Title: Medicare CERT Audits: The Physician
1Medicare CERT Audits The Physicians
Perspective
- Brian S. Parsley, MD
- 2nd Vice President AAHKS
- Clinical Associate Professor
- Baylor College of Medicine
- Houston, Texas
2Who Do We Serve?
- The PATIENT
- We Want to Get It Right
- Outline the Rules and We Will Follow Them!
- We Want to Maintain Access to Care for Our
Patients. - We are in this Together!
3Medicare Claims Data
- Medicare receives over 1.2 Billion claims
- per year. This equates to
- 4.6 million claims per work day, or
- 575,000 claims per hour
- 9,580 claims per minute
- 160 claims per second
4Why Are Audits Beneficial???
5Error Rates and Improper Payments
6Improper Payments vs. Fraud
- ALL FRAUDULENT CLAIMS ARE IMPROPER PAYMENTS BUT
ALL IMPROPER PAYMENTS ARE NOT FRAUDULENT
CLAIMS!!!!! - MOST ARE DUE TO IMPROPER DOCUMENTATION!
7Is This A Hospital Problem?
- You bettcha!
- It can affect the cost of borrowing
- It raises the costs to hospital
- It increases the cost of care
- Purchase of new equipment
- Maintenance of facility/ equipment
- Staffing ratios and salaries to attract good
staff - Marketing (information in the public domain)
8Is This Just a Hospital Problem?
- No!
- Physician payments are now coming under review.
- If the hospital services are denied then you will
be denied! - Physicians are now being audited directly
9DOCUMENTATION, DOCUMENTATION, DOCUMENTATION
- CMS Wants to know what YOU are thinking
- Accurate and complete documentation in the
physician records as well as the hospital records
is the key - A medical evaluation must be performed. The
evaluation should include - clear documentation of the patients functional
status - documentation of the patients mobility and
pain. - evaluation may be done all or in part by the
surgeon. - the surgeon must sign off on the report and
incorporate it into their records.
10What Is My Hospital Requiring Now?
- Pre certification and
- approval of DRG 470
- patients prior to posting
- on surgery schedule
- Screening for sufficient
- data to justify surgery
- This effects both Medicare and commercial
insurance patients
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14Advanced DJD Must Be Demonstrated By
- pain or functional disability from injury due to
trauma or arthritis of the joint and - non-surgical medical management must have been
tried and failed and such management must be
clearly addressed in the pre-procedure medical
record - non-surgical medical management have been tried
for a sufficient period (usually three months) to
assess effectiveness. Treatment should include
one of more of the following - anti-inflammatory medications
- analgesics
- flexibility and muscle strengthening exercises
- supervised PT (DATE OF
TREATMENTS???) (COST OF TREATMENT?) - activity restrictions as is reasonable
- assistive devices (canes, braces, etc.)
- weight reduction as appropriate
- therapeutic injections into the joint as
appropriate - radiographic supported evidence (X-ray) or MRI
supported evidence
15How Can I Help?
16Clear Documentation Improves Likelihood of Payment
- Chief Complaint End stage osteoarthritis, right
knee, for knee replacement. - History Patient has had bilateral
osteoarthritis, gradually progressive over 10-15
years. Most recent X-ray (7/22/11), right knee
shows joint space near obliteration along with
marginal osteophytes and subchondral sclerosis.
Has been treated as follows Ibuprofen 400 mg QID
since January PT 3 x week from 3/15/11 to
6/30/11. Patient started using a cane in May.
Right knee pain is continuous at level 3/10 with
6/10 on ambulation. Sometimes pain keeps him up
at night. No longer able to climb the five steps
to his front door. Knee pain and stiffness limit
walking to less than 25 yards without resting. - Physical Exam Bilateral knee deformity
consistent with severe osteoarthritis. Right
knee reduced to less than 90 degrees. Unable to
rise from a chair unassisted. - Impression Worsening pain, deteriorating range
of motion and significant interference with
function. Current therapy ineffective. Total
Knee Replacement is only option for pain control
and functional restoration. - Orders Admit to inpatient care for right TKR.
17Operative Report
- MUST be dictated for transcription within 24
hours - Operative findings should support the diagnoses
describe pathology observed in detail. - For your and the surgical assistants benefit,
describe the need for any surgical assistance. - Include type of metal or ceramic surface of
prostheses, orthopedic devices, use of cement and
rationale for biological products. Include every
item used in this description. - Describe any complications and how handled
intraoperatively.
18Discharge Summary Report
- RECOMMEND dictating within 24 hours of discharge
for optimal coding. - This intended to be more than a recap of the
surgery performed. - If complication occurs, THEN DOCUMENT IT IN THE
D/C - OP patients discharged the day of surgery also
must have pertinent information filled in the
form.
19Tips to Avoid Denial of Claims Properly
Documenting Medical Necessity
20Tips to Avoid Denial of Claims Properly
Documenting Medical Necessity
- MR should contain enough information to support
the determination that the total joint procedure
was reasonable and necessary presence of
advanced DJD - Currently, audits show medical records commonly
lack documentation that justifies the need for
payment. - Not Fraud and Abuse but lack of Documentation!
21Do You Have EHR? Then USE IT!
- Set up templates to ask the questions that you
need to include and allow for comment sections so
that you can explain yourself - Describe the treatment plans and include as many
dates as possible - Add X-ray detail check-offs
- Instruct your office personnel on the importance
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25If Your Hospital Has NOT Been AuditedIt
Will Be !!!
- Take this information and educate your Hospital
and Colleagues on Medicare Audits - Work with your hospital NOW to begin to screen
and review all cases for compliance with
criterion and educate them prior to review - Recommend and Implement changes in your office
process and EHR to ensure documentation
26 An Ounce of Prevention is Worth a Pound of Cure
27What Do I Do If My Record Is Audited?
- DO NOT TAKE THIS LIGHTLY!!!!!!!!
- Work with Your Hospital
- Spend the time to pull all your data together
- Contact your patients for additional data to
submit for your appeal. This includes requesting
information from prior orthopaedic and primary
care records. - The more information provided at first appeal,
the higher the success on Appeal!
28YOUR FEE IS NEXT!!!!!!!!!!!!
29Knee Case Audit Example
No discussion of level of knee pain, degree of
limitation, ambulation status, need for
assistive devices
30Knee Case Audit Example
No Discussion regarding function, ambulation,
assistive aids, crepitus, pain with ROM X-ray
reports somewhat limited
31Lessons Learned When Initial Audit Request
Received
- 1. Review all documentation prior to submitting
to MAC on the initial request. Try to submit a
complete package that addresses the criteria as
completely as possible. - 2. If any criteria point was not done, state in
the record why it was not done. List all
contraindications to the interventions that were
not appropriate for the patient. - 3. Strictly adhere to the time frames for
submission and appeal, the MAC certainly will. - 4. Appeal every denial.
32Lessons Learned When Initial Audit Request
Received
- A physician advisor is invaluable to the process,
especially as you move to the higher levels of
appeal. - We consulted an audit advisory consultant
MedManagement who was recommended thru our Coding
Oversight Consultant - Engage them on all appeals at the time of the
initial request for information. This is the most
successful timeframe.
33Knee Case Audit Report
34Knee Case Audit Response Example
Payment Approved on Appeal!
35Hip Case Audit Example
- Short HP Form no longer allowed at the hospital
36Hip Case Audit Example
Documentation does not support evidence of end
stage osteoarthritis that warrants Hip
replacement surgery. Inadequate documentation of
conservative management. NO EXAM! X-ray report
inadequate
37Hip Case Audit Clawback
38Hip Case Level I Audit Appeal
- Submitted Pre-op management screening sheet
- Included additional detailed data
- Reviewed past records
- Contacted patient
- Revised the HP and resubmitted
39Hip Case Level I Audit Appeal
More Detailed information provided regarding the
treatment history and failure of the
conservative management and degree of
difficulties.
40Hip Case Level I Audit Appeal
X-ray details provided outlining key elements
required Plan summarizes the thought process
leading up to the recommendation for surgery.
41Again DENIED!!!
42Level II Audit Appeal
- Must be submitted within 180 days of the initial
denial - Med Management, a Medicare Audit Consulting Group
- The MAC will provide a detailed response
outlining reasons for denial
43Reasons for Denial Outlined
44Hip Case Level II Appeal
- A more detailed response was made to CMS on
Second Appeal - Point by point rebuttal in the response letter
- The Second Appeal was approved by Maximus
45Second Appeal Payment Approved!
46If You Follow These Steps..
- You Can Show Me The Money!
- Thank You