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Yes, Medicare Does Make Mistakes

Posted by J. Paul Spencer, CPC, CPC-H in Coding and Compliance

At the root of my professional skills is that of a certified coder, which I have been since 1998. Anyone worth anything knows that coding, reimbursement and compliance are inextricably linked. I often tell colleagues in the coding realm that if you are not making a gradual transition towards compliance within two years of becoming a certified coder, you more than likely have chosen the wrong career.

The biggest problem I tend to have in this line of work is the volume of knowledge. I say “problem” because any person that I know in my personal circles who doesn’t happen to be connected to the healthcare field usually has absolutely no clue as to what is happening in health care until they themselves need treatment. That treatment moment usually becomes the time when I am called in to remold their medical bills from the origami crane shapes in which they now appear.

This post is specifically about a payment paradox that exists on a few CPT codes. It is something I discovered a few weeks ago, but am only now getting to due to travel schedules and hours on the telephone in a professional capacity.

Let’s talk about soft tissue tumors. These are little deposits that creep up in the subcutaneous skin layer that are removed most often by either dermatologists, plastic and reconstructive surgeons or general surgeons. The codes for the removal can be found under the Musculoskeletal section of CPT based on body area, and they are normally split into two codes based on the size of the tumor.

Having stated that, there is a catch. In most cases, due to CPT code reseqencing, the numerical code for the removal of a larger tumor is lower than that for the smaller tumor. Unfortunately, the problem doesn’t end there.

As an example, let’s use CPT code 24075, which is for the removal of a subcutaneous soft tissue tumor of the upper arm or elbow measuring less than 3 centimeters. The code that follows it in CPT is 24071, which is for a tumor of 3 centimeters or greater from the same body area.

Now, go to this link for the Medicare Physician Fee Schedule Search. Choose the bubble that says “List of HCPCS Codes”, and then the one somewhat below it that states “Specific Carrier/MAC”. Put 24075 in the box that says “HCPCS Box 1″, then place 24071 in the box that says “HCPCS Box 2″. Below that, choose the drop-down stating “All modifiers”, and then select your Carrier/MAC from the last drop-down. After that, click “Submit”.

The next screen shows you two disturbing things. The website has not only re-ordered your codes to show 24071 as the first code, but (and this should make the surgeons and dermatologists out there furious) the allowance for the larger tumor is roughly $100 less than that for the smaller tumor, depending on your MAC locality.

This pattern will repeat itself no matter which area of the body has subcutaneous soft tissue tumors. What I think is happening is that Medicare set the Work RVUs based on numerical order, rather than the actual amount of work involved with the procedure. CMS is not recognizing CPT resequencing, which is leading to providers being underpaid for their large soft tissue tumor removal expertise. 

Appendix N of the CPT code book contains the entire list of resequenced codes. I am a simple blogger with a lot on my plate right now, so I’m not going to go through all 100 codes on that list to find similar payment inconsistencies. I shall leave that up to an enterprising reader out there. The larger point here is that Medicare is the straw that stirs the drink with regard to reimbursement for services. If Medicare makes a mistake in setting reimbursement, that error is compounded by every commercial carrier who uses Medicare allowances as a baseline for setting a fee schedule.

At the very least, I hope dermatologists take to the streets with their scalpels and benzoyl peroxide and demand change. At most, I’d like to point out that just because Medicare happens to be the Irish Wolfhound in a room full of Pomeranians doesn’t necessarily mean that they always have the first and only correct answer.

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May 3rd, 2013 | 1 Comment »

The “P” in PHI Does Not Stand for Public

Posted by J. Paul Spencer, CPC, CPC-H in Protected Health Information

A quick look at my personal Facebook page prior to my commencement of this post revealed that I currently have 121 friends that I have connected with through the “popular networking site”.

My experience with Facebook is hit and miss. I am now careful to limit incoming friend requests to “friends of friends”. The reader might find this next bit of information surprising, but I can actually be quite aggressive on certain topics that I come across in my personal life (that was a demonstration of my sarcasm, of course). When I need to pop off about something with the colorful language I learned in my youth as a Philadelphia sports fan, it is best that these are kept sequestered from the majority of my professional contacts. We have LinkedIn for actual professional networking. As a footnote, in order to satisfy any of your lingering curiosity, I have only ever “unfriended” 3 people, and it has been because I discovered retroactively that some of the friends of my actual friends are political troglodytes.

With the generations coming up behind my own (quick note: please do not refer to mine as Generation X; you young punks would be cynical and disconnected too if you grew up around AMC Javelins and Disco music) feeling free to share anything and everything online, intersections with reality are sure to follow. We’ve learned that it’s not a good idea for the local elementary school teacher to post pictures of herself on vacation doing body shots off the locals in Cancun. Additionally, a few frustrated employees have learned that criticizing your employer with language not normally shared in your typical convent earns you an express ticket to the Island of Free Time.

One such intersection with reality was this recent story from Mission Hills, California. An employee at Providence Holy Cross Medical Center, who was recently hired through a staffing agency, came across a patient’s medical record with featured conditions that he found amusing. He then took it upon himself to post the page from the medical record, complete with patient name and date of admission, as a photo on his Facebook page, accompanied by comments that mocked the reasons for the patient’s encounter. When told by his more level-headed, law-abiding friends in the Comments section of the post that he was violating  HIPAA laws, he said (and I must quote this verbatim so the reader can fully internalize it), “People, it’s just Facebook…Not reality. Hello? Again…It’s just a name out of millions and millions of names. If some people can’t appreciate my humor than tough. And if you don’t like it too bad because it’s my wall and I’ll post what I want to. Cheers!”.

It has never been my professional goal, but how I wish I had law enforcement power for just 10 minutes when I read things like this.   

I was born in the semi-mythical Time Before Pong, but there were two lessons I learned before the age of 6. There are five distinct human senses, and everything on television is fake. With new technology, my 22 years in health care and with the story above in mind, allow me to add an extremely important caveat; while your computer can stream television shows, what you type on Facebook is not, in fact, a mythical television show, but reality. Yes, it is two-dimensional, but no, it is not fake. If you create it, it exists. Additionally, thanks to online archiving, if you create it on a popular networking website, it exists beyond your lifespan, allowing succeeding generations to see not only that you had a bad sense of humor, but that your version of belly laughs came at the expense of someone’s legally codified right to privacy.

Social networking, and the prevalence of internet usage in general, offers challenges that did not exist at the time the HIPAA laws came into being. Health care providers of all types now find themselves playing catch-up to a public social structure that is quickly migrating away from meaningful, face-to-face discourse and toward two to three sentences of unexpurgated online communication (complete with photos) to hundreds – or perhaps thousands – at a time. Many employee policies on technology usage remain woefully inadequate for this environment.  

People employed at all levels of the health care field must be made aware of what is and isn’t allowed when discussing their work in a permanent public forum. Since I have your attention, I’ll start, using myself as an example. I’m a compliance officer for a company that does high-end data analytics that allows health care entities to quickly identify their highest areas of compliance and audit risk. We also provide some medical billing services, but I’m not going to tell you for whom. I see protected health information for medical conditions as part of my daily duties, but that also is none of your business, and I keep it at work.

On a personal note, I am currently employed by bosses whom I actually like and respect and who have done wonders for my professional development. If that happened not to be the case, I would save it for happy hour, which I never document or photograph for public consumption anymore, as my multiple glasses of dark beer kept spilling on my camera phone. To round out, I live with my wife, son, dog and obnoxiously loud nocturnal cat, my main hobbies are music and being a fan of ice hockey, and my bar trivia team can usually be found on Wednesday nights trouncing the local competition at O’Lydia’s Pub in Milwaukee.

Now you have all you need to know to begin to update your employee policies for social networking, as well as my general background, demonstrating once again that there are indeed acceptable paths to spreading wisdom on the internet.

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January 6th, 2012 | 2 Comments »

The RAConteur: Place of Service, or “Where Are You?”

Posted by J. Paul Spencer, CPC, CPC-H in J. Paul Spencer, CPC CPC-H, OIG Issues, Place of Service, RAC / Recovery Audit Contractors, The RAConteur™

People I know like to criticize my driving. I drive fast, I drive aggressively and I make no apologies for it. The sooner that the rest of the world learns to stay out of my way, the better.

When I get into a car, I know exactly where I’m going. I don’t own a GPS device. I map it out before I leave the house, and arrive on time. If you have no idea where you’re headed or how to get there, what are you doing in a large, multi-ton piece of metal racing down the highway? At this point, you are no longer a responsible driver. You have now become a potential battering ram, and if I happen to be on the road at the same time, I shall be more than happy to give you a stark visual reminder of what you can do with yourself and your car.

Thanks to technology, we have a number of ways to find our exact location on the planet at any time of the day or night. We can now also share that with friends and acquaintances thanks to cell phone applications. As an example, I type this from my current location of Latitude 43.0582351° North and Longitude 88.0474888° West.

Apparently, determining one’s whereabouts are not quite so easy for physicians.

As part of the automated review process, the RAC contractors have been comparing place of service codes on physician claims and finding that the same beneficiaries are incurring hospital outpatient services on the same date. This leads to a recoupment of the difference between reimbursement of a claim at the higher non-facility rate and the facility rate.

The results of an OIG review of 100 non-facility services from 2007 was released on July 28, 2010 by CMS. The services were selected from a universe of claims where a correlating facility charge existed for the same patient on the same date of service. Of the services reviewed, only 10 were found to have the correct place of service on the claim. The OIG estimated from this review that CMS overpaid physician claims to the tune of $13.8 million. As a result of this review, CMS is referring over 484,000 physician claims of this type to the RACs and other recovery entities to pursue overpayments.  

This appears to be a fairly easy fix. Before performing services in a place of service, ask yourself three questions: where am I, will a facility billing be generated for the services I am about to perform and (if you don’t know the answer to number two) am I responsible for the expense of this space that I currently occupy. Are we in an office or an independent or hospital-owned surgical suite? It’s not that difficult when broken down to the bare minimum.

I’ll equate this to driving. In the same way that you should know where you’re going in your car, if you don’t know where you are and what your costs are for performing the services you are about to deliver, why are you examining me?

November 17th, 2010 | No Comments »

The RAConteur: What About DMEPOS?

Posted by J. Paul Spencer, CPC, CPC-H in Durable Medical Equipment, J. Paul Spencer, CPC CPC-H, RAC / Recovery Audit Contractors, The RAConteur™

Afternoon television used to be a place where a person like me could go to satisfy a  fix for classic situation comedies. On days when I find myself eating a vacation day in my living room, I now spend much less time in front of the television, mostly because of the incredibly low quality of advertisers on at that time of the day. What I see is commercials for assorted trade schools, many of which in the modern flat job market are for medical coding careers (which encourage me not so gently to get back to work or else be replaced). These are followed by the ever-popular “Have you been hurt in an accident/worked around asbestos/had a medical crisis due to drug X being prescribed for you” ads from the many now-familiar ambulance-chasing law firms across the country. The third set of ads are usually for power scooters for the elderly. In addition to being amazed at how much thinner the scooter drivers in the commercial are to their real world, 2-miles-per-hour counterparts that I see at my local Target, my thoughts turn, as they are wont to do for a compliance officer, to the world of durable medical equipment fraud.

In my weekly review of health care fraud’s many police blotters, rarely is there a week of reading that does not include at lease one durable medical equipment supplier. In the past 2 years, literally hundreds of millions of dollars in Medicare fraud has been unearthed by OIG and Department of Justice investigations, with the states of California and Florida providing a target-rich environment for DMEPOS fraud investigations.  

With the number of issues related to inpatient hospital reimbursement currently outpacing those of other health care providers, it is easy to overlook the fact that a few DME issues have been approved for investigation by the RAC’s. A quick glance at the active issues lists for the 4 recovery audit contractors indicates that there are currently different levels of engagement in DME audits. CGI, the Region B contractor, has only 5 current approved issues related to DME claims. HealthDataInsights, the Region D contractor, currently leads the pack with 17 active issues. With these facts in mind, I’d like to spend some time today looking at what currently exists on the approved issues lists.

There are 2 specific issues for DME that currently find themselves on the lists of all of the contractors, the most prominent of these being identifying claims for durable medical equipment dispensed after the date of death of the beneficiary. This is an easy issue, as most funeral directors agree that cremation rarely requires a wheelchair. This leads me to the second issue that appears on all lists, which is the unbundling of claims for wheelchair bases and additional options and accessories, with DCS, the Region A contractor, paying particularly acute attention to this issue.

Issues related to the bundling of supplies appear on multiple issue lists, but not all, including the billing of additions or substitutions to different types of knee orthoses, which are not billed separately. Currently only Connolly Consulting, the Region C contractor, is not reviewing these claims. All contractors but CGI are looking at the billing patterns of urological supplies for bundling issues. Two contractors are currently looking at claims for parenteral nutrition solutions, with HDI looking at daily over-utilization and DCS focusing on the improper separate billing of additives to the solutions.     

The dispensing of drugs is slowly becoming an audit focus of the contractors. Connolly, along with CGI, is looking at the unit billing for the asthma drug budesonide, with CGI focusing on the maximum units allowed in a three-month period, and Connolly reviewing  the per vial billing. Connolly is also focusing on the unit billing on claims for the inhalation drugs Perforomist and Brovana. Aside from the drugs themselves, DCS and Connolly are also looking at the billing of pharmacy supply and dispensing fees to verify that these fees are only being reimbursed when accompanied by claims for oral anti-cancer drugs, oral anti-emetics, immunosuppressive drugs or inhalation drugs.

An assortment of other issues exist under the carriers, but it is worth noting that all review issues related to DMEPOS are currently of the automated variety, which is an indicator that DME issues are currently below the radar. Given the scope of the fraud found in this portion of Medicare billing, to say nothing of the fact that not one RAC is currently looking at power scooters for billing irregularities, it appears that the RAC’s have a long way to go, with a number of potential issues still to be considered. It looks like the aisles of my local Target will be clogged with scooters for the time being.

October 20th, 2010 | No Comments »

The OIG Plan for 2011: A New Pattern Emerges

Posted by J. Paul Spencer, CPC, CPC-H in Coding and Compliance, Industry Updates, J. Paul Spencer, CPC CPC-H, OIG Issues

While zipping through traffic this morning, doing my usual bang-up job of treating the drivers around me like the inconvenient road cones that they are (the truth hurts), I was deep in thought about how best to present the salient points of the OIG Work Plan for 2011 to the world at large.

The last song that I heard on my satellite radio player this morning was “Will It Go ‘Round In Circles” by Billy Preston. This isn’t bad, I thought to myself, as there are a lot of repeating issues making an encore in the new work plan. Then I started dreaming about what I would look like in Billy Preston’s hair because let’s face it, that man had serious hair. Before I knew it, my car arrived at the door of the office parking garage, I still didn’t have an Afro, and I had completely lost my train of thought.

Having returned to the land of the coherent, I took another, closer look at this year’s plan, and discovered two new patterns of investigation emerging that, while not yet directly impacting the bottom line of the provider community, point to an expansion of focus in a few areas.

The first thing I noticed in an understated, yet increased spotlight on quality of care to Medicare patients. A few examples of this include:

  • In the portion of the work plan for hospitals, the OIG will undertake a review of restraint and seclusion-related deaths, looking at the volume of such deaths and what actions were taken based on state investigations of these incidents;
  • In the realm of nursing facilities, hospitalizations of nursing home residents will be reviewed, with the OIG believing that these may be an indicator of quality-of-care issues at nursing homes. The CMS oversight of nursing homes with high rates of resident hospitalization will also be assessed;
  • As part of the OIG’s review of Part B payments for prescription drugs, the costs and usage patterns of Avastin and Lucentis for treatment of age-related macular degeneration will be assessed.
  • The work plan includes a review of services provided to hospice beneficiaries residing in nursing homes, as well as looking at facilities with high percentages of utilization of hospice services. After reading this article in the past week, this couldn’t possibly come at a better time.  

 

These types of reviews appear to be consistent with the quality of care initiatives put forward by CMS and other carriers, who have at long last decided that as gatekeepers of the health care dollar, they want the majority of the money to go to providers and institutions who demonstrate the best patient outcomes.

The second thread had to do with the increasing reliance on private contractors to monitor payments made by the Medicare and Medicaid programs.  The OIG is undertaking reviews of the Zone Program Integrity Contractors (ZPIC) for general performance and disclosures of potential conflicts of interest, The Recovery Audit Contractors’ (RAC) performance will also be assessed. In addition to looking at the quality of the contractors themselves, the OIG will review the value of the program oversight that CMS currently maintains over these programs, as well as CMS’ response to issues raised by the contractors in the course of their audit activities.

I found this second thread interesting, especially coming on the heels of the recent court decision regarding the definition of “good cause” for RAC audits, an answer that by all rights should have been answered either by CMS or the RAC Validation Contractor. It would appear that these types of reviews of contractor activity are overdue. I do wonder whether these appraisals will carry enough substance to accurately assess the work product of the contractors, given the planned expansion of their activities currently taking place. In other words, which came first, Pandora or the box?

There are some repeat topics of particular interest, especially with regard to Part B claims. Despite the end of reimbursement for consultation codes in 2010, the coding and payment of evaluation and management services will continue as a focus of the OIG work plan. Closely following a recently released report from the OIG regarding the large number of claim payment errors related to incorrect reporting of place-of service, this issue has been retained in the new work plan.

When reading the OIG Work Plan (for those of us who are gluttons for punishment), it is important to keep in mind that while this is an important component of combating fraud and abuse in the Medicare program, this is no longer the sole battle plan that it once was. A calculated wager has been made by the current administration that anti-fraud efforts can pay for the many changes put forth in the Patient Protection and Affordable Care Act (PPACA). The efforts behind this wager are going to dramatically alter the current regulatory environment. While the OIG Work Plan for 2011 carries as much importance as it always has in highlighting areas of fraud and abuse, the work of the private contractors will have a tremendous effect on the plan going forward. And before you ask, yes, it will be greater even than the hypnotizing effect of the thoughts of Billy Preston’s hair during a morning commute.

October 8th, 2010 | 1 Comment »

How The Economy Threatens Patient Data

Posted by J. Paul Spencer, CPC, CPC-H in In the Press, J. Paul Spencer, CPC CPC-H, Protected Health Information

The other day, I was coming home from work and witnessed a troubling site. A couple roughly my age with their dog in tow, obviously down in the luck department, were walking down my back alley in the city of Milwaukee, going through recycling bins and taking out aluminum cans by the dozen in an obvious cash grab. Because Milwaukee has mandatory recycling, this activity is considered theft of city property and is illegal. As a compliance officer, it may strike some as disturbing that I didn’t report this activity immediately to the police. In my defense, it’s never a pleasant moment when the less desirable realities of an economic downturn arrive so starkly at your door, but it is not my duty as a member of the human race to jeopardize the survival of someone else if I face no imminent or immediate personal threat.

History teaches us that increasing levels of desperation become a threat to everything in their midst. Primary among human instincts is the instinct for survival. If established tools of survival in a civilized society are threatened - the big three being food, clothing and shelter – the instinct for survival becomes its own morality, and begins to look for opportunity.

The official unemployment rate in the United States, also known as the U3 index, stands at 9.5% based on the latest statistics available through August. Being a man ruled by facts, I tend to look not at the trumpeted U3 figure, but the U6 unemployment rate, which measures newly unemployed, under-employed and discouraged workers who have stopped looking for work, but still maintain the ability and the will to work. The U6 number stands at a staggering 16.7% currently, and has been as high as 17.1% during 2010.

Taken hand in hand with the home foreclosure crisis, the overall economic picture is beyond bleak. What the chattering class sees is a recession that officially ended in the middle of 2009. What the general public sees is the same economic system that has shifted from manufacturing to services and concentrated wealth into the hands of the few continuing unabated, with the antique promise of “trickle-down” being exposed as a myth. Thinking that jobs will magically appear with this backdrop has become a proposition that has moved from “difficult” to “unrealistic”.  

It was with this new reality in mind that I read a story out of Los Angeles this week concerning a privacy breach of roughly 33,000 medical records at Martin Luther King, Jr. Multi-Service Ambulatory Care Center (MLK-MACC).

Files stored at the facility were discovered as missing on July 29th, prompting a search and investigation by the facility, which led to two uncomfortable discoveries. First, the files in question may have been mistakenly marked for destruction. Second, and central to today’s post, the records were subsequently stolen by an employee and taken to a recycling center so he could cash in on the value of the paper contained in the files.

With this new piece of information, it’s time to review our threats to HIPAA privacy. We have identity theft, which was a motivation of the very first HIPAA violation and continues to this day. Next, we have potential unfettered access to information, leading to the more gossipy among those with access spewing forth patient medical data to anyone who is interested. Beyond these and other threats, we can now include an unnatural curiosity for the profit motive of renewable resources.

If I am in charge of compliance at any health care organization, after reading this, I expand my privacy and security focus from “How do I protect patient information?” to “What isn’t nailed down?”. The breach detailed above involves equal parts negligence and opportunism, but this leads me to do an informal exercise with the reader. If you are reading this from your job in the health care industry, I invite you to look around you for a moment and find something containing patient data that can be easily transported and either sold or stripped for cash. Chances are this exercise didn’t take long. I know the most obvious answers to this question, but being a compliance officer, it would be irresponsible of me to supply these to you. I mean, who’s reading this in the first place? If you read my writing with any sense of anticipation, there’s something devious about you that’s well-established.  

Anyone who regularly deals with securing protected health information should try to take every threat into account. We’ve long known that your typical identity thief can come into an organization with PHI and wreak absolute havoc. As economic threats to social order continue, I challenge all of those charged with protecting patient data to look outside well-known breach threats and sharpen your focus to include threats posed by the current economy. It is up to each and every organization to determine the best way to assess potential breaches caused by economic circumstances of those with access to data, but as the MLK-MACC breach illustrates, the time to do so has rudely arrived.

October 1st, 2010 | 1 Comment »

The Long Goodbye for ICD-9

Posted by J. Paul Spencer, CPC, CPC-H in Coding and Compliance, J. Paul Spencer, CPC CPC-H

With Autumn’s arrival this week, I begin a yearly moment of reflection on loss.

Trees lose their leaves many times in the cycle of their existence. It doesn’t take a great philosophical leap to realize that each one of us is a leaf, dangling in the sun and rains ever briefly, displaying ourselves to the world as part of an immovable whole, seemingly similar to those around us, but not quite, before disappearing and returning to the Earth.

As human beings, we tend to measure the changes in ourselves by what we what we’ve gained, but it’s the measurement of that which we’ve lost, either in our own personal space or in the world at large, that is the true measure of change. In times alone, I think of things that are gone, never to return. Are there any among us who can’t think of one thing for which they’d trade all they’ve gained in order to experience again? If it were me, what I wouldn’t give to sit in my grandmother’s kitchen again by her side, talking about nothing in particular. Or maybe it would be to walk down the street to the old candy store I remember from one of my childhood homes, since torn down for the building of a development full of  McMansions. What I wouldn’t give for one more album of new material from John Lennon.

Yet not all losses are a negative. As a Philadelphia sports fan, I was among many who was relieved when they imploded Veteran’s Stadium, the all-purpose dump that was home to the Phillies and Eagles for roughly 30 years. A more sterile and unfeeling structure was never created, and virtually every bad stereotype I’ve ever heard or experienced with regard to Philadelphia sports fans had its genesis in this stadium. With regard to disposal, they should have imploded it, burned the scraps and buried what was left underground. Why take chances?

It is with similar feelings that I, much like many other certified coders, approach the 3-year swan song of the 9th revision of the International Classification of Diseases.

I am positive that 20 years from now, I won’t be thinking of ICD-9 with romantic visions usually reserved for the original Shelby Mustang. There will be no happy, misty memories about that wonderful year when they added a fourth digit to chronic renal failure codes, or the expansion of codes for fevers, or that magical time when they added a code for anthrax exposure. More than likely, I’ll think of ICD-9 in much the same way as I currently think about some of the more severe diseases it identifies numerically, which is something along the lines of ”I know what you are, and you’re not welcome here. Get out!”.

ICD-9 was first conceived and brought into the medical reporting world in the decade of the ’70’s, a decade that gave us Nixon, disco, odd-even gas rationing and the AMC Pacer. With these and other best-forgotten horrors as a cultural backdrop, did ICD-9 ever really stand a chance of being looked upon fondly as it approaches its long-delayed demise? ICD-9 has reached a point where it is seen as a working reporting structure idea about as good as the pet rock, and about as stylish in the modern world as a leisure suit. Its time has come and gone, gone again, and just for good measure should now be pointed at, openly mocked, abandoned, vandalized with spray-painted obscenities from a can of brown Rust-Oleum and razed.

All one needs to do to feel the extent of ICD-9’s problems assimilating in the modern world of medical billing and reporting is to pick a Local Coverage Determination (LCD) – any LCD – and take a look at a listing of accepted ICD-9 codes needed for a positive coverage determination for a selected medical procedure. Take for example LCD L28238, which is Palmetto GBA’s LCD regarding claims for bariatric surgery. According to the LCD, you need one code for morbid obesity, one code for a chronic disease for which the morbid obesity is having a negative impact and one code for the patient’s body mass index.

I tried to find a way to illustrate this reporting model to the reader, and found a parallel in The Three Stooges trying to hammer a nail. Moe stands behind Curly, who is holding the hammer while Larry holds the nail, Curly draws back the hammer, hits Moe on the forehead and follows through and smashes Larry’s hand. If the Three Stooges were certified coders, I can picture Moe Howard looking at a bariatric surgery claim, turning to Larry and saying, “Hey Porcupine, give me a code for someone fat”.

ICD-10 goes a long way to changing ridiculous reporting practices like this with a structure that creates codes that focus on multiple conditions at once, rather than the compartmentalized jumble we currently deal with in ICD-9.

CMS recently stated that as the overdue transition to ICD-10 approaches, the revisions to ICD-9 will be purposefully small. This is one of the few occasions in recent memory where coders and billing specialists have spoken with one voice and recommended this very path to CMS unanimously. Put Turtle Wax on an AMC Pacer, and you have but a shinier car that looks like a goldfish bowl on wheels.

Your best course of action for diagnosis coding is one that I would recommend to all coders. Start researching the replacement for that well-traveled clunker in your driveway, and leave the old model out in the cold to face the elements, praying all the while that someone steals it while you’re not looking. In the end, when ICD-10 is implemented, you won’t be burdened by fond memories of ICD-9.

September 24th, 2010 | 3 Comments »

Reintroducing…….The Clock

Posted by J. Paul Spencer, CPC, CPC-H in Coding and Compliance, J. Paul Spencer, CPC CPC-H, RAC / Recovery Audit Contractors

I live in a self-contained world with 20-hour days at my disposal.

I’m not much for sleeping. Many years spent in the dark battling my own brain to see which runs out of energy first – coupled with the fact that my wife and a majority of my friends must have at least 8 hours of sleep to function – comes with the realization that I spend up to 25% of my time awake and unable to interact with the sleeping humans around me. If you ask me the programming schedule of any basic cable station between the hours of 12 Midnight and 3 AM, odds are very good that I can answer the question without looking at the program guide. My internal clock would be viewed by some as a curse, but I’m beginning to love those late-night reruns of Route 66 and The Banana Splits.

While the limitations of a clock are foreign to me, it strikes me that an awareness of time is something that can be of tremendous benefit to a medical practice from the viewpoints of practicality and compliance.

Utilization of Evaluation and Management codes is a good topic to insert into this idea. A glance at the new and established patient E/M codes in any CPT book indicates that these codes have an average total time assigned to them. From an auditing perspective, it’s important to keep this in mind. If you are a provider who has a tendency to bill E/M services at a higher level, you may not realize that you are reporting to carriers that the average total time for the visit reported was spent with the patient. Granted, in most cases the billing of E/M services is absent documentation that could show the medical necessity for the level of service selected, but statistically this is significant.

A fellow compliance auditor once related a story to me of a physician audit that, when the average total time of all of the doctor’s encounters for a calendar year were added up, the doctor was averaging over 20 hours a day in reported patient encounter time. Since this doctor wasn’t me, with my accompanying habits of conducting a pitched battle with sleep, he flunked his audit.

I have conducted chart audits in the past for high level E/M services. When my findings reveal that a high level E/M service was not substantiated by the documentation, the very next sentence from the physician is invariably “I remember spending a lot of time with this patient”. I would then go into my well-traveled spiel about being able to code by time only if more than 50% of the visit was spent counseling or coordinating care and only if this is very specifically noted in the documentation. For my efforts, I get nods of agreement during the meeting, and 80% of subsequent documentation using some type of time caveat, sometimes correct and sometimes not. I usually see them again with a new set of results shortly afterwards.

I am not opposed to choosing an E/M code by time, but in addition to writing “…more than half of this XX-minute visit was spent counseling the patient about XXX…”, the documentation must include a summation of the subjects discussed during counseling for the time caveat to have any value in an audit. The CMS E/M guidelines are not designed for brevity of documentation, so by extension, a phrase such as “patient counseled on treatment options” without further elaboration has absolutely no value in audit.

The bigger issue related to the ol’ clock on the wall is the changes facing every provider of service over the next four years. The mechanized behemoths that are electronic health records, 5010 billing standards, mandatory quality reporting, e-prescribing and ICD-10 continue their long march towards the forced remodeling of the current clinical model. While I would not suggest my particular time management techniques, a little investment of time now will pay dividends for the next few years and beyond.

And if you wake up in the middle of the night with anxiety about  all of the changes coming to your doorstep, by all means give me a call. I’ll be up.

September 10th, 2010 | 1 Comment »

The Many Ways of Being Newsworthy

Posted by J. Paul Spencer, CPC, CPC-H in Coding and Compliance, Electronic Health Records, In the Press, J. Paul Spencer, CPC CPC-H

As I begin this post, it’s been a typical Friday. My 4-year-old son took an interminably long time getting dressed this morning, I showered, shaved, ate breakfast and my picture ended up on the front page of the Milwaukee Journal Sentinel….

OK, so one of those things is atypical. I’ll give you a hint: I usually eat breakfast.

For more information on my 14th minute and 58th second of fame in my lifetime, click here (I’m the guy with the orange guitar). The story accompanying my grainy image is self-explanatory. So as not to worry readers who may not click through about the reasons for appearing in the newspaper, it doesn’t involve an indictment, a drunken man running onto a baseball field or (surprisingly, to those who know me) a vicious automobile accident. In these troubled and trying times, it’s nice to be part of a good story for a change, and I’m looking forward to tomorrow’s events as described in the article.

So now that we all know what a happy story looks like, let’s explore the flip side as it applies to health care compliance. I came across a story out of Florida that is a good case in point. A couple from a town called Land O’ Lakes (like you, I immediately thought of butter) were making their Sunday run to their local recycling center. When they got there, they found that there was no room for their paper items in the designated dumpster at the center. This was because someone had filled the paper bin to capacity with discarded medical records. In some cases, the records included Social Security, credit card and driver’s license numbers in addition to medical information.  

The first thing I thought of with this story was regarding EHR, and how stories like this may become obsolete within five years. Then I begin to think the opposite, with the personal theory that as practices transition from a paper record to an electronic record, we may see instances like this more often thanks to record destruction companies attempting to cut corners.

Then I begin to daydream, first about dancing in rain made of Newcastle Brown Ale to the music of the Who, then shaking my head and quickly transitioning to the government’s recent re-dedication to recovering money lost from Medicare and Medicaid due to fraud.

Having been involved with coding and compliance for several years, I’ve learned that there really is no end to to the devious machinations of the ethically-challenged in our business. From podiatrists who bill foot care on patients who have had previous foot amputations to DME suppliers forcing unneeded power mobility devices on the local population of elderly residents, extending to the virus of identity theft currently infecting  some medical practices, you need a chain saw to cut through the levels of immoral behavior in this industry.

The damage that these assorted criminals inflict is not restricted to the CMS trust funds. Medical providers who spend their waking hours operating by the rules inadvertently find themselves in the outer remnants of the spotlight that shines on the crooks. The doctors acting above board and rendering legitimate services ultimately pay a high price for the actions of the bad seeds in increased regulation, investigation and bad public relations for the health care industry as a whole.

The current administration has doubled down on recovery of overpayments through fraud and abuse investigations. For the future of Medicare and Medicaid, I see this as overdue. There are many ways to make the news, but perhaps the best approach for the honest medical provider is to implement and follow policies that insure that you end up in the non-”perp walk” portions of the local news.

July 30th, 2010 | 1 Comment »

Of Pay Fixes and Whistleblowers

Posted by J. Paul Spencer, CPC, CPC-H in Coding and Compliance, Hot Topics, J. Paul Spencer, CPC CPC-H

It has now been roughly 37 hours since I returned home from a vacation in Austin, TX.

A vacation is not usually a time of positive personal accomplishment. From this particular respite, I can say that the only net gains in my column were 4 1/2 pounds of buffet weight, the free beer I had bestowed upon me in an Irish bar on 6th Street from a friendly couple who enjoyed my musical interlude (thank you again, kind strangers) and the bodies of dead bugs from seven different states that now decorate my windshield in all of their Jackson Pollock-esque splendor.

When it comes to a permanent fix to the Sustainable Growth Rate formula (SGR) for Medicare payments, the U. S. Congress accomplished little more than I did during the same period of time.

Currently, there is a plan being floated by the Democrats in the House of Representatives that would delay a permanent fix to SGR until 2015. The plan would provide pay increases for a four-year period. This legislation would again need to advance prior to the latest deadline of June 1, 2010 to avoid the oft-delayed 21.3% cut that was set to originally take place at the beginning of this calendar year.

As with all past temporary fixes that have taken place, this legislation has the effect of kicking the larger problem down the road and feeding the vulture that is the pay cut, which by some estimates could be as high as 37% when 2015 rolls around.

Looking at the calendar, we are again faced with five working days to attend to the latest temporary fix before Congress takes a one-week recess for Memorial Day. This recess is expected to be spent knee-deep in the process of campaigning in an election year. If I had to make a prediction, I would begin to get comfortable with the idea of another CMS-induced delay of 10 business days for claims processing beginning on June 1st until either the legislation above or a different package offering a stay of execution of the current planned pay cut is implemented.

Also greeting me upon my return was another bit of news regarding a study published in the New England Journal of Medicine. The study was conducted jointly by scholars at Harvard Medical School and Tufts University School of Medicine among others, and focused on the effects felt by insiders who decide to file qui tam, or “whistleblower” lawsuits in the pharmaceutical industry. Despite the fact that $9 billion had been recovered due to qui tam lawsuits between 1996 and 2005, the study concluded that there is a high personal and professional toll felt by those who file qui tam lawsuits against their employer.

Twenty-six informants were interviewed for the study, which in addition to the above, led to a variety of findings:

  • 82% were subjected to firing, intimidation or blackballing upon filing the lawsuit;
  • The filing of lawsuits in most cases is precipitated by a job change, such as a promotion or other career change that makes the person privy to inside information about company operations;
  • Most of the whistleblowers attempted in vain to find an internal remedy to the unethical behavior, but were either ignored, dismissed or given orders to continue the behavior unabated.

 

What jumped out at me was that last bullet. With 90% of fraud suits starting with the qui tam process, I find it amazing that after years of awareness of the consequences of non-compliance, the primary reaction of companies whose policies are questioned from the inside tends not to be “OK, let’s investigate and if necessary, fix this”, but instead defaults to “Don’t rock the boat”.

The study recommended several steps to improve the qui tam process, including better employee protections against retaliation, increased resources for the U. S. Justice Department for enforcement (over 1,000 qui tam cases are pending currently with the department) and rewards for insiders that are equitable based on the dollar amount of the fraud that is uncovered.

The co-authors also recommended that policymakers try to instill an ethical sense that encourages more people to come forward. While that is a noble endeavor, it is also up to the companies themselves to operate in an environment of ethics and integrity that encourages the solving of problems as they arise, rather than the time-honored tradition of sweeping the problem under the rug in hopes that problems disappear permanently. 

To put it another way based on recent personal experience, if you’re driving the same road without windshield washer fluid and the bugs are continually hitting your windshield, there will come a time when you can’t see where you’re going and you lose direction.

May 21st, 2010 | No Comments »

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