A mid-year check-up on compliance and revenue
[This quarterly column is written by Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, President of Edelberg Compliance Associates, Baton Rouge, LA.]
Want to rest easy about your compliance and revenue maximization efforts for the rest of the year? No time is a better time than right now to check up on how things are performing before the fall rush to implement ICD-10, add new codes to charge masters, update fee schedules, and train all of those new providers who started over the summer.
1. First and foremost, the time is right to perform an audit on your coding and billing by selecting a random sampling of your medical records and their code/charge assignment. Any problems you identify need to be remedied. Governmental and private payers are stepping up their audits on our Emergency Medicine Evaluation and Management levels — particularly 99284 and 99285 — so you want to start comparing you Medicare professional E/M distribution to Medicare’s.
If you are an outlier, you may be selected for a special audit, so now is as good a time as any to determine why you may be coding higher or lower than your state Medicare statistics indicate. The American College of Emergency Physician (ACEP) website provides the most current E/M Medicare distribution for each state.
If your internal audit identifies issues that need to be addressed for any specific issues or physicians, begin corrective action by providing in-service on documentation improvement and coding; then re-audit to assure all issues have been corrected. You may want to compare each individual physician’s E/M utilization to your state data as well. Remember, payers generally track individuals, not practices, so if you have a small group of physicians that are outliers, now is the time to determine why. Some of the reasons individual physicians might treat higher acuity patients:
• they may work at Level I trauma centers or in EDs surrounded by Urgent Care practices that see the many of the lower acuity patients; or
• they may work in practices that employ nurse practitioners and physician assistants that see the lower acuity patients while the emergency physicians treat higher acuity problems.
Also, practices that utilize better documentation tools such as user friendly EMRs or scribes could have higher-acuity profiles. Your unique practice and location may contribute to a higher acuity profile. If so, now is the time to understand the factors that contribute to it and prepare to defend your practice if audited.
2. Are you ready for lCD-10? If you haven’t revisited documentation improvement issues, now is a good time to plan documentation reviews and in-service. The October 1, 2015 date is still the "go live" date unless another delay is posted, so plan to touch base with providers and coders to assure it’s a go. Continue your parallel coding efforts to identify gaps in documentation that will prevent you from appropriately coding services with the ICD-10 code set.
3. October and January are generally the months that fees are revised. That means now is the time to review the current year’s resource utilization, estimate your costs of providing service, and address negotiations with payers, where indicated, to revise fees and payment rates. This requires detailed reporting on your payer-related service utilization. (Some practices simply increase fees by the cost of living index.) Regardless of the methodology you use, now is a good time to review your options and begin the process. And while you are at it, be sure that every service performed in the emergency department has an HCPCS code and charge in the ED fee schedule or charge master. If it doesn’t have an associated fee, you can’t bill for it.
4. Many hospitals and practices bring new physicians in over the summer months. Of course that’s vacation time for the individuals tasked with documentation improvement, coding, and billing, but that shouldn’t prevent you from meeting with new providers, reviewing specific medical record requirements, and reviewing documentation requirements. Consider putting all of the necessary in-service materials on audio or video files so new providers can review materials at their leisure, "test" out on reviews, and start the busy fall months prepared.
5. For those of you responsible for the facility side of things, your facility assessment (nursing) criteria probably need to be reviewed and, perhaps, revised to assure that all of the services performed as part of your evaluation and management routine are itemized and accounted for. One of the biggest areas in question today is how to document and bill for facility critical care. Medicare has one set of rules; private payers have another. Medicare billing of critical care requires close adherence to documentation of bedside time, where private payers generally follow the CPT descriptors that count "unit" or "attention-to" time (face-to-face bedside time is not required) to qualify for the initial 30 minutes of critical care. Check with your local Medicare Administrative Contractor (MAC) for their audit activity and articles/clarifications on the subject. Be sure your compliance department reviews your recommendations to keep you consistent with other providers at your facility.
The coming year (2015) promises to be a busy one for compliance and revenue assurance. Institutions will be developing many new programs to cut costs, assure quality and meet financial projections for our emergency departments. As always, a team effort among all stakeholders goes a long way toward assuring success.