I try as best as I can not to be a social theorist around people I know, reason being is that the conclusions I tend to draw are uncomfortable realities for people who see themselves as above the fray. The two primary theses I reach are that people generally do not really listen, and when confronted with a truth, a random person has a rather naive tendency to believe that the particular fact doesn’t affect them personally.

I include myself in this group. As an illustrative example, until very recently, I never wore a seat belt in my car. When I add the fact that in 1988 I had an automobile accident in which my car spun out, hitting a stone wall and ejecting me out of my car headfirst through the back windshield, my friends do a combination of bugging out their eyes and adding the local mental health complex to the speed dial on their cell phones. The truth of it is that after surveying what was left of my old car, had I been wearing a seat belt, I would have been dead at the age of 22.

What convinced me to wear a seat belt? One would think that setting a good example for my 4-year-old son had something to do with it, but that wasn’t it. The impetus of my change was that I got ticketed for it in downtown Milwaukee as an adjunct to mistakenly making an illegal left turn at rush hour. Welcome to America, the place where nothing exacts change faster than someone you don’t know or like making you pay for your bad habits.

What a perfect stepping-off point in today’s narrative to turn our attention to expanded audits of medical services billed to Medicare and Medicaid.

This week, I received two more examples of warning shots fired from two Medicare Administrative Carriers signaling what’s ahead in the world of hyper-investigation of physician billing. First, I received a CD in the mail from National Government Services, the Part B MAC for New York, Connecticut, Indiana and Kentucky. The CD was a compendium of all education materials from the carrier related to the Comprehensive Error Rate Testing (CERT) program. In reviewing the materials, it was interesting to note what topics received the most attention, namely E/M services, physician orders and CMS’ updated signature requirements.

On this particular CD is a 60-slide PowerPoint presentation about the common pitfalls of E/M coding and documentation. Roughly 25% of this was related to time-based E/M coding, including critical care and prolonged services. I found this to be significant in that most of the physicians I’ve ever spoken to hold an unwavering belief that time documentation is the overarching solution to all the intangibles of E/M documentation.

For critical care, a common error was that the time was not documented at all, which is quite the oversight for one of the few E/M codes where total time is listed as part of the code descriptor. The NGS materials reinforced the notion that when time is used as the main factor in E/M code selection, at least 50% of the time must be spent in counseling and/or coordination of care for the patient. Additionally, the time indicated must be accompanied by documentation of what was specifically addressed during the extended time. 

For prolonged services, a common finding was that the duration and content of the visit was not supported in the submitted documentation. Based on the increased utilization of these codes since the elimination of consultation reimbursement from Medicare at the beginning of 2010, it is extremely helpful for a carrier to spell out the documentation standards for these codes. A perception has crept into physician billing that billing for prolonged services is as simple as time documentation, which couldn’t be further from the truth. As the NGS materials reiterated, the prolonged services must be face-to-face time with the patient, and documentation for the circumstances necessitating prolonged services must be present.

A CERT E/M tip sheet contained on the CD indicated high error rates for CPT codes 99213, 99214 and 99232 and went into the rules for usage, as well as further detail about the documentation standards for each code. This would seem to be consistent with nationwide CERT findings showing high error rates for these particular E/M codes.

Also of note among the materials was a tip sheet related to physician orders. When placed aside the realm of the early returns from the medical necessity reviews of Part A services by the RACs, this information couldn’t be more important. The medical necessity reviews are finding that the orders from the admitting physician are not going far enough to document the subsequent treatment rendered to the patient during an inpatient stay. When Part A services are denied due to medical necessity, Part B services related to the stay end up caught in the crossfire, with denials and recoups being the result. With these findings, conversations are beginning to occur as to whether the perceived value of hospitalist programs nationwide is currently too high. At a minimum, the documentation of the admitting hospitalist is gaining renewed attention, which given the growth of the specialty in the last decade is somewhat overdue.   

The second bit of news I received was from WPS, the current MAC for the state of Wisconsin and seven other states. This past Monday, the results of this carrier’s latest service specific probe were released, this time focusing on CPT code 99233 for the specialty of Family Practice. In the prospective (prepayment) review of 153 services appearing on 100 claims sent to the carrier, 137, or nearly 90 percent, were denied. The reasons were similar to previous probes, with the highest percentage of denials resulting either from lack of adequate documentation of the service or the request for medical records going unheeded by the provider of service. Twenty services were denied, stating that the documentation received did not support a face-to-face encounter with the patient.

The CERT programs and probes such as the ones conducted by WPS serve to set the table for the Recovery Audit Contractors’ expected expansion into Part B services. The many years of findings from the CERT review contractor have served warning after warning about what services are being reviewed. Yet much like the driver without a seat belt, the yet-to-be-reviewed physician has a tendency to ignore all the warnings until the letter arrives in the mail requesting a substantial amount of the doctor’s past income that has long ago been spent. Excuses no longer exist for this particular brand of “it’s too late” moment.

It doesn’t take a magnifying glass and a slavish devotion to the news to realize that as our domestic economic troubles deepen, the after effects begin to resemble falling dominoes.

The sudden fanaticism about federal spending has been followed by tough decisions by state governors on how to balance theirs states’ budgets. In this environment of ever diminishing returns, you would think that the very last thing the states would need is a mandate to come up with another program by the end of the year.

You would be wrong.

On the heels of the beginnings of the permanent RAC program, the Patient Protection and Affordable Care Act (PPACA) mandated the expansion of RAC’s into Medicaid services. On October 1st, an 8-page letterwas sent to all state Medicaid directors outlining preliminary time lines and guidance for the Medicaid Recovery Audit Contractor programs. A number of important points were raised in the letter for the programs going forward.

First, states have until December 31, 2010 (that’s 79 days from now) to establish programs to contract with RAC’s to audit payments to Medicaid providers. This will require states to submit a state plan amendment, or SPA, to their CMS regional offices which includes either an attestation of the establishment of a plan or a statement of intent to seek an exemption from the provision. The letter is clear in stating that complete exemptions from the plan would be granted “rarely and only under the most compelling circumstances”. I translate this to be the federal way of saying “never”.

Second,  there was an interesting note regarding contingency fees. CMS expects to publish the highest allowable contingency fee payable to a Medicare RAC no later than December 31, 2013, with this published rate coming into effect for all RAC activity after July 1, 2014. In the interim, the states contingency fee rates should be “reasonable and determined by each state”. States have the option to pay the contingency fees either as a percentage of collections or as a flat fee, but should be structured to offer an incentive to identify underpayments. Given that the Medicare ratio of overpayment/underpayment identification is currently 9:1, coupled with the compressed time frame that states are facing, a majority of these contingency fees will be structured for percentage of collections. 

Third, the Medicaid RAC program is not meant to replace existing cost control programs already in place. The federal rules state that these efforts must continue to be fully funded and uninterrupted. This is where the true usefulness of the Medicaid RAC program will s0meday come into play. I can see a day in the near future, based on the results of the Medicaid RAC program, where states either urge the government to make the Medicaid RAC’s the sole fraud control unit for Medicaid, or they request exemptions from the RAC program. The direction the states take would be based on the costs of maintaining both programs via state budget and which program has the best return on investment.

After initial contracting, states are expected to fully implement their RAC programs by April 1, 2011.

The letter is clear in stating that continuing guidance is forthcoming regarding Medicaid RAC programs. This would appear to be the first of many such letters about to appear. For the physician community, this is yet another entity in the alphabet soup listing of regulations requiring adherence in the near future. For the states, it is one more bombarding salvo of regulatory munitions aimed directly at their already strained budgets.

I remain to this day a fan of older TV shows. The adults in my life are perplexed at the reasons why I am perfectly happy to waste perfectly good brain cells watching episodes of Quincy from my DVD collection (one mystery is solved; I’m the guy who bought those). I also consider it a victory that I got my 4-year-old son hooked on old episodes of Scooby Doo. In times before sleep, we can often be found watching yet another costumed carnival operator being thwarted by those meddling kids.

While there are dozens of other shows for which I’ll always make time, I chose the two above because there is a thread of aggressive problem solving running through both. When Quincy’s on the case, you know there’s going to be a fight, complete with self-righteous yelling and hand gesticulations, to reach the proper conclusion. If you have a ghost, the Mystery, Inc. kids and their dog, with a healthy balance of skepticism and fear in tow, will solve the problem.

If only the recipients of negative RAC determinations fought this hard.

The American Hospital Association (AHA), in a continuing attempt to monitor RAC activities of hospitals, has established the RACTrac initiative. Part of this program is a quarterly survey of hospital RAC activity. The results of the survey for the 2nd quarter of 2010 have been released and are available in executive summary form here. While most of the findings did not particularly surprise me, one set of statistics jumped out at me, and if placed in the realm of old TV, would make someone like Quincy have a meltdown.

The 1,389 hospitals taking part in the survey reported that only 16% of RAC denials available for appeal are actually being appealed. Of those, only 13% were reported to be overturned on appeal, with the dollar total of those claims adding up to a pittance of slightly over $420,000.

Let’s take a moment to compare this to the appeal numbers released for the RAC demonstration this past June. In that report, 13% of RAC overpayment determinations were appealed, with 64.4% overturned on appeal. While no dollar figures were released in the RAC Demonstration report, it would appear that the volume of successful appeals topped out. Yet the good news for future physician RAC audits is that this may not be the case after taking a closer look at previous data.

Remember that the RACTrac data is only compiled from surveys of hospitals, and not other types of providers. If we look at the final numbers from the RAC Demonstration project, of the 1.1 billion plus claims reviewed by the RAC’s during the project, only 14.5% were from hospital providers. The overwhelming majority of reviews under the demonstration project came from physicians, clocking in at a whopping 68% of total claim reviewed. Despite this large percentage of claims reviewed, these claims made up only 25% of the total dollars audited under the demonstration project, or over $79 million.  

The RAC’s decided to concentrate their audit efforts on facilites based on the return gained during the demonstration project. Nearly 97% of overpayments collected during the project came from facility providers. Despite all of the claims audited from physicians, the effort only returned $19.9 million dollars, or roughly 2% of total dollars in overpayments recovered. With RAC’s being paid a healthy percentage of all recoveries, hospitals have thus far absorbed the brunt of the permanent RAC program.

This stew of numbers illustrate that despite the relatively low appeal success rate in the RACTrac survey, successful appeals under the RAC Demonstration Project had to come from somewhere for there to be such a wide divergence in the two numbers. Is it such a leap to say that physician appeals had at the very least a modest success rate? Having taken that leap, if I happened to be a physician, wouldn’t I then begin to develop an extremely combative attitude towards RAC determinations?

Despite the fact that it appears that non-facility providers have a high appeal success rate, anyone involved with the audit end of the RAC experience can tell you that this is not the time for an overabundance of self-confidence. The RAC’s are being designed to become stronger and more efficient as they increase their focus and learn on the fly. However, in the end, RAC’s are mercenaries, and the only language mercenaries respect is one of aggressive response. The most abrasive approach you can think of can’t help you if your documentation doesn’t give you a leg to stand upon, but when you do have definitive reasons for appeal, fight back with the strength of 1,000 Quincys and the desire of a million meddling kids. The data up to this point says the odds are in your favor.

For today’s look at Recovery Audit Contractors, I thought I’d start with some essential truths about the RAC’s and their function.

I see RAC’s as golems. While the four regional RAC’s are now self-sufficient, they are a creation borne out of a recognized need to control dollars paid from the Medicare and Medicaid programs. They are given their shape by Medicare’s proprietary software and as an extension of limited investigations, either by the OIG or the Medicare Administrative Carriers (MAC’s), that have already been completed. In other words, the creator starts small with a scale model of an audit, followed by their man-made, unfeeling behemoth that is the RAC bringing down their earthen fist and smiting everything in its path of a similar nature. The current appeals success rate for RAC determinations strongly indicates that the golems do so indiscriminately, without an instinctive need to be correct.

In anticipation of the inevitable RAC investigational expansion into physician services, experts in the industry have trained their attentions on the Comprehensive Error Rate Testing (CERT) Reports. These reports are a good indicator of what services require additional investigation, but there are a few stops in between a CERT and a RAC that further narrow the focus of the eventual RAC investigation. A quick review of my inbox this morning revealed one of these interim studies, the results of which illuminate the world of RAC audits like an H-bomb test on Bikini Atoll.

WPS, the current MAC for Jurisdiction 5 (covering Iowa, Kansas, Missouri and Nebraska) and the legacy MAC for Illinois, Michigan, Minnesota and Wisconsin, released the results of a Service Specific Probe of CPT code 99214 for the specialty of Family Practice this past Monday. 100 such services were randomly selected for prepayment review. Of these, 52 were allowed as billed following documentation review. Based on the utilization of this code, that number seems low. With the belief that we learn from our mistakes, I now present the results of the remaining 48 claims.

11 claims were down-coded based on the documentation provided. To review, a level 4 established patient visit requires that two of the following three elements be satisfied by the documentation:

• Detailed history
• Detailed examination
• Moderate medical decision making

While not specifically stated in the CMS E/M guidelines, with established visits, it is always a good idea to have medical decision making be one of the two elements selected. I recommend this based on medical necessity most often being defined based on treatment options selected for the condition being treated. Even in a patient with a list of comorbidities written on a 3-foot scroll, if a patient has a bit of a rash, the greatest history ever taken and an examination and auscultation of every square inch of a patient is still treating a bit of a rash, and the E/M code selection needs to reflect this.

2 of the claims in the study were determined not to support the billing of an E/M service based on the documentation forwarded for the study. If I had to venture a guess, I would say that these were related to encounters where a minor procedure was planned upon scheduling, the patient presented for the procedure, and the physicians in question billed both a procedure and an E/M service.

The remaining 35 claims represent a different kind of hurdle for physician practices. These claims were denied outright because the providers did not provide the requested documentation for the services within the alloted 45-day period. This study included only 100 claims. If we expand that number out by a few zeroes, apply it to RAC documentation requests and then extrapolate that 35% of these requests will either be mishandled or ignored, the obvious conclusion is that by virtue of their internal practices, physicians are doing the RAC’s work for them. Who knew doctors had this kind of time on their hands? 

Part A providers knew the RAC’s were coming, and any facility worth its salt set up processes long ago to respond to RAC requests. It is my personal belief that a connection can be made between provider readiness for RAC audit requests and the so-far successful appeal rate of RAC decisions by Part A providers. A physician practice, in most cases, lacks the organizational infrastructure to prepare to respond in the same way as Part A providers. A solution to response readiness is not – and in many ways, cannot be -  a one-size fits-all proposition. A good start would be educating administrative staff to be able to recognize a RAC request upon receipt.

With a 48% error rate in this limited probe, it is safe to say that high level established patient visits are now officially warming up in the RAC bullpen. A surprise occurs when you never see it coming. Like the relief pitcher who replaces the obviously tired starter, we saw them warming up. The RAC’s, in the same manner as the next pitcher jogging in from the outfield, is easy to see. In fact, based on their size, so are most golems.

As a strict adherent to the world of science, I’m often frustrated by human imperfection. I try to do my level best to surround myself in my personal life with people who demonstrate that they are continuing on a journey towards a higher level of human achievement. In the end, due to the acute level of imperfection that exists around me, this makes me something of a lousy friend, while at the same time making me a razor-sharp critic. This is my imperfection, and I attempt to overcome this with equal parts good humor and beer. Sometimes, one works better than the other.

Yet the undisputable fact of human imperfection doesn’t necessarily mean that under the right conditions, a human can’t achieve something perfect every once in a while. Baseball pitchers throw no-hitters, musicians record the perfect song, or the rare student will get a perfect score on their SAT’s. These achievements are rare, but behind each one lies hours upon hours of repetition, self-examination and exploration.

From this idea, we look at the documentation for initial inpatient encounters, represented by CPT codes 99221 thru 99223.

As stated in last week’s edition of The RAConteur, CPT code 99223 has revealed itself to be paid incorrectly 21.5 percent of the time according to the results of Medicare’s Comprehensive Error Rate Testing (CERT) program, which places this code at the top of the list. The Recovery Audit Contractors have recently added medical necessity to their stable of audit issues, which virtually guarantees that CPT code 99223 and how it is documented will be a focus when the RAC’s begin to expand their focus in the physician arena.  

As if we didn’t have enough to worry about with this particular set of codes, 2010 marked a major change in the usage of these codes with Medicare’s elimination of reimbursement for consultations. High-level inpatient consultations are now reported with the CPT codes for initial inpatient encounters, driving utilization of this code set through the roof. What two years ago appeared to only affect services by the managing physician during a patient stay has now rapidly expanded to include initial specialist encounters in the inpatient setting. Prior to the elimination of reimbursement of consultation codes, the CERT program determined that up to 50% of consultations billed in some jurisdictions were billed incorrectly. While some of this error rate could be chalked up to poor documentation of the request and report, quite a bit more had to do with the level of service not being supported by documentation. My suspicion is that this problem is still pervasive with the change to initial inpatient encounter codes, as the underlying documentation issues may still not be remedied.

With all of this as a backdrop, let’s take a look at the documentation for these services, particularly 99223.

In order to bill a 99223, the documentation requires a comprehensive history, a comprehensive examination and medical decision making of high complexity. For the first two elements, this means describing the presenting problem at least four ways, reviewing at least 10 of the 14 body systems, documenting a past, family and social history and performing an exam on at least 8 body systems. This is an opportune time to point out that if your history and exam does not include everything catalogued above, you cannot bill a level higher than a 99221. Given the stark differences in reimbursement between 99221 and 99223, I can’t begin t0 stress this point enough. Anything short of a comprehensive history and examination means you cannot bill higher than a 99221. Additionally, if your history and exam fail to reach a detailed level, Medicare regulations instruct providers to bill with the code for unlisted E/M services (99499) along with documentation, with reimbursement determined based on the veracity of the documentation (translation: not much).

 Now that you have a service with a comprehensive history and examination documented, the determination of the level of service to be billed now depends on the medical necessity and decision making for the service. If testing of any kind is scheduled for the patient, you are now halfway to attaining an audit-proof 99223. It is the other half of this equation where the problem lies, which is determination of patient risk and treatment options. This is where a philosophical discussion ensues.

A patient admitted to a hospital has been discovered to be in a physical state that is beyond self-care, necessitating a hospital stay. The burden of proof for the hospital stay falls squarely on the shoulders of the physician managing the patient upon admission and beyond. When it comes to documentation of treatment course, a lack of detail can do much more than decrease your reimbursement for the initial encounter. Poor documentation of treatment course, or a deviation from the documented plan of treatment, has the potential to put the hospital’s reimbursement in jeopardy if medical necessity isn’t established for the length of stay.

With this set of facts established, being honest about the patient’s treatment course is the best path to accurate billing and “audit-proof” reimbursement of the initial encounter. In simple terms, tell me where the patient is medically right now, and what you plan to do about it.

Of course, no discussion of E/M is complete until we discuss coding by time. The average total time of a level 3 initial inpatient visit is 70 minutes. Unlike office encounters, hospital floor time dedicated to the admission and treatment course of the patient can count towards the total time of the encounter if billing by time, and if more than 50% of the encounter was spent in counseling and coordination of care.

The RAC’s are teaching us through their first medical necessity audits that no service performed for a patient in the inpatient hospital setting will be overlooked if necessity isn’t properly established. Human imperfections can and will continue on the road of human evolution. Increasingly, less-than-perfect initial inpatient visit documentation will not be welcome along the road. With repetition and internalization of what is needed, perfection need not be an idea far, far away.

I’ve been around long enough in a society so chock full of people equally split between those with neuroses and those in denial to learn that there are varying definitions to the term “seriously ill”, depending on who you happen to encounter in a given day. My Aunt Edith, a lovable lady to her core, so enjoyed talking about her various maladies that she could describe her latest paper cut in terms usually reserved for near-amputations. Yet in the end, a band-aid and a few days was usually the best treatment option.

Having audited inpatient documentation, I can draw a parallel between poor Aunt Edith’s fingers and a physician selecting a level of service for a subsequent hospital visit. The preponderance of evidence suggests that in both cases, there’s quite a bit of self-defeating exaggeration to be found.

When someone asks me what I believe to be the most over-reported E/M service, it takes me very little time to say “99233″. I can count on one hand the number of times where I have seen this code reported where the documentation actually justified the billing of a level 3 subsequent hospital visit.

The Medicare Comprehensive Error Rate Testing (CERT) reports bear this belief out to some extent. CPT code 99223 (level 3 initial encounter) was shown to be overpaid 21.5 percent of the time, but coming in a close second was 99233, with an error rate of over 18 percent. I have seen poor documentation for both of these codes numerous times, and I can tell you that 99223, from a documentation perspective, can be fixed with provider education in a fairly short time frame. For 99233, the documentation in most cases doesn’t even come close to substantiating the reporting of the code. The nature of subsequent hospital visits being handwritten makes correcting the problem a laborious task from start to finish.

When the topic of subsequent hospital visits comes up, from an educational standpoint, I like to go back to the very beginning, which is the CPT definition for each of the three codes. In the CPT, at the bottom of each code description, is a small paragraph which gives an overview of a typical patient’s condition for the code. As the level of service goes higher, there is an acuity level that must be met to satisfy the usage of the code. To start, 99231 states “Usually, the patient is stable, recovering or improving”. Moving forward, 99232 states “usually, the patient is responding inadequately to therapy or has developed a minor complication”. Finally, 99233 states “usually, the patient is unstable or has developed a significant complication or a significant new problem”.

If you are currently a provider billing a large volume of 99233’s, take a good look at these descriptions. In a philosophical sense, I am in agreement with the idea that a hospital stay is usually reserved for those whose illness has exceeded the person’s capacity for self-care. Yet it should not be a common occurrence for a patient whose illness has been identified upon admission and whose course of treatment has been defined to be unstable throughout a large portion of their hospital stay. Utilizing the definitions above, 99231 and 99232 would describe the large percentage of subsequent hospital visits. To put it in the context of a recent example, Aunt Edith seems like a 99233, but is more than likely a 99231.

Additionally, if you’re billing a 99233 a day prior to discharge, I would hope that your discharge documentation includes the words “magic wand”, as you are reporting that the patient is unstable and/or has a complication of care. A discharge the following day would be unlikely.

Based on the direction that CMS has been taking with hospital-acquired conditions (HAC’s), I can see a day when 99233’s are only paid within 1 to 3 days of admission. Currently, taking HAC’s into account is in a reporting-only stage, but I believe we are headed towards a time when hospitals will face little (or perhaps, no) reimbursement for the treatment of HAC’s. This is a fact that, unfortunately, cannot be remedied by improved documentation on the part of the managing physician.  

We now have three of the four recovery audit contractors looking at certain hospital DRG’s for medical necessity, with the current list expected to expand over time. As RAC’s begin to widen their efforts into the physician arena, it would make sense for 99233’s to be on their immediate radar. This is particularly true if they have determined that a hospital stay did not fall under the parameters of medical necessity based on a complex review of the hospital records for an inpatient stay.

For the tens of thousands of physicians who happen to come across this particular posting and say, “…but I spend a lot of time with my patients, and….”, I offer this. While there are average times for each of the three codes for subsequent hospital visits (to save you time, 15 minutes for 99231, 25 minutes for 99232 and 35 minutes for 99233), it is important to remember a few points. First, the documentation must state “I spent XX minutes with this patient, more than 50% of which was spent counseling and/or coordinating care”. Second, there must be documentation of what topics were covered during the counseling (weather and other local and national news updates do not count for purposes of coding), or what specific steps were taken to coordinate the care for the patient. Simply writing something like “spent time counseling” is insufficient.

Finally, know that RAC’s are enforcing CMS’ recently implemented and heightened signature requirements when auditing your documentation. If it does not include a recognizable signature, your service is not authenticated and did not happen from the RAC’s point of view.

To complete our cycle, next week’s edition of The RAConteur will take a look at the reporting and documentation of  initial inpatient encounters (CPT codes 99221 thru 99223).

Having lived in and around Philadelphia for most of my younger days prior to living in Milwaukee, three things still hold true about me: I prefer cheesesteaks and hoagies to bratwurst, I drive extremely fast compared to others in my new adopted home and I’ll forever be a rabid sports fan.

My hero growing up was Steve Carlton of the Phillies, a pitcher so inscrutable and so focused on getting people out that the only nickname teammates could come up with for him was “Lefty”. With each passing day, in a world of pitch counts and fanatical devotion to quantifying every at-bat with statistics, I appreciate Carlton that much more. He was the classic power pitcher, going in for at least 7 innings, throwing a baseball as if his life depended on it, then strolling off the field with his eyes looking down to the unexpected applause of a sports city known for such class acts as booing the Easter Bunny and pelting Santa Claus with snowballs.

Every one of his 4,136 strikeouts was a testament to mental discipline and a workout regimen that included, among other circus-like feats, driving his fist to the bottom of a bucket of sand. This devotion to his workouts yielded 329 wins and a ticket to the Hall of Fame.

So what does Steve Carlton have to do with the Recovery Audit Contractor program? Bluntly, it’s about time you asked.

Most physicians, based on the years of training involved with becoming a member of their profession, possess a certain level of discipline. Fortunately for their patients, and unfortunately for themselves, this discipline often includes only the practice of medicine and does not extend to the documentation of the services rendered to their patients. The RAC’s have already taught us many lessons, but one painful lesson on the horizon is how much of a disservice physicians do to themselves by not capturing all that they do in a clinical setting in the patient’s medical record.

As RAC’s now expand their focus to include medical necessity, with more attention being paid to physician services, there is a school of thinking that the best beginning course of action for physicians to identify their RAC vulnerability is a review of CMS’ Comprehensive Error Rate Testing (CERT) reports and specialty peer comparison of billed services. Unequivocally, I agree that this is indeed the best place to start, but once this first step is completed, the hard work begins. Specifically, it’s time to take a long and critical look at the documentation for your services. This is the point, in today’s and subsequent postings, where I’d like to insert myself into the larger conversation.

Creating “audit-proof” documentation is far from an easy task. For one thing, “medical necessity”, as any person at all connected to medical delivery will tell you, is not a one-size-fits-all proposition. Similar symptomology can have different effects depending on the presentation of the patient. This inconvenient fact places the burden of proof for medical necessity squarely in the hands of the treating physician and his or her documentation of the services rendered. With CERT reports indicating that the biggest risk area for physician audit being evaluation and management services, it is long since past the time to look at documentation of these services.

It has been 15 years since the first E/M guidelines were released by Medicare. With the volume of writings dedicated to documentation of E/M services, you would think that physicians would be at least halfway to resolving documentation inconsistencies, but this simply isn’t the case. It is my belief that the problem lies not in wanton and deliberate physician non-compliance, but rather a lack of an attempt by CMS to translate the E/M guidelines into usable clinical language that physicians can understand and utilize.

With mandatory electronic health records on the horizon, the absolute worst line of thinking a physician could internalize is “the EHR will handle it”. EHR’s possibly offer a solution, but only if set up in the clinical setting to be utilized properly. EHR’s can lead to such things as templated and cloned documentation, which in established patterns can bring exponentially increased risk. Remember that the main reasoning behind the government’s push for EHR is simplicity and portability of retrieval, and not as a panacea to documentation of services.

Because I tend to look at RAC audits of physicians from this angle, I’d like to offer a preview of next week’s edition of The RAConteur, where I’ll begin taking a look at the most common CERT E/M errors and offer analysis you can use to make better decisions about code selection, beginning with subsequent hospital service codes 99231 thru 99233. I can promise the reader ahead of time that finding permanent and lasting answers will require discipline, but much less than is required to plunge your fist to the bottom of a bucket of sand.