All right, so we are going to kind of discuss tips for educating providers on coding and billing issues. We're going to look at some of the types of payer audits that you might receive in your practice. And then we're also going to give you tips on how to respond to a payer audit. So again, communication is key. Do not, this is one that I always say, like, do not assume your providers are, have extensive, extensive coding and billing knowledge. They don't teach this stuff in medical school, all right? You might get some sort of basic level of coding and billing when you're in fellowship, residency, et cetera, depending upon the medical school you go to. But no, there is no requirement for the doctor has to be a coder before they're a doctor. No. Okay? So we have to teach them those, give them those tools to make it easier on them too. And again, know kind of a little bit about that, especially some of your providers have to know a lot about coding and billing because you might not have coders. GI-specific benchmarking. This is one thing that I like to talk about when I do, like, my E&M talks is educating, running reports in your practice on E&M and bell curves. So to minimize the risk of an audit, providers must be aware of and understand their utilization of E&M codes prone to an audit. Providers should know if their use of each level of service is in line with benchmarking of your specialty. When the benchmarking or bell curve for that specialty is determined, a physician's claims for E&M services can be compared to identify deviations from that benchmark. And this is kind of one of the things we see is that if the provider is off or the practice is off that benchmark or bell curve, you may receive letters from payers or routine or random audits are being done. It's not that you're doing anything wrong. And we get that comment or question a lot is just, you know, Dr. So-and-so in our group got a letter from XYZ insurance company saying he's billing too many level fours. Well, that doesn't mean he's wrong. They're just saying that he's a little bit higher than that national average. They're following that bell curve. And if you get a letter or get anything like that, just do an internal audit, make sure that the levels are supported and be done with it. Document what you did and be done with it. So this sheet here, this slide has the current benchmarking national percentages for your visits. And so you could actually take this slide, run a report in your practice and can kind of compare the two to see where you're at. So if you look level for your new patient in the office, level three and four are close together. Four is definitely a little higher. I would agree with that. Follow-up office visits, again, level three, four, four would be our peak there. Hospital care, our peak is a 99222, but closely behind there is a 99223. And then for subsequent care, not a lot of level ones, got some twos for sure is our peak. And then you've got level threes at 22%. So just kind of be aware of that. Kristen, before we go on, can you go back to the last slide? From a gastroenterologist standpoint, I do hope that because of talks like this, we can move those national benchmarks. I definitely think, I mean, I'm a gastroenterology hospitalist, I'm a GI hospitalist. Most of my bills, initial hospital care are 99223s. Most of my subsequent hospital care bills are 99233s. I think the point though, is if you can document appropriately, if you can justify your level of billing, then you're well positioned to be able to defend any audit. And I wouldn't assume that just because these are the national benchmarks, this is how it should be. Because as hopefully the audience gets clearly from our talks, if you're documenting well, you can move that needle and you should. Yeah, absolutely. And that's an excellent point. Again, this is national average. So again, the more knowledge you know, the more documentation tips, the more things that you can put in your note to increase that level, now that we've went over this stuff with you. Yeah, you can definitely move those numbers. I definitely agree that 99223 is too low for us. And again, some of our level fours can be level fives, maybe more so on time than decision making, but still utilizing those tools that you've learned, hopefully we can move these numbers. Types of audits. Okay, so we've got first the OIG, Office of Inspector General, provides independent and objective oversight that promotes economy efficiency and effectiveness in the program and operations of HHS. So OIG's program integrity and oversight activities are shaped by legislative budgetary requirements. All right, so I'm not going to go read into all this stuff, but we all pretty well know what the Office of Inspector General is. They have a task list, they kind of tell you what they're looking at, they have little targeted reviews, it's on their website, they don't hide it. But we are all subject to an OIG review. It applies to hospitals, home health, physicians, chiropractors, ambulances, labs, DME. In other words, an entity that accepts federal money is subject to review. All right, so what are they looking at? Incident two and split shared services, which I am going to cover later on. More than 85% of claims reviewed for these types of services were found to be incorrect. I'm hoping that's a lower percentage now, but I don't know. It is a very, I'll just say it's murky. Incident two and split shared billing is a very murky subject. So again, we'll get into those details. We talked about modifier 25, making sure that your visit can stand alone, it's significantly separate above and beyond the other service that you performed that day. Use of modifier 59, all right. Modifier 59, and I'll go into this when I talk about top denials. Modifier 59 says I did a separate technique to a separate lesion, etc., pay me some money. We can't just slap modifier 59 on everything and move on. Some things are bundled and no modifier will bypass the edit. So again, understanding the correct use of 59 modifier. Funded records, I'm also going to talk about this in my, I believe, last talk. Auditors are trained on quality, not the quantity of your record. I would much rather audit a good old soap note than a 10-page progress note where 80% of it has nothing to do with why you took care of the patient or what you did for that patient. Each note stands alone. If cloning, if there looks to be cloning, the auditor can completely disallow the visits. You have to have customization, and I'll hold it there. Go into a little bit more detail on that later. Place of service errors. So Medicare pays physicians a higher amount when you do non-facility services. So if you scope in the office, you're going to get a heck of a lot more money, more reimbursement than when you scope over at the hospital or the ASC, okay? Because in that aspect, they get money for the technical stuff. When you do it in the office, you get everything. So making sure you're not billing, like, place of service office when you really went over to the facility to do it or the ASC to do it. So knowing your place of service is very critical. RACs. So those are just some of the top things that the OIG can look at or are looking at. RACs, these are recovery audit contractors. They're there. You will get the reviews from them. You will get routine requests. And they are contracted by Medicare to find deficiencies, all right? And they get paid. The more they find, the more they get paid. So know who your RAC is. If you get a RAC request, so I am in Region 2. I live in Missouri. Performant recovery, okay? So if I'm working in my doctor's office and I get a letter from performant recovery, I am not going to just throw that as junk mail. I'm not going to just put it on the physician's desk and hope they respond. These are often time-sensitive letters and requests, okay? So know who your recovery audit contractor is. Also, check their websites. A lot of times, they have good information on their websites as to what types of things that they are reviewing. CERT, okay, so a CERT is established by the CMS to monitor the accuracy of claim payment for Medicare fee-for-service program. The intent of a CERT is to protect the Medicare trust fund by identifying errors and assessing error rates at both the national and regional levels. Claims are randomly selected for a CERT review. When a claim is selected for review, the provider will receive a letter via fax or U.S. mail from CMS requesting the medical documentation to be submitted for the review. To ensure your letter is a valid CERT request, the first page contains your CMS logo, a barcode, and has been signed by the task leader. Again, be sure who in the practice is responsible for receiving these audits and do they know what to send, when to send it, et cetera, and we'll go through that. CERT errors are typically not because the services were not necessary, but they usually indicate like a failure to submit documentation or lack of documentation to support medical necessity. This is one thing, and I know Kathy touched on this earlier, and it has to do with this came from a CERT audit, and so Noridian, who is a Medicare contractor, some of you listening in may be under Noridian, and they basically in their audit that they did, they're like, you know what, we need to put some information out here because it looks like medical record signatures are not being, you know, if you do an addendum, et cetera, need to be done appropriately, okay? So I wanted to talk a little bit about what is a signature, what's an appropriate signature, and if you have to add additional information, what should you do to the record? So some excerpts from this guide. It says late entries, addendums, or corrections to a medical record are legitimate occurrences in documentation of clinical services. A late entry, an addendum, or correction bears the current date of that entry and is signed by the person making the addition or change, okay? So the definition of a late entry would be the late entry supplies additional information that was omitted from the original entry, okay? So the late entry bears the current date, is added as soon as possible, and is written only if the person documenting has total recall, all right? So for example, a late entry following treatment of multiple trauma might add abdominal soft with no masses, no organomegaly. So maybe we just forgot. You're like, you're sitting there on to the next patient, and you're like, oh, no, I forgot the physical exam. I did it, I just forgot to put it in my note. That would be an appropriate late entry attestation. Addendum, it was not available at the time of the original entry. So this would be a situation where you saw the patient, you completed the note. Let's say two days later, you get their imaging back, and you wanted to document that in the record just for ongoing continuing care for when they come back. So here's an example of this. A CT scan on 2-12-24 was reviewed and showed an enlarged area of the tail of the pancreas suggesting pseudocyst, and then electronically signed by Sally APP in the date. Correction, all right? So oops, I put the wrong indication, or oops, I did do a biopsy, but I forgot to document it. There's a lot of oopses we can do, but we have to correct the report. We have to correct the report correctly. When making a correction to the medical record, never write over or obliterate the passage when an entry in the medical record is an error. We have to know what the original information said, and we have to know what the current information said. Guys, I cannot stress this enough. Do not unlock your notes, okay? Once your note is signed, if you need to add, change, delete, whatever, anything in that medical record, you have to do it in an addendum attestation form. You cannot unlock your note because we have to know what that original entry stated. So this is kind of an example that I give. So the original entry said bowel sounds positive, no tenderness, okay? But my correction, tenderness was noted in the left lower quadrant and then signed. So I know when I originally made the original entry, what it was because it's a strikethrough, and then again, what my new information was. They also remind you of falsified documentation. So deliberate falsification of medical records is a felony offense and is viewed seriously when encountered. So examples, creation of new records when records are requested. Yeah, that's a no-no. You're not supposed to do that. Backdating, postdating, predating, writing over or adding to existing documentation, except for if you're doing it correctly as a late entry addendum or correction. Also, guys, sign your notes on time. You have to have total recall and Medicare states, it has to be done when the encounter was performed. You know, yes, there's going to be some scenarios where we have, you know, we got behind and maybe we're a day late or a few hours late, but it better be done as soon as possible. You have to have total recall. Then we have to deal with individual payer reviews, and they are a thorn in our side more so sometimes than Medicare or the OIG or the RAC, whoever audits you. You know, we were in a practice just recently, and, you know, they were telling us that they had stacks, stacks of requests from a specific commercial insurance carrier. So it can be very unfortunate because not like you have enough staff or time to respond to all these requests. And again, a lot of these requests are time sensitive. We've got ZPICs, zone program integrity contractors. These guys are, they know something sketchy is up with your practice. You've committed point blank fraud. Okay, they are coming in investigating your practice. Okay, so I don't think we have to deal with ZPICs, but they investigate potential fraud and abuse from CMS. They're conducting investigations in according to the priorities established by the fraud prevention system. So basically, they work with the FBI. So if you get a ZPIC, yeah, just be scared. I'll just say that, just be scared. So polling question. What should I do if I receive a letter from my local Medicare contractor requesting one of my endoscopy reports? A, send the entire patient record. B, send the order. C, send the requested document along with any other supporting records like the order, the pathology results, et cetera. D, call Medicare and tell them they can't have access to that information. Wow, is this our first 100% of the day? I think it is. Yes. Send the document that they're requesting along with anything that helps justify the way you coded and billed it. Yes, absolutely correct. Okay, so responding to an audit. So these are, again, usually routine. Usually, there's a date on them. Usually, it's one big thing. But if you get like a big, nasty FBI audit, you definitely want to just go ahead and get a healthcare attorney. All right, so I'm going to just skip over a couple of these slides and just talk about the direct response. So read the audit letter carefully and provide all information requested in the letter. So we just talked about that. Include anything that helps support your level or the CPT for the procedure that you did. The pathology would help support maybe the more specific diagnosis code that you used. Make sure your records that you send in are legible and copied. If the record is not legible, have the illegible record transcribed and include the transcription along with the handwritten note. We don't typically have to worry about this anymore. We don't really do a lot of handwritten documentation anymore. Never alter your record after you send it in. If you do, make sure that it's in the correct order. If it's in the wrong order, make sure that it's in the correct order. If it's in the wrong order, make sure that it's in the correct order. Never alter your record after a notice of an audit. You're only altering a record when you forgot to add in one more indication or something, a fluke, but not, oh, they're auditing me for XYZ, so I'm going to add some more information into my note to support that level that I had already billed. You can't do that. Copy each page of the record correctly and completely as well. Don't cut off anything. Don't make bad copies. Make colored copies. That's better. Include a brief summary of the care provided to the patient with your record and kind of just like a little medical necessity letter if you need to. Include any extra notes, so like local coverage determinations, journals, other documents to support unusual procedures or billings or to explain missing record entries. Most of the time when you guys get an audit, it's just an audit for a level of service or it might be an audit for some certain procedure. Again, it doesn't mean you're doing anything wrong. They're just looking to make sure that you're correct and you're compliant and all that good stuff. Keep complete legible copies of what you provided to them. Consult an experienced healthcare attorney for the audit. Be prepared to contest the results of the audit. If they say, well, we stand by our original decision, and you're like, no way, no how. We coded it right. We did it right. I tell practices you have to sometimes involve your providers. Take it to the medical director. Take it all the way up the chain. Become a thorn in their side. All right. That was the end of my talk, and now it looks like I am handing this off to Dr. Littenberg.

healthcare coding

payer audits

E&M codes

documentation practices

audit management

healthcare compliance