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Posts Tagged ‘Compliance’

The Hidden Disadvantages of Buying on Faith

Posted by J. Paul Spencer, CPC, CPC-H in Industry Updates

My house is not usually stocked with junk food, despite the fact that it tends to find me. In those many moments when snack food isn’t available, I tend to reach for the nearest box of cereal.

There has always been one thing that annoys me about breakfast cereals in this country. I have never possessed a box of cereal that contained all perfect specimens. The best example I can give is your basic box of Rice Krispies. Among all of the perfectly toasted grains of dried rice making noise in my bowl, I inevitably find that one black piece of rice that disguised itself among hundreds of other grains poured into my bowl. This outlier grain of rice is always found after I pour the milk in the bowl, which then leads to me spending five minutes trying to fish it out of my bowl before I accidentally eat it. To this day, I have no idea of the consequences are of consuming the black Rice Krispy, and I don’t want to know.

Each one of us, no matter what the product, is susceptible to attractive packaging. The picture of the cereal on the box, strawberries happily floating on top like little red clouds, always looks good, and let’s face it; if the house is out of cereal, you’re going to buy the box. It’s only later that your frustration rears its ugly head when the myth of the packaging is exposed.

It is on this final point that I begin today’s discussion topic; physician alignment with hospitals.

In the lead-up to ACO formation, hospitals are currently on a physician buying spree that would make a sailor on shore leave blush. In a recent research paper by Thomson Reuters, 44 hospital CEOs indicated that physician alignment was an issue of increased focus. If we pair that with another report from Merritt Hawkins stating that 76% of all physician openings offer a signing bonus, and the conclusion can be made that now is a very good time to be a physician looking for employment by a hospital.

Yet as I examine the issue further, there is one critical component missing, that being the due diligence required to determine whether the physician in question is a compliance nightmare waiting to happen.

In the current audit environment, most hospital systems are just beginning to get their arms around the RAC process for facility services. Because the audit entities have yet to expand into physician services, hospitals with large physician populations haven’t focused on the risks presented by the billing practices of doctors. Into this environment comes recently-acquired physicians and their accessory baggage. They look great, what with their shimmering CVs and smart ties, but it’s what you can’t see (or what is not volunteered) that poses the greatest risk.

If a newly-acquired physician comes to your organization either as an outlier based on billing, a poor documenter or someone lacking familiarity with your chosen electronic medical record, he or she can pose an immediate risk to the entire system.

Thankfully, one area where I spend a great deal of my time is in the area of practice analytics. The operative principals are available to determine the risk a physician poses to a facility, and it can be done in a manner that is time-sensitive prior to acquisition. It is a clear choice between paying a little bit now, and paying a lot later. To rephrase, are you buying the Rice Krispies because of the package and trusting that the alluring box contains cereal without flaws? If so, get your spoon ready, as black Rice Krispy fishing isn’t as easy as it appears.

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September 9th, 2011 | 1 Comment »

Denial Management Made Easier With Version 5010 Billing Standard

Posted by J. Paul Spencer, CPC, CPC-H in Fi-Med Services, Hot Topics, In the Press, Industry Updates, J. Paul Spencer, CPC CPC-H

We are often told that life has no instruction book. Personally, I have seen this blatantly come true in the form of my daily dealings with my 3-year-old son. I also longed for a better set of rules back in 1990, when I found myself briefly dating a woman who thought she was telekinetic, but was actually a hypochondriac. No worries, though. I came out unscathed and not once was she able to throw me across the room using only the power of her mind.

In the realm of Medicare denials, currently, under Version 4010 of the X12 electronic billing standards, Medicare offers very little in the way of pointing the EOMB recipient to a solution for a denial. With time, an experienced follow-up specialist can train themselves to understand in what direction each claim adjustment reason code (CARC) and remittance advice remark code (RARC) is pointing, leading to faster resolution.

Version 5010, set to be implemented by CMS beginning on January 1st, 2012, is slated to make this process much easier. As part of Version 5010, if a claim is denied due to a conflict with a Local Coverage Determination (LCD) or a National Coverage Determination (NCD), the Explanation of Medicare Benefits will indicate what LCD or NCD is being applied in the denial of this claim.

Given that local carriers now have their LCD’s categorized on the CMS website, first by carrier, then in alphabetical order (which is helpful roughly 30 % of the time),  referring the follow-up specialist to the exact coverage determination will cut down on the amount of time needed to research these denial issues.  As someone with daily involvement in Fi-Med’s denial management process, I cannot begin to tell you how I welcome this change.

While there are many other benefits to Version 5010, such as compatibility with ICD-10 and the removal of some redundancies found in the current version, finding a clearer path to a denial solution may turn out to be its most substantive change.

I look forward to the day when my lack of psychic powers ceases to be an impediment to the timely correction of Medicare denials. This whittles down my list of  ”50-10″ challenges in my life down to what happens in 7 years when I’m 50 and my son is 10. I really need to get in shape….

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November 24th, 2009 | 2 Comments »

Referring Physician PECOS Phase II Delayed

Posted by J. Paul Spencer, CPC, CPC-H in Fi-Med Services, Hot Topics, In the Press, Industry Updates, J. Paul Spencer, CPC CPC-H

Following up on an earlier post here, CMS announced today that Phase II of Change Requests 6417 & 6421, dealing with referring physician mismatches between the NPI database and the PECOS system, has been delayed until April 5th, 2010.

Phase II of this change request orders the denial of any services referred by a physician who has a conflict between information found on the national NPI registry (NPPES) and the PECOS system. The change to the implementation schedule is being undertaken to give those physicians with conflicting information sufficient time to correct any irregularities.

For the present time, providers who bill for services referred by providers with this conflict will continue to get warning messages stating that the referring physician’s information is inaccurate. If this information has not been updated by the referring provider by April 5th, 2010, these services will be denied.

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November 24th, 2009 | 1 Comment »

Calling Health Care Fraud What It Really Is

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

I’ve got theft on my mind this week.

Last Saturday night, while I was spending some spare time acting as the opening musical act for a handful of stand-up comedians, someone took a football-sized rock and threw it through my passenger-side front window. Aside from the costs of repairing the damage, I was relieved of my satellite radio player and a pair of $3 sunglasses.

This episode taught me a little something about crime, and that is that criminals aren’t know for their skills of selection. The satellite radio player is virtually worthless, as it is only good as long you have an antenna, power supply and a subscription. Perhaps they thought it was in actuality a GPS device, but a cursory check of my back seat would have shown them all they needed to know, as there was a rather large road atlas in plain view. My thesis has now morphed into the idea that it takes a special combination of hubris and stupidity to be a criminal on any level.

Which brings me to the world of Medicare compliance. I read a variety of trade publications from week to week that catalog the numerous billing violations – and subsequent fines paid – by health care providers around the country. To highlight just a few from the past few weeks:

  • An Atlanta radiologist found himself under federal indictment for falsely claiming that he had personally reviewed thousands of x-rays and radiological studies over a period of 8 months, when in fact the work was done by non-physician radiology techs;
  • A New York podiatrist was charged with multiples counts of fraud for billing out complicated surgical procedures of the feet, when in actuality, he was performing the less-complicated act of clipping his patients’ toenails;
  • A Boston man pleaded guilty to a 54-count indictment that accused him of enlisting people to stage auto accidents in the greater metropolitan area, then turning around and billing insurance companies for therapy services at his clinics stemming from “injuries” sustained in the fake accidents.

 

These are only three of the more egregious examples among dozens of other cases nationwide, and remember that these are all within the last month.

When I present Fi-Med’s compliance plan to new employees, I define “health care fraud” as “theft”. In a world where “stewardesses” have transformed into “flight attendants”, and “shell shock” is now “post-traumatic stress disorder”, it is tempting to use less pointed language to describe all-too-common objects and occurrences. Yet whether it is Medicare, Medicaid or a commercial insurance plan, the thieves such as the ones highlighted above exact a heavy toll not only on the resources of the insurer, but on the entire health care infrastructure with the increased costs of premiums and enforcement.

Having grown up in a family with 5 physicians of different specialties, one of the happier aspects of my job as a compliance officer is working together with health care providers to find simple solutions, whether it be for front desk processes or documentation, that keep them from inadvertently slipping onto the wrong end of the regulatory process. There is usually a “light bulb moment” in each of these conversations when a satisfactory conclusion is reached and where peace of mind is achieved.

While health care fraud has more subtlety than the mentally prehistoric toss of a rock through a window, it is no less an act of theft. Going forward, with a major national health care overhaul on the horizon, it particularly falls on those of us in the medical reimbursement field to give the best guidance possible to the providers we service to assist them in avoiding the sinkholes along the regulatory highway.

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November 20th, 2009 | 1 Comment »

Time Documentation in the Post-Consult Era

Posted by J. Paul Spencer, CPC, CPC-H in Hot Topics, Industry Updates, J. Paul Spencer, CPC CPC-H

I don’t wear a wristwatch. 

I have three basic reasons why you’ll never find a time piece in my possession. The first being my dislike of all things related to jewelry. I’ve been married for nearly 5 years and I still play with my wedding ring, which is my only piece of jewelry. The second is I am surrounded by clocks at all times.  As I type this, I have a clock on the phone, computer and fax machine in my work area. Why complicate it by putting something on my wrist? The third is more cultural. Having a bloodline that is 1/2 Mediterranean in descent, the odds of my arm hair covering the face of any watch I own increases with each passing day, and not even I want to see that.

Having said all this, as we approach January 1st, 2010, a date which marks the end of Medicare’s acceptance of consultation codes for reimbursement, a wrist watch could very well end up being the best friend of specialists nationwide who suddenly find themselves without a longstanding reporting tool for patient encounters.

Evaluation and management documentation guidelines state that if more than 50% of your face-to-face time with the patient is spent in counseling and/or coordination of care, the E/M service can be selected based on time. For a specialist who invests time determining a proper course of treatment in either the office or hospital setting, this rule deserves a second look.

As an illustrative example, one problem that has presented itself is in regard to what used to be considered consultations in the hospital setting. Physicians will now bill an initial hospital care code (CPT codes 99221-99223) upon their first encounter with the patient in the hospital. On the surface, one can immediately see a problem, as there are 5 inpatient consultation codes, but only 3 initial hospital care codes. Because of differing documentation standards, there is no clear crosswalk between the two code sets. 

Now let’s look at two of these codes for comparison. CPT code 99252 (level 2 inpatient consultation), strictly from a documentation standpoint, requires an expanded problem focused history, an expanded problem focused examination and straightforward medical decision making. Using Southern California in 2009 as a reimbursement benchmark, CPT code 99252 is listed in the $81 range. Compare that to CPT code 99221 (level 1 initial hospital care). This code requires either a detailed or comprehensive history, a detailed or comprehensive examination and straightforward to low medical decision making. Using the same reimbursement benchmark, 99221 is listed at around $96.

Now on the surface, it appears that the documentation standards work against the specialists if given the choice between the two codes, but let’s add the documentation of time spent in counseling and/or coordination of care into the mix. The average total time for a 99252 is 40 minutes, but the average total time for a 99221 is 30 minutes. The lesson taken away from this is that an awareness of the time you are spending with the patient could lead to less of an investment of total time, but for a higher reimbursement.

Before jumping headlong into time-based billing, it is in the physician’s best interests to remember the two most important things with regard to documenting for this type of code selection. First, the medical decision making portion of your E/M documentation must detail the counseling and/or coordination of care. It is not enough to use generic statements such as “Spoke w/ Dr. X” or “Orders written”. The documentation must include the results of that conversation and detail about the physician’s care orders for the patient. Second, and most importantly, your time caveat statement must show that more than 50% of the total encounter time was spent in counseling and coordination activities. This can be stated either by using the exact minutes or as a clear statement of percentages. Good examples of this are:

  • I spent 50 total minutes with the patient, 30 minutes of which were spent in counseling and coordination of care.
  • I spent 50 total minutes with the patient, more than 50% of which were spent in counseling and coordination of care.

Documentation that simply states “I spent 30 minutes with the patient” is insufficient for choosing your CPT code based on time.

And while I’m on the subject of time, from previous entries on this blog, you know that I was recently in Georgia doing some musical recording. That particular investment of time on my part has yielded an unexpected dividend, as one of my songs that I recorded during my stay was selected as the Track of the Day in the Folk Rock category on Garageband.com yesterday. In an ironic twist, my friend in Georgia who recorded this track is employed by day as a high-end watchsmith. I may not wear a watch, but I guess it helps to befriend people who do. Have a great weekend!

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November 13th, 2009 | 3 Comments »

A Quick Glance at the Medicare 2010 Physician Fee Schedule

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

As I stated in a previous posting here, I have a long-standing interest in Russian literature. Developing a love of the novels of Tolstoy and Dostoevsky requires a large amount of free time as well as a hearty concentration level. Yet possessing both of these things does not remove oneself from the fact that War & Peace, owing to its size, works better as a doorstop than most bricks.

Which brings me to the Final Rule for the 2010 Part B Physician Fee Schedule. Weighing in at 1,669 pages, it was a lot to take in. Unfortunately for me, unlike War & Peace, there is no corresponding movie to simplify and edit its contents, yet onward I plunged. Many of the changes were specific to services and specialties, but there were a few things that jumped out at me that I’d like to share with you.

Beginning on January 1, 2010, consultation codes (99241-99245 for office/outpatient, 99251-99255 for inpatient) will no longer be reimbursed by Medicare Part B. In the preamble to this portion of the Final Rule, CMS decided that after many years of attempts at education and clarification of the rules for consultations, there remained mass confusion as to the rules regarding consultation vs. transfer of care, as well as widespread documentation deficiencies and problems with consultation code selection.

To make up for the loss of revenue for consultation codes, There will be a 6% increase in the RVU value on outpatient E/M services (99201-99205 for new patients, 99211-99215 for established patients). Going forward, in the office environment, rather than considering a consultation code for patients referred to their practice from another provider. the physician need only choose an E/M code based on whether the patient has been seen within three years of the service date.

Selecting hospital services in the absence of consultation codes will be a little trickier. CPT codes 99221-99223, which in the past have been used solely by the admitting physician, will now be used by all physicians upon their first encounter with the patient. In order to differentiate from the admitting physician and other physicians providing care to the patient, the admitting provider will be required to add a modifier to his service signifying that he/she is the admitting physician. The modifier to be used was not indicated in the Final Rule, but should reveal itself upon release of the 2010 HCPCS.

One specialty reduction of interest affects chiropractic services (CPT codes 98940-98942). These codes will be subject to a 2% reduction beginning in January.

For advanced imaging services such as nuclear imaging, CMS is now requiring that facilities providing the technical component for these services meet an accreditation standard in order to be reimbursed for these services.  

Of course, the biggest adjustment in the Final Rule is the CMS-projected 21.2% pay cut for physician services. As in past years, this cut is expected to be adjusted by Congress prior to the new year.

In any document almost 1,700 pages thick, there is bound to be information that I have left out. For your reading enjoyment, the Final Rule can be found at the following link:

  http://www.federalregister.gov/OFRUpload/OFRData/2009-26502_PI.pdf

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November 6th, 2009 | 1 Comment »

Stop Me If You’ve Heard This One Before…

Posted by J. Paul Spencer, CPC, CPC-H in Hot Topics, Industry Updates, J. Paul Spencer, CPC CPC-H

Do I hear four?

The thrice-delayed Red Flag Rules have been delayed again, this time until June 2010.

This particular delay was requested by Congress, which is currently working on legislation to exempt creditor businesses with fewer than 20 employees from the rules. As one can imagine, this would include quite a few free-standing medical providers. We’ll be following any new developments closely as the proposed legislation works it way through Congress. For now, enforcement of the rules remains on the shelf until an adequate compromise is reached.

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November 3rd, 2009 | No Comments »

NCCI Updates-Version 15.2

Posted by Lisa Velasquez in Hot Topics, Industry Updates, Webinars

The National CCI database now contains 626,582 edit pairs of procedure codes that, when billed at the same time for the same patient by the same doctor on the same day, either will not be paid at all or will be paid at a reduced rate. Within the database are some hidden data points that could be critical to your reimbursement and/or compliance, such as duplicates, triplicates, reversals, etc. The data you download from the CMS website does not contain these data points nor can you always determine new and terminated pairs for a given period by just looking at dates. This quarter, there are over 5,000 edit pairs that have been terminated retroactively to April, 2009.

In this short, free webinar, Frank Cohen, analyst and developer of the most popular CCI search engines, will walk you through a brief introduction to the NCCI policy but more importantly, will show you the updated data pairs and the data points that are most often missed. Registered attendees will receive a list of worksheets that contain the duplicates, triplicates, reversals, additions and terminations for Version 15.2, which are effective July 1, 2009

Space is limited. Reserve your webinar now by visiting Frank’s website.

Did you find this information helpful? If you have information that you think would be valuable to the medical community and would like me to post the information on our blog, please submit your request for review to my attention at (or via DM on Twitter @fimed).

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June 22nd, 2009 | No Comments »

Coding for the Non-Coder

Posted by Lisa Velasquez in Fi-Med Services, Industry Updates, Webinars

For over 30 years, Frank Cohen has worked as a health care data analyst, knowledge engineer and consultant. He has written many books and is the Senior Analyst for MIT Solutions. I have attended several of Franks webinars, which are scheduled 3-4 times a month, covering such topics as coding, code and modifier utilization, cost accounting, work RVUs, etc. This is a great resource that I want to share with all of you and best of all it’s free! Here is a brief intro to one of his webinars that I particularly liked: Coding for the Non-Coder

“Health care, like other industries, has its own language; and not just from a clinical perspective, either. Diagnosis and treatment codes are necessary in order to get paid for the services you provide and determine your level of compliance with the myriad of complex rules and regulations we face day to day. As the industry continues to tighten up with respect to finances  and regulation, physicians, practice managers, consultants, advisors and others are finding that understanding the relationship of coding to other areas of the practice has reached critical mass. You don’t have to be a coder to acquire a basic, foundational understanding of medical coding; the language of the business of medicine. Coding for the Non-Coder was specifically designed with the non-coder in mind.

In this short (and free) webinar, Frank Cohen (a non-coder himself) will help you understand the relationship between coding, billing, reimbursement and compliance without teaching you how to become a coder. It focuses on the big picture; understanding the language of coding, its importance within the medical practice and most importantly, how to identify and understand coding problems; from the common to the arcane.”

Although this webinar has already been presented, it is available to view by going to Frank’s website.

Did you find this information helpful? If you have information that you think would be valuable to the medical community and would like me to post the information on our blog, please submit your request for review to my attention at (or via DM on Twitter @fimed).

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June 10th, 2009 | No Comments »