments 262 Providers 1555 Records , , % M'care & M'caid Other 24% Resident No resident 61% 76% 35% EMR Paper 41% Outpatient Office 65% 59% HCCA Compliance Institute 20

22 Acuity & Medical Necessity in E/M Accuracy by Department 100% 80% 60% 40% 69% 2004 Pass Rate 20% 0% A B C D E F G B Accuracy = documentation of severity supports level billed C HCCA Compliance Institute Acuity & Medical Necessity in E/M Error Rates for , , % 40% 35% 30% 25% % 15% 10% 5% 0% *No Chief Complaint *Consult Req Not Met *Upcoding Down coding *Lack of Doc'n *No Signature HCCA Compliance Institute 21

23 Modifier -25 Objective Investigate use of -25, which allows billing E/M visit on same day as procedure Process Data mine IDX to find departments with highest utilization of modifier - 25; identify providers within these departments with highest utilization Define Medicare carrier guidance on use of -25 Develop audit tool Collect sample; audit Develop metrics tracking format; enter findings Design graphic report format; report to participants and leaders HCCA Compliance Institute Was modifier -25 billed correctly? NO Only bill E/M & educate -25 not required Only bill procedure & educate Do not bill - insufficient doc n; Is E/M coded correctly? Charge correction for Mcare/Caid YES E/M coded correctly? No Yes Procedure coded correctly? Yes No Due to downcoding Amend code & educate Due to upcoding Amend code & educate; Charge correction for Mcare/Caid Due to TP documentation Amend code & educate; Charge correction for Mcare/Caid Is Dx correct? Yes No OK Educate re: correct diagnosis & linkage Educate re: correct procedure; Charge correction for Mcare/Caid HCCA Compliance Institute 22

24 Modifier -25 Audit Summary Analyst Department Division How many Providers reviewed? How many records reviewed? How many times was modifier 25 used correctly? How many of those were coded correctly? How many of those had E/M upcoded? How many of those had procedure upcoded? How many times was modifier 25 used incorrectly? How many of those should only have an E/M billed? How many of those should only have a procedure billed? How many services should not have been billed due to lack of sufficient documentation? How many E/M s should have been billed without mod 25? Who applies modifier 25? CPT coding Issues --- E/M and Procedures Diagnosis coding Issues Process Issues HCCA Compliance Institute Legend for Modifier -25 Review 25 A = Modifier 25 Used Correctly SB E/M = Should only Bill E/M 25 NR = -25 Mod not Required SBP = Should only Bill procedure DNB ID = Do not Bill Insufficient Documentation E/M CIC = E/M Coded Incorrectly P = No Personal Documentation L = No Link to Res Note S = No Signature PCIC = Procedure Coded Incorrectly YU = Upcoded Procedure UB = Unbundled Procedure or E/M DX = Diagnosis Incorrect CIF = Comment In File R = Refund to Medicare or Medica Department # of Prov MC HCH MC D RES EMR IP OP OV 25 A SB 25 N E/M R SB P DNB ID E/M CIC UH UE UM D P L S A B C D E F G H I J K L M N O Total #### #### #### #### 0 #### #### #### ### #### ###### 7486% #### #### #### ### ### ### ## #### HCCA Compliance Institute 23

25 Modifier -25 Sample 15 Departments 240 Providers 746 Records Investigate use of -25, which allows billing E/M visit on same day as procedure 30% M'care & M'caid Other 9% Resident No resident 70% 91% 21% EMR Paper Outpatient Office 79% 57% 43% HCCA Compliance Institute Modifier -25 Accuracy by Department 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% A B C D E F G H I J K L M N O B C HCCA Compliance Institute 39% 2004 Pass Rate 24

26 Modifier -25 Error Rates 35% 30% 25% 20% % 10% 5% 0% -25 Not Needed Bill Procedure Only *Upcoding Downcoding *Lack of TP Doc'n No Signature HCCA Compliance Institute Report Results & Distribute Best Practice Applying Modifier -25 to Evaluation & Management Services (E/M) Best Practice The purpose for the best practice of using Modifier -25 is to ensure correct use when reporting an Evaluation & Management service along with a significant, separately identifiable minor procedure, performed on the same day, by the same physician. In our recent Compliance Review of services billed with Modifier - 25, we found that in the majority of the cases, Modifier -25 was not used appropriately. To assist the departments in the proper use of this modifier, the Compliance Team created this document. The following information was compiled by the Compliance Team (Carol Edwards, Jeff Giusti, Luanne Novak, Patty Sherry, Terrie Trimble, and Betty Yancy). Do Use Modifier -25 When: A physician performs an E/M service beyond the usual pre- and postoperative work for a minor procedure (e.g day global; see Trailblazer Medicare Fee Schedule) on the same day, provided the key components (history, exam, & medical decision making) are met. (continued) HCCA Compliance Institute 25

27 Closing Remarks Base audit program on identified risks Reinvent your process to energize your team Seek input from colleagues, carriers and consultants Document project objectives Data mine and apply sampling strategy Design audit tool and identify metrics Track and trend findings Graphically report results Characterize compliance as a quality process HCCA Compliance Institute Georgette Gustin, CPC, CCS-P, CHC, Director, Healthcare Advisory PricewaterhouseCoopers georgette.gustin@us.pwc.com Mary Ann Swann, MBA, FACMPE, CPC Corporate Compliance Officer & Privacy Officer Baylor College of Medicine mswann@bcm.tmc.edu HCCA Compliance Institute 26