#18: Avoiding Coding and Billing Disasters

[AdminWolf]

Episode 18: Avoiding Coding and Billing Disasters

As the medical model and the use of high-tech instrumentation has grown, ECPs have been increasingly subject to audits by insurance companies and the federal government.

The fines for incorrectly coding and billing can easily run into six-figures, and in some cases can be even higher!

In this episode of ODwire.org Radio, noted expert John Rumpakis, OD, MBA stops by to talk about how to avoid getting hit with major fines by properly coding and billing your patient encounters.

He discusses some important coding strategies as well as disasters he's seen as a consultant.

If you are responsible for the billing in your practice, you won't want to miss this show!

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Feel free to ask follow-up questions of John in this thread.

 

[AdminWolf]

Thanks again to John

Our thanks again to John for taking the time to talk.

I was really sort of floored by one statement he made -- that he hasn't seen an audit come back with a fine of less than six-figures in a long time. Scary stuff.

 

[Mark Margolies]

Electronic Records Required ?

I personally do use electronic records but i question the statement that John Rumpakis made namely that EHR will be required in 2014. How so ? There may be lower Medicare reimbursement but that is different from saying they are required ? Who is requiring them and what will the consequences be for those who don't comply ?

 

[Robert Garfield]

I personally do use electronic records but i question the statement that John Rumpakis made namely that EHR will be required in 2014. How so ? There may be lower Medicare reimbursement but that is different from saying they are required ? Who is requiring them and what will the consequences be for those who don't comply ?

I'm also interested in the answers to Mark Margolies' above inquiries.

 

[Paul Farkas]

Point of information...and a word from our sponsor.

Dr John Rumpakis will be answering question on this forum. He may be traveling today but I'm confident he will address concerns as quickly as possible.

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Take less than five minutes and pull out your credit card...
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[John Rumpakis]

I personally do use electronic records but i question the statement that John Rumpakis made namely that EHR will be required in 2014. How so ? There may be lower Medicare reimbursement but that is different from saying they are required ? Who is requiring them and what will the consequences be for those who don't comply ?

My understanding is that in 2004, President Bush signed an executive order stating that all medical records must be EMR within 10 years. That is where the 2014 number came from. Additionally, President Obama has also reiterated this timeframe and stated that is his goal through the implementation of the meaningful use requirements that are part of the ACA that goes into effect on January 1 2014. The consequences that I am currently aware of are related to financial penalties placed on CMS and Medicaid billings.

 

[Conley Marcum]

Audits

So, if you are not a member of any insurance panel, ie did not sign up as a preferred provider, would you ever get audited?

I was under the impression that in 2014 if you didn't have EHR your medicare reimbursements would be decreased but it was not mandated.

 

[John Rumpakis]

So, if you are not a member of any insurance panel, ie did not sign up as a preferred provider, would you ever get audited?

I was under the impression that in 2014 if you didn't have EHR your medicare reimbursements would be decreased but it was not mandated.

If you have never been a provider for a third party payor then you would not be subject to an audit because you have always been paid directly by the patient - not with a third party's money. as far as the 2014 mandate, please see my comments above.

 

[Steven Nelson]

John, excellent interview and probably the most profound thing you said is precisely what I try to hammer into folks over and over. The record rules. They're going to audit not using a time machine, but rather the medical record and HOW you document things determines your success or failure when push comes to shove. If you didn't document, you didn't do it. If you document improperly, it doesn't MATTER what you did.

 

[Conley Marcum]

Audits

If you have never been a provider for a third party payor then you would not be subject to an audit because you have always been paid directly by the patient - not with a third party's money. as far as the 2014 mandate, please see my comments above.

I guess I should have phrase my question better. I receive 3rd party payments but I am not a participating provider for the plans.

Thanks for your talk and input, John!

 

[Charles A McBride]

Hi John. I hope you are well. I'm not done with the podcast yet, but a question:

Am I required to record the reason for ordering a test on the main portion of the chart or is including it in the interpretation and report sufficient? -Charlie

 

[Kevin J. Gross OD]

Hi John. I hope you are well. I'm not done with the podcast yet, but a question:

Am I required to record the reason for ordering a test on the main portion of the chart or is including it in the interpretation and report sufficient? -Charlie

and, is the reason 'for further evaluation of dx xyz' or 'to compare to previous' sufficient?

 

[John Rumpakis]

Hi John. I hope you are well. I'm not done with the podcast yet, but a question:

Am I required to record the reason for ordering a test on the main portion of the chart or is including it in the interpretation and report sufficient? -Charlie

Hey Charlie! Long time, my friend... Hope you are doing well also. The reason for ordering the test should be recorded in your plan, thus prior to running the test, so recording it in the I&R wouldn't be the best place. You are correct on your second question as well. For example, if you examined a patient and discovered a disk heme in the right eye, the order would read something like this. Order fundus photo of OD optic nerve for further evaluation secondary to hemorrhage noted today. Take care...

 

[Richard Pagan]

medical coding and billing is for sure a hot topic and I enjoyed the broadcast, all good advice. I think though that the elephant in the room is "vision vs medical". For ODs and MDs this is a growing problem, and is easily the largest point of contention. I wonder if you had any current opinions or other comments to share on this issue?

 

[Bruce DeBeer]

John, I use Officemate and ExamWriter and have a question concerning the recording of Chief Complaint.

I'm always careful to list a chief complaint on all medically related exams as required by insurance, but I don't place it in the "Chief Complaint" box simply because I think it is stupid and redundant to list "Flashes of light" there followed by "Flashes of light seen for the past 3 days which is increasing in frequency" in the very next box. What purpose is served by stating the same thing, first in an abbreviated fashion followed by a more detailed fashion.

Instead, I list the chief complaint in the History of Present Illness under either Vision Complaint or Ocular Symptoms depending on what the complaint is. My rationale is that a Chief Complaint is a Chief Complaint because it IS the Chief Complaint, not because it is labeled Chief Complaint. On a paper chart or an electronic chart, I feel you could have "Reason for Visit", and it would still be the Chief Complaint.

I know that it is plainly documented that you must have a chief complaint, and I also know that many, if not most people list the chief complaint in two or three words followed by a more detailed description in the next section, but do the written rules (not opinions) say that it must be labeled as such, or can it be obvious that what you have recorded under HPI is the reason why the patient came to you? That is, their Chief Complaint.

By the way, when the exam is printed out, if nothing is recorded under "Chief Complaint", then that label is not printed, just like "Fields", "OCT" or other labels don't print if you don't do those tests. In the above example, only "Ocular Symptoms" would print out.

 

[David Tabak]

Best Practices

The lecturer state that we should have a bell curve of medical codes, yet I here over and over that "best practices" will use 99XX4 by far the most.

The majority of my medical visits in my office do not require 2 and 3 follow up visits. When they do we, of course, code 99XX1, (99XX2 and 99XX3. If they are only coming in for medical care on a specific complaint (red eye most common) we always bill a 99XX4, assuming we treat the patient.

What am I missing here?

 

[Kandi S. Moller]

The lecturer state that we should have a bell curve of medical codes, yet I here over and over that "best practices" will use 99XX4 by far the most. The majority of my medical visits in my office do not require 2 and 3 follow up visits. When they do we, of course, code 99XX1, (99XX2 and 99XX3. If they are only coming in for medical care on a specific complaint (red eye most common) we always bill a 99XX4, assuming we treat the patient. What am I missing here?

How do you meet more than 10 ROS for a new 99204? That's hard for an eyeball visit. You only need 2 for 99214.

 

[Paul Farkas]

Point of information...

Although I was part of the program, I finally had the opportunity to listen to the complete 30 minutes. Dr John Rumpakis did a great job!

You should have your staff members dedicated to billing and coding in your practice listen to the program as well.

Keep asking questions.

 

[Charles A McBride]

I finished the podcast on the road tonight. A few questions...

Let's say I incorrectly order a test in my plan with the phrase "Pt. needs OCT." Assume that I ordered it for the right reason and carefully documented the reason for ordering the test in the interpretation and report along with the results, reliability and how the outcome of the test might affect any decision to treat the patient, all the right stuff. If the primary aim of the auditing insurance company is to educate, educate, educate, would an auditor in this case STILL order me to replay the cost of the test?

Some of the guidelines set by insurance contracts seem to consist of shades of gray open to interpretation. If one is audited, does the insurance auditor hold the trump card or is there some sort of an arbiter involved?

Lastly, John, can you take moment to describe how your system to ensure proper and up-to-date coding works/what is costs etc.? Thanks much! -Charlie

 

[Steven Nelson]

I finished the podcast on the road tonight. A few questions...

Let's say I incorrectly order a test in my plan with the phrase "Pt. needs OCT." Assume that I ordered it for the right reason and carefully documented the reason for ordering the test in the interpretation and report along with the results, reliability and how the outcome of the test might affect any decision to treat the patient, all the right stuff. If the primary aim of the auditing insurance company is to educate, educate, educate, would an auditor in this case STILL order me to replay the cost of the test?

Some of the guidelines set by insurance contracts seem to consist of shades of gray open to interpretation. If one is audited, does the insurance auditor hold the trump card or is there some sort of an arbiter involved?

Lastly, John, can you take moment to describe how your system to ensure proper and up-to-date coding works/what is costs etc.? Thanks much! -Charlie

I actually took some of John's advice and changed my templates in Practice Fusion to the following:

"Order refraction" is now "order refraction to access medical condition's effect on corrected acuity"
"Order fundus photography" is now "order fundus imaging with associated interpretation and report for documentation of medical condition and future comparison" - similar change for anterior photography.
"RTC for re-assessment in 6 months" now reads "return for re-evaluation of medical condition in 6 months. Written report of findings forwarded to primary care physician"

I also am now adding "as indicated on imaging" to any documented abnormality I am going to photo as in "2+ rpe dystrophy as indicated on imaging".

It's annoying in some ways using Practice Fusion because its in SOAP format, but it does allow you to word things exactly as you like and when the record is finished, it makes a very nice narrative for referrals and reports.

 

[Charles A McBride]

And one more question. Does the fact that you've only seen $100,000 rewards the past umpteen months mean that mostly larger practices are being targeted?

 

[Richard Pagan]

I actually took some of John's advice and changed my templates in Practice Fusion to the following:

"Order refraction" is now "order refraction to access medical condition's effect on corrected acuity"
"Order fundus photography" is now "order fundus imaging with associated interpretation and report for documentation of medical condition and future comparison" - similar change for anterior photography.
"RTC for re-assessment in 6 months" now reads "return for re-evaluation of medical condition in 6 months. Written report of findings forwarded to primary care physician"

I also am now adding "as indicated on imaging" to any documented abnormality I am going to photo as in "2+ rpe dystrophy as indicated on imaging".

It's annoying in some ways using Practice Fusion because its in SOAP format, but it does allow you to word things exactly as you like and when the record is finished, it makes a very nice narrative for referrals and reports.

While it makes sense to word it that way from a charting "flow" standpoint, I've seen, and read many opinions that state the reason for the testing can just as readily be written in the test I and R, and does not have to be in the record. Obviously it doesnt need to be written twice, so once in either the record, or the test interpretation, should be fine.

 

[John Rumpakis]

John, I use Officemate and ExamWriter and have a question concerning the recording of Chief Complaint.

I'm always careful to list a chief complaint on all medically related exams as required by insurance, but I don't place it in the "Chief Complaint" box simply because I think it is stupid and redundant to list "Flashes of light" there followed by "Flashes of light seen for the past 3 days which is increasing in frequency" in the very next box. What purpose is served by stating the same thing, first in an abbreviated fashion followed by a more detailed fashion.

Instead, I list the chief complaint in the History of Present Illness under either Vision Complaint or Ocular Symptoms depending on what the complaint is. My rationale is that a Chief Complaint is a Chief Complaint because it IS the Chief Complaint, not because it is labeled Chief Complaint. On a paper chart or an electronic chart, I feel you could have "Reason for Visit", and it would still be the Chief Complaint.

I know that it is plainly documented that you must have a chief complaint, and I also know that many, if not most people list the chief complaint in two or three words followed by a more detailed description in the next section, but do the written rules (not opinions) say that it must be labeled as such, or can it be obvious that what you have recorded under HPI is the reason why the patient came to you? That is, their Chief Complaint.

By the way, when the exam is printed out, if nothing is recorded under "Chief Complaint", then that label is not printed, just like "Fields", "OCT" or other labels don't print if you don't do those tests. In the above example, only "Ocular Symptoms" would print out.

Bruce,
Herein lies the problem or dilemma. I think that many EMR's are flawed in how they record things. For example, there is one prominent EMR that allows duplicative and conflicting statements in the medical record. Others don't actually include any logic on medical decision making, but simply ask the practitioner to "ballpark" it so it can score the EM encounter. I would encourage you to fill out the CC where the CC is to be recorded - I totally agree that sometimes the flow is not desireable where the programmers put things, but it is clearly stated that one must be recorded. Keep in mind that I have posted many times here on ODWire that there are two things that fulfill the CC requirement. If it is a patient intitiated visit, then the CC in the patients words is one. The second woud be the "reason for return visit" as specified by the physician when it is a physician initiated visit. Thanks.

~John

 

[John Rumpakis]

While it makes sense to word it that way from a charting "flow" standpoint, I've seen, and read many opinions that state the reason for the testing can just as readily be written in the test I and R, and does not have to be in the record. Obviously it doesnt need to be written twice, so once in either the record, or the test interpretation, should be fine.

Richard,
Reason for testing can certainly be included in the I&R, but that alone does not remove the need to have it in the medical record as well. An interpretive report is designed to be duplicative as it is part of a special ophthalmic procedure and must meet those requirements as per CPT definition.

~John

 

[John Rumpakis]

I guess I should have phrase my question better. I receive 3rd party payments but I am not a participating provider for the plans.

Thanks for your talk and input, John!

Conley,
I am not sure how you do this. If you are not a provider, the patient should always be paying you in full and then they would be the ones getting reimbursed by their carrier for out of network services. You are potentially creating a A/R nightmare by waiting for payments from carriers which have no contractual obligation to actually pay you.

~John

 

[John Rumpakis]

And one more question. Does the fact that you've only seen $100,000 rewards the past umpteen months mean that mostly larger practices are being targeted?

Charlie,

Sadly, that is not true at all. I have seen these same type of judgements from practices that gross $250K up to those well over $1MM.

John

 

[John Rumpakis]

I finished the podcast on the road tonight. A few questions...

Let's say I incorrectly order a test in my plan with the phrase "Pt. needs OCT." Assume that I ordered it for the right reason and carefully documented the reason for ordering the test in the interpretation and report along with the results, reliability and how the outcome of the test might affect any decision to treat the patient, all the right stuff. If the primary aim of the auditing insurance company is to educate, educate, educate, would an auditor in this case STILL order me to replay the cost of the test?

Some of the guidelines set by insurance contracts seem to consist of shades of gray open to interpretation. If one is audited, does the insurance auditor hold the trump card or is there some sort of an arbiter involved?

Lastly, John, can you take moment to describe how your system to ensure proper and up-to-date coding works/what is costs etc.? Thanks much! -Charlie

Charlie,
I think that would be a defendable position, however the carrier may recommend that you change your practice for future records. The indication for testing really needs to be in the record, which chronologically occurs when the test was ordered and before the test was performed.

John

 

[John Rumpakis]

How do you meet more than 10 ROS for a new 99204? That's hard for an eyeball visit. You only need 2 for 99214.

Kandi,
My point exactly!! The reason that I have always maintained that it is very difficult for an OD to reach the level of a 99204, 99215, or 99205 is because of the ROS requirement in the history. Not impossible, just difficult since the ROS that are reviewed must be specific and pertinent to the office visit.

~John

 

[John Rumpakis]

The lecturer state that we should have a bell curve of medical codes, yet I here over and over that "best practices" will use 99XX4 by far the most.

The majority of my medical visits in my office do not require 2 and 3 follow up visits. When they do we, of course, code 99XX1, (99XX2 and 99XX3. If they are only coming in for medical care on a specific complaint (red eye most common) we always bill a 99XX4, assuming we treat the patient.

What am I missing here?

David,
I have never heard that "best practices" will use the 99XX4 the most. That would really concern me because while a 99214 is an easily met standard (the equivalent of a 99203), a 99204 is very difficult for us to meet. Secondly, when you say you always bill a 992X4 assuming you treat the patient also worries me. Each patient, must be individually assessed and coded based upon what you did with that patient. Naturally you would have a much wider distribution of codes you used as not every patient would be scored exactly the same.

John

 

[John Rumpakis]

A Word About ReimbursementPLUS

Since I have had a number of requests about ReimbursementPLUS, I thought I would provide some basic information about it. The annual cost is $1299/year per practice. 95% of all practices require only a single subscription even if you have mutliple offices. The ODWire price is $1105/year per practice, representing a 15% discount. We are ~67% less expensive that our nearest competitor and provide greater depth of information including our proprietary Fee Schedule Analyzer, our Clinical Care Protocol Advisor, our real-time ICD-10 converter, just to name a few. Here are some details from the ReimbursementPLUS.com website. Thanks for the interest.

~John

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[Richard Pagan]

Richard,
Reason for testing can certainly be included in the I&R, but that alone does not remove the need to have it in the medical record as well. An interpretive report is designed to be duplicative as it is part of a special ophthalmic procedure and must meet those requirements as per CPT definition.

~John

just wondering if, in your opinion, the above example would/could qualify as an example of how insurance companies might recoup fines/penalties. If it is then there is something seriously wrong with that process. I'd call you a criminal if you walked in and said "well you listed the reason for the test in the I and R, but you did not duplicate that reason in the record", and then attempt to collect money from me for services rendered. Thats gratuitous abuse IMO.

 

[John Rumpakis]

just wondering if, in your opinion, the above example would/could qualify as an example of how insurance companies might recoup fines/penalties. If it is then there is something seriously wrong with that process. I'd call you a criminal if you walked in and said "well you listed the reason for the test in the I and R, but you did not duplicate that reason in the record", and then attempt to collect money from me for services rendered. Thats gratuitous abuse IMO.

Richard,
The order for the test must come chronologically before the test is performed, thus before the I&R is created. The reason for the test is included in the order.

~John

 

[Lisa Heuer]

Question about I&R for visual field results

Regarding I&R for visual field testing, if you complete a proper and thorough I&R report, do you need to repeat any of those notes on the printout from the instrument? Out of habit and convenience, I still jot a few notes and my signature on the printout, but I'm thinking that this is redundant and unnecessary, especially since those on EMR would be importing the result into the record without making written notes. The same question could apply to printed reports from OCT, topography, etc. Those of you who are still using paper records, what do you do? (We are moving to EMR later this year...)

 

[David Tabak]

David,
I have never heard that "best practices" will use the 99XX4 the most. That would really concern me because while a 99214 is an easily met standard (the equivalent of a 99203), a 99204 is very difficult for us to meet. Secondly, when you say you always bill a 992X4 assuming you treat the patient also worries me. Each patient, must be individually assessed and coded based upon what you did with that patient. Naturally you would have a much wider distribution of codes you used as not every patient would be scored exactly the same.

John

Sorry, I made a mistake.We use 99214 a lot --we rarely use 99204. Here is my requirements for using a 99214:
Any of the below qualify me to use a 99214, in my opinion...

1)If the patient has a new complaint with the potential for sig. morbidity if untreated or misdiagnosed
2)If the patient has 3 or more old problems
3)If the patient has a new problem that requires a prescription (this is the classic "hot/red eye")
4) If they have 3 stable problems that require medication refills
5) One stable problem one inadequately controlled problem that requires med. refills or adjustments

Dave Tabak

 

[Anonymous Post Bot]

An Anonymous Poster asks...



"I understand a vision exam only covers a screening for health issues and a new prescription if needed. A medical exam includes diagnosis and management of all range of medical issues.

Can a patient you've never seen before choose which exam they do? As many other doctor's do, I work in CP with a nice big sign showing my vision exam price. We tell all patients, and have forms that the pt signs as modified by suggestions on this forum,that medical exams cost more than the vision exam.

So a pt comes in, "wants new glasses", denies knowledge of cataracts or mac deg. BCVA is 20/50.

This pt has a medical insurance that you can't get on and the patient must go see a provider on the panel to use the medical insurance. You find catarcts, but since pt refuses to pay more than the posted vision exam fee, how much detail are you supposed to give the pt about their medical condition? 'You have cataracts but need a medical exam to check how m bad they are.'

Or are you obligated to tell the patient how severe they are and when you think surgery is needed, all at the cheaper vision exam price?"

 

[Steven Nelson]

"I understand a vision exam only covers a screening for health issues and a new prescription if needed. A medical exam includes diagnosis and management of all range of medical issues.

Can a patient you've never seen before choose which exam they do? As many other doctor's do, I work in CP with a nice big sign showing my vision exam price. We tell all patients, and have forms that the pt signs as modified by suggestions on this forum,that medical exams cost more than the vision exam.

So a pt comes in, "wants new glasses", denies knowledge of cataracts or mac deg. BCVA is 20/50.

This pt has a medical insurance that you can't get on and the patient must go see a provider on the panel to use the medical insurance. You find catarcts, but since pt refuses to pay more than the posted vision exam fee, how much detail are you supposed to give the pt about their medical condition? 'You have cataracts but need a medical exam to check how m bad they are.'

Or are you obligated to tell the patient how severe they are and when you think surgery is needed, all at the cheaper vision exam price?"

If you're telling them at checkout, that's your bad and you eat that extra MDM for what BETTER NOT BE A $49 EYE EXAM! If it is, I will find you.

You HAVE to clear these things up BEFORE you ever see them. Find out what insurances they have, both medical and vision. If you're not on their medical, then you need to decide UP FRONT whether you're going to charge them for a medical visit should that scenario present itself or are you going to pretend those medical issues aren't there and bill as a wellness visit on a patient that clearly isn't "well" and inform the patient accordingly so that they have the option of saying "no thank you".

Either way, if you're not figuring this out until the patient has been seen, you're doing it wrong. Implement better check in protocols. Tomorrow would be good.

 

[Richard Pagan]

a "routine exam" is not something you choose, like on a menu. It really is just one of many possible outcomes. That being true they need to know in advance if they are willing to risk having to pay higher fees, because you just dont know (and they sure don't know) if its routine or not until you perform the exam. If they dont want to risk it, and demand that they just have the "regular exam" (whatever that is ), we decline to see them.

 

[Steven Nelson]

a "routine exam" is not something you choose, like on a menu. It really is just one of many possible outcomes.

Love that

 

[Mike Sandy]

Or are you obligated to tell the patient how severe they are and when you think surgery is needed, all at the cheaper vision exam price?"

If you raise your routine wellness exam fee closer to your medical fee, the sting of doing MDM for wellness pay hurts less financially and emotionally. I think Dr. Pagan's exam fees are the same.

 

[Anonymous Post Bot]

Anonymous Poster responds...

"I knew you guys would chime in like that.

But the patient didn't want a medical exam, and it's been said here that the pt has the final say.

I'd really like to know what Dr. Hom and especially Dr. Rumpakis think of this."