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California Medical Bill Reviewer Certification
California Medical Bill Reviewer Certification Unit 1: Workers’ Compensation Benefit Program Module 7: Medical Evidence Overview What Medical Evidence Is How Medical Evidence is Documented How Medical Evidence Determines Payment Errors & Discrepancies in Medical Evidence How Bill Review Systems Identify Discrepancies ‹#› CA Regulations Training – Medical Evidence In this module, you willof Have you ever heard learn about medical the old adage, “If it Let’s start discussing evidence andbythe important isn’t documented, it what medical evidence role it plays in determining wasn’t done?” This is payment. Then, you is, and how it truth iswill not far from the learn how errors in medical documented. when dealing with evidence can negatively medical evidence... affect payment. So, What is Medical Evidence? Medical evidence: documentation that shows medical necessity for procedures, services, or equipment provided to treat a patient. In bill review, the reality is that NOTHING is billable if it is not documented. If a surgeon routinely performs a service as part of a major surgery but it isn’t documented in a particular operative report, it should not be billed. ‹#› CA Regulations Training – Medical Evidence How is Medical Evidence Documented? Medical evidence is documented in medical reports, tests, and records. Reports, results, and other types of records need to tell the whole story and should simplify billing for the provider and payment for the insurance carrier. Types of medical evidence include: ‹#› CA Regulations Training – Medical Evidence Office notes Test results Operative reports Emergency room notes Anesthesia records Consultation reports California Regulations In fact, the Workers’ Compensation Appeals Board requires that medical evidence be provided in written reports. ‹#› CA Regulations Training – Medical Evidence According to the California Workers’ Compensation regulations: “The Workers’ Compensation Appeals Board favors the production of medical evidence in the form of written reports. Direct examination of a medical witness will not be received at a trial except upon a showing of good cause.” Why Are Reports Required? Standard forms are discouraged for documenting procedures. This is because the likelihood of variation between patients makes a standard form less compelling as medical evidence. ‹#› CA Regulations Training – Medical Evidence In contrast, a specific report states exactly what happened and justifies the specific service. When is Medical Evidence Collected? Medical evidence that documents a worker’s injury and treatment is collected from the start. The first pieces of medical evidence required in workers’ compensation are the: Report of Injury Initial Evaluation Report ‹#› CA Regulations Training – Medical Evidence Medical Evidence Determines Payment Medical evidence does more than show the necessity for medical services. Medical evidence also determines how much providers are paid for billed services. ‹#› CA Regulations Training – Medical Evidence In determining correct payment for services billed, there are a number of factors that come into play. Factors include: Date of injury Place of injury Cause of injury Diagnosis codes Procedure codes What if Evidence is Insufficient? When sufficient medical evidence is not submitted, a bill cannot be accurately evaluated. If an MRI is billed but no report can be produced, there is no medical evidence the MRI occurred. ‹#› CA Regulations Training – Medical Evidence What if Evidence is Contradictory? Different types of evidence that document a single medical case must all coincide. If an anesthesia bill is submitted for 4 hours of anesthesia services, but the anesthesia record shows the patient was in at 3:00 PM and released from anesthesia care at 5:30 PM, the medical evidence only justifies 2.5 hours of anesthesia. ‹#› CA Regulations Training – Medical Evidence What if Evidence is Contradictory? ‹#› The procedure codes billed must also match the diagnosis. Suppose a provider diagnoses an industrial injury as a fractured finger and the procedural note describes a finger joint injection. CA Regulations Training – Medical Evidence However, the CPT code billed is #20610, for a large joint injection. Since the medical evidence describes a small joint injection, the procedure will be paid at the lesser rate of the small joint injection. Evidence Should be Specific and Detailed Some reports require very specific information. For example, operative reports must report AND describe a procedure that was performed. Even if the surgical heading on an operative report states that a procedure was performed, but the procedure is not described in the body of the report, it should not be billed. ‹#› CA Regulations Training – Medical Evidence Unlisted Procedure Codes As you can see, providers make mistakes when billing for medical procedures. These mistakes result in: ‹#› Denied payments. Reimbursements that are less than they anticipate. CA Regulations Training – Medical Evidence A common error that providers make when billing is the incorrect use of unlisted procedure codes. Just like other discrepancies, incorrect use of unlisted procedure codes can result in denied payments. Unlisted Procedure Codes An unlisted code is applied correctly if used for a new procedure for which a code has not yet been assigned or listed. “I know…an unlisted code!” Unlisted procedure codes are incorrectly used when billed for: ‹#› CA Regulations Training – Medical Evidence However, too often, an unlisted procedure code is used incorrectly. A service that already has a valid CPT code. A service that is not a separate billable service. Unlisted Procedure Codes Consider this example: If a provider bills for CPT #97799 (unlisted Physical Medicine)... ...but the documentation describes the service as manual traction using a new type of table... the medical evidence supports paying the service as manual traction, not as an unlisted service. ‹#› CA Regulations Training – Medical Evidence Documenting DME In keeping with the need for medical evidence, invoices are required for expensive durable medical equipment (DME). If the State allows payment of cost plus a percentage and the provider has billedExample quadruple1 the cost, medical evidence does not support the charge. ‹#› Just like medical procedures, DME that is not properly documented will not be paid. CA Regulations Training – Medical Evidence If the operative report does not support an implant insertion, and the hospital Example is charging 2 for that implant, that charge will not be paid. Changes to Reports A physician is allowed to amend a report, but The Are The reports answer set is must sign the changes, answer and is subject to FRAUD in stone? NO. charges if the changes is NO. are false. ‹#› CA Regulations Training – Medical Evidence The Key to Success Medical evidence is the key to the successful review and reimbursement of medical bills. ‹#› Bill reviewers rely on medical evidence to identify billing errors, but also to ensure that providers are adequately reimbursed for their services. CA Regulations Training – Medical Evidence The bill review system is also designed to identify some billing errors. Let’s take a look… Bill Review System Some system edits set to require that the bill reviewer verify documentation to determine payment or denial. If the billed procedure is unlikely to be related to a work injury, edits set to suspend a bill for review. For example, if a provider bills for procedures that involve tumor excisions, cosmetic surgery, or preventive medicine visits, documentation must support why these services are related to a work injury and why they are eligible for payment. ‹#› CA Regulations Training – Medical Evidence Bill Review System Other system edits set to prevent payment when diagnoses do not match the services billed. ‹#› CA Regulations Training – Medical Evidence In this case, additional medical evidence of necessity needs to be submitted before payment can be made. The Bottom Line Medical evidence accomplishes the following: Ensures Accurate Payment for Services Justifies those Services Communicates What Services were Performed ‹#› CA Regulations Training – Medical Evidence Summary What medical evidence is. How medical evidence determines payment. How medical evidence is documented. How discrepancies and errors affect payment. ‹#› CA Regulations Training – Medical Evidence Module 7 Quiz Quiz: U1M7: Medical Evidence ‹#› CA Regulations Training – Medical Evidence Click on the link to go directly to the quiz. Feel free to review any of the material before you move on. Good Luck!