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Internal Audit Pass Rates; Nonphysician Credentialing


Our practice does internal chart reviews on our physicians for coding accuracy. What do you feel is an appropriate passing score?

Internal Audit Pass Rates

Q: Our practice does internal chart reviews on our physicians for coding and compliance accuracy. What do you feel is an appropriate passing score on audits without a re-audit being necessary? Our threshold is 90 percent but we are thinking about lowering it if it is based on a 10-chart sample.

A: There is no federally sanctioned threshold of accuracy below 100 percent. You can see why the government has to maintain that all claims and supporting documentation are 100 percent accurate. However, an individual who worked closely with the Office of Inspector General recently made it clear to me that a 90 percent pass rate in these types of reviews is pretty good, and that this is clear evidence that your compliance plan or program is working.

Most practices that I work with use an 80 percent rate as passing, although some with more mature plans are now moving to 90 percent. As you seem to be aware, this doesn't leave much room for error with a 10-chart sample. Normally people only move to 20-chart samples if they are trying to use increments of 5 percent, such as an 85 percent pass rate. I'm not sure that this is necessary. Don't lose sight of the fact that the purpose of these reviews is to find out which providers need guidance in what areas, and to provide the needed education and support. Don't get too caught up in the numbers, they are just indicators.

Poor Code Combinations

Q: Can a nonphysician provider bill for the wellness exam on the same day that a physician bills for follow-up care? I'm thinking Medicare will not pay in this particular instance.

A: You are correct. It's likely that no payer will pay that combination of codes if the providers are in the same group and of the same specialty. But yes, Medicare and most other commercial plans will pay if it is the same provider and both components are properly documented.

Nonphysician Credentialing

Q: Should nonphysician providers be credentialed with commercial plans?

A: If the plan will allow it, credentialing nonphysician providers is likely prudent. It is also a good idea for Medicare. This will allow the nonphysician provider to see patients without regard to supervising physician presence.

Most practices understandably want to capitalize on the 100 percent payment associated with the incident-to criteria, but for commercial payers, direct billing often better reflects the actual nature of some of these visits. It is less "incidental" and more independent management. Incident-to is an old idea.

ACO Diagnoses in the A/P

Q: Our coders coach us that we should have a balance between the number of diagnoses in the history of present illness (HPI) and in the assessment and plan (A/P). Our practice participates in an accountable care organization (ACO), and at least once a year we must include in our claims submission all diagnoses that contribute to each patient's risk score.

In our EHR, we have no way to indicate that some diagnoses are included for this purpose rather than actively managed that day. When we include the diagnosis we can indicate that this problem is managed by a specialist, or we may be able to use a statement to indicate that all pertinent problems are included to reflect the overall severity of illness.

What should we do? The diagnoses that contribute to the risk score must be submitted with the claim, but we don't want the active management to seem inflated.

A: The issue you raise below is not unique to you. The documentation requirements for a chronic disease visit seem to get a bit distorted when the ACO or Hierarchical Condition Categories (HCC) diagnoses are included in the A/P.

One way to handle this, and I don't know if your EHR would accommodate this, might be to indicate on the ACO diagnosis codes that these are annual assessments. If you can separate the active diagnoses for that day from these annual ones, that would be best.

I'm glad that you are mindful of the distinction. Try and find a way to label the ACO diagnoses for what they are in the A/P. It wouldn't hurt to have a sentence in the HPI that states that, "All problems that impact the patient are assessed today to meet ACO reporting requirements and reflect the overall severity of illness."

The Half Time Rule

Q: I am a psychiatrist and use CPT codes 99213, 99214, and 99215 for outpatient medication management. Could you kindly explain the "half time rule"?

A: Per the AMA and the CPT manual, the history, exam, and medical decision making are considered the primary key components in selecting a visit code. These service descriptors, not time, are most often used to select the correct level of code.

You can use time to select a code when counseling or coordination of care accounts for more than 50 percent of the time spent with the patient. The way to write it is: "Spent over 1/2 of 'X' counseling the patient on 'Y.'"

You say you use these codes for medication management. If you are using these, the nature of the visit should be more one of discussion. If it is not, then it is better to do the standard history of present illness, review of systems, mental status exam, and medical decision-making kind of note. The pharmacologic management codes were discontinued for physicians in 2013.

AWV and E&M

Q: Our policy is not to bill a new patient, problem-oriented office visit along with a preventive visit. This is because we don't think we can count the exam component when "carving out" an additional E&M service. That said, can we bill a new patient problem visit with an AWV because the AWV does not require an exam?

A: First, I don't agree that you can't bill a new patient preventive visit and a new patient E&M visit. It's done all the time, and yes, there is overlap on the exam. When the payers get smart, they'll pay one at 50 percent, as they do with multiple surgeries.

You're right that the AWV doesn't have that overlap, so that potential point of conflict is eliminated. There should be no problem with billing an AWV and an E&M.

Proper Documentation

Q: If a provider writes a note in the chart the day the patient is seen, but does not dictate what he jotted down, does that count as part of the history? On the paper chart the page is stamped with the date, the nurse writes down the information for the provider, and the provider makes notes on the page while examining the patient. Does that information count?

A: Any documentation the provider creates can be considered when evaluating a given charge for supporting documentation. So yes, that information can count. Please mention to the provider, however, that it is better to have the information in one place, with the notable exception of review of systems on new patients and past family social histories. These are regularly referenced in the dictated note or EHR note.

Auditors are just like anyone else, they don't want to have to look too far for what they need.

Medicare Fraud

Q: Is the following scenario Medicare fraud? A physician stands in the doorway of a Medicare patient's ICU room and he views the patient's labs and diagnostic medical images. The physician's note reflects nurses' examinations and nurses' verbal comments. The physician does not touch the patient and he does not enter the patient's room. The physician codes critical care (99291).

A: Good question. The CPT manual does not specifically state that the provider must examine the patient. The text focuses more on the critical nature of the illness/injury and other circumstances. The CPT manual states: "Time spent on the unit or at the nursing station, on the floor reviewing test results or imaging studies, discussing the critically ill patient's care with other medical staff, or documenting critical care services in the medical record would be reported as critical care even though it does not occur at the bedside."

Medicare states: "This time (CC time) must be spent at the patient's immediate bedside or elsewhere on the floor, or unit, so long as you are immediately available to the patient. For example, time spent reviewing laboratory test results or discussing the critically ill patient's care with other medical staff in the unit or at the nursing station on the floor would be reported as critical care, even when it does not occur at the bedside; if this time represents your full attention to the management of the critically ill/injured patient."

The part of your scenario that might raise some fraud alarm bells is that the physician's note reflects nurses' examinations and nurses' verbal comments. This could suggest some borrowing of others work and the representation that it is the physician's work. If the examination detailed in the note appears to be his examination, and it is not, that is certainly a poor practice. However, the examination elements could be presented in a way that obviates ownership. I can see why this might disturb an observer, particularly if they felt the patient was not receiving the care needed. The bottom line, however, is that the exam portion is not needed for the code and would not represent fraud regarding the critical care code itself as long as the physician's assimilation of all the relevant data resulted in appropriate care for the patient.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years.

This article originally appeared in the November/December 2014 issue of Physicians Practice.

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