TrailBlazer Medical Review Activities

Transcription

A CMS Contracted Intermediary and Carrier
Education Makes the Difference
Medicare Update 2010
Texas Tech University School of Medicine
May, 2010
Debra L. Patterson, M.D.
J4 Medicare Medical Director
Published Month Year
Discussion Topics
• Identifying Aberrant Billing Patterns
• Documentation Risks
Basics
Teaching Physicians
EMR
Recent TrailBlazer Medical Review Audit Examples
• TrailBlazer Concerns
• Questions
Medicare Administrative Contractors
Correct payment?
Honest payment error?
Fraud?
Abuse?
Fraud and Abuse Definitions
Fraud – An intentional deception or misrepresentation
made by an individual knowing it to be false, resulting in
unauthorized benefit(s) for himself or another person.
Abuse – Practice that is inconsistent with accepted, sound
medical or fiscal standards. The practice may directly or
indirectly result in unnecessary costs to the Medicare
program, improper payments for services that fail to meet
professionally recognized standards of care, or services
that are medically unnecessary.
Fraud and Abuse Definitions
There is no absolute data or medical review
finding to clearly differentiate honest billing
errors and/or poor documentation practices
from fraud and/or abuse.
Progressive Corrective Action
• Problem Identification
• Problem Validation
• Intervention
• Monitoring
• Problem Closure
Problem Identification
Wound Care –
• OIG-HHS/DOJ
• CERT
• Part A and B Contractors
• PSCs
• RACs
OIG Report May 2007
• Medicare spent $188 million in 2004 for surgical debridement
services
• $64 million in improper payments
• 64% of services did not meet one or more Medicare program
requirements
–Incorrectly coded = 39%
–No documentation or insufficient documentation = 29%
–Not medically necessary = 1%
POINT #1
Numerous suspicious observations
DC 24-Month Trend by Allowed Amount
Procedure Codes 11040-11044
11040
11041
11042
11043
11040
11044
Allowed Services Per Patient
Allowed Amount
$250,000
$200,000
$150,000
$100,000
$50,000
$0
OctDec
2003
JanMar
2004
AprJun
2004
Jul- OctSep Dec
2004 2004
JanMar
2005
AprJun
2005
11041
11042
11043
11044
3.50
3.00
2.50
2.00
1.50
1.00
0.50
0.00
OctDec
2003
JulSep
2005
JanMar
2004
AprJun
2004
JulSep
2004
Paid Quarters
Oct 2003 thru Sept 2004 compared to Oct 2004 thru Sept 2005
Procedure Codes
11040
11041
11042
11043
11044
Percent change of
allowed amount
-0.12%
4.76%
17.58%
-3.01%
-3.35%
Percent change of
allowed services
-2.50%
-0.23%
13.90%
-6.21%
-4.73%
OctDec
2004
JanMar
2005
AprJun
2005
JulSep
2005
DE 24-Month Trend by Allowed Amount
11040
11041
11042
11043
11044
Allowed Amount
$60,000
$50,000
$40,000
$30,000
$20,000
$10,000
$0
Oct- Jan- Apr- Jul- Oct- Jan- Apr- JulDec Mar Jun Sep Dec Mar Jun Sep
2003 2004 2004 2004 2004 2005 2005 2005
11040
11041
11042
11043
11044
3.00
2.50
2.00
1.50
1.00
0.50
0.00
OctDec
2003
JanMar
2004
AprJun
2004
JulSep
2004
OctDec
2004
Paid Quarters
Procedure Codes
11040
11041
11042
11043
11044
Percent change of
allowed amount
32.93%
23.69%
23.79%
-23.89%
-27.13%
Percent change of
allowed services
31.78%
19.45%
22.11%
-28.30%
-31.06%
JanMar
2005
AprJun
2005
JulSep
2005
MD 24-Month Trend by Allowed Amount
Procedure
Codes 11040-11044
11041
11042
11043
$400,000
Allowed Amount
11040
11044
$350,000
$300,000
$250,000
$200,000
$150,000
$100,000
$50,000
$0
Oct- Jan- Apr- Jul- Oct- Jan- Apr- JulDec Mar
Jun
Sep Dec Mar Jun
Sep
2003 2004 2004 2004 2004 2005 2005 2005
11040
11041
11042
11043
11044
3.50
3.00
2.50
2.00
1.50
1.00
0.50
0.00
JulOct- Jan- AprJul- Oct- Jan- AprSep
Dec
Mar
Jun
Sep
Dec
Mar
Jun
2003 2003 2004 2004 2004 2004 2005 2005
Paid Quarters
Procedure Codes
11040
11041
11042
11043
11044
Percent change of
allowed amount
-10.59%
2.97%
30.12%
12.16%
-5.20%
Percent change of
allowed services
-11.75%
-0.30%
23.41%
8.61%
-5.76%
TX 24-Month Trend by Allowed Amount
11040
11041
11042
11043
11040
11044
Allowed Amount
$1,600,000
$1,400,000
$1,200,000
$1,000,000
$800,000
$600,000
$400,000
$200,000
$0
OctDec
2003
JanMar
2004
AprJun
2004
JulSep
2004
OctDec
2004
JanMar
2005
AprJun
2005
JulSep
2005
11041
11042
11043
11044
5.00
4.50
4.00
3.50
3.00
2.50
2.00
1.50
1.00
0.50
0.00
Oct- Jan- Apr- JulOct- Jan- Apr- JulDec
Mar
Jun
Sep
Dec
Mar
Jun
Sep
2003 2004 2004 2004 2004 2005 2005 2005
Paid Quarters
Procedure Codes
11040
11041
11042
11043
11044
Percent change of
allowed amount
11.95%
11.36%
14.04%
46.69%
21.39%
Percent change of
allowed services
9.86%
6.78%
11.23%
45.29%
19.61%
VA 24-Month Trend by Allowed Amount
11040
11041
11042
11043
11040
11044
$200,000
11041
11042
11043
11044
3.00
$180,000
Allowed Amount
$160,000
$140,000
$120,000
$100,000
$80,000
$60,000
$40,000
$20,000
2.50
2.00
1.50
1.00
0.50
0.00
$0
OctDec
2003
JanMar
2004
AprJun
2004
JulSep
2004
OctDec
2004
JanMar
2005
AprJun
2005
Oc t- Jan- AprJul- Oc t- Jan- Apr- JulDec
Mar
Jun
Sep
Dec
Mar
Jun
Sep
2003 2004 2004 2004 2004 2005 2005 2005
JulSep
2005
Paid Quarters
Procedure Codes
11040
11041
11042
11043
11044
Percent change of
allowed amount
0.56%
4.14%
17.82%
-3.56%
31.66%
Percent change of
allowed services
-2.20%
1.55%
17.08%
-3.11%
23.42%
POINT #2
Trends and Patterns
TX Scattergraph
Procedure Code 11042
TX Scattergraph of Allowed Dollars versus Frequency of Therapy
Dates of Service: January-December 2007
Paid Dates: January-December 2007
Modifiers: KX + GN, GO, GP
500
450
400
350
300
250
200
150
100
Peer Average = 34.23
50
0
$0
$500,000
$1,000,000
$1,500,000
$2,000,000
$2,500,000
$3,000,000
Modifier KX Allowed Dollars
* Therapy is based on modifiers GO, GN, and GP.
$3,500,000
$4,000,000
$4,500,000
$5,000,000
POINT #3
Absolute utilization difference
TX Scattergraph
TX Scattergraph
Extreme outlier removed from graph.
Total allowed dollars $1,408,820.29
and allowed services per patient
12.15.
TX Scattergraph
POINT #4
Multiple code utilization variation
TX Procedure Code 11043
by Allowed Dollars
the Difference
Paid Dates:Education
AprilMakes
– September
2005
Top Specialties
TOP DIAGNOSES
10%
5%
6%
2,615
2,615
$420,410.63
$397,490.66
16.93%
190
1,397
1,397
$243,076.22
$203,959.06
8.69%
25081 - DIABETES WITH OTHER SPECIFIED MANIF
103
1,004
1,004
$171,662.15
$169,042.34
7.20%
8911 - OPEN WND KNEE/LEG-COMPL
202
993
993
$234,309.85
$164,841.80
7.02%
NBR PATS
BILLED ALLWD
BILLED AMT
SRVCS SRVCS
97 - Physician Assistant
All Others
% OF
TOTAL
ALLOWED
AMT
9,639
9,639
$1,737,589.68 $1,567,374.19
66.74%
920
2,936
2,936
$1,081,882.46
19.81%
TOP MODIFIERs 1
$465,232.02
% OF
TOTAL
ALLOWED
AMT
$1,830,754.70 $1,417,990.25 60.38%
$678,013.89 $431,102.03
18.36%
$361,233.91 $193,869.33
8.26%
$126,778.82 $62,492.78
2.66%
BILLED ALLWD
NBR PATS
BILLED AMT
SRVCS SRVCS
58 - STAGED OR RELATED PROCEDURE BY SAME
No Modifier Used
59 - DISTINCT PROCEDURAL SERVICES
RT - PROCS PERFORMED ON RIGHT SIDE
1,149
1,322
629
206
TOP MODIFIERs 2
NBR PATS
No Modifier Used
51 - MULTIPLE SURGERY
2,434
596
564
77
9,022
2,146
1,695
339
9,022
2,146
1,695
339
11 - Internal Medicine
48 - Podiatry
ALLOWED
AMT
1,118
9%
02 - General Surgery
% OF
TOTAL
ALLOWED
AMT
188
22 - OUTPATIENT HOSPITAL
25 - Physical Medicine & Rehabilitation
ALLOWED
AMT
70709 - DECUBITUS ULCER, OTHER SITE
11 - OFFICE
61%
BILLED ALLWD
BILLED AMT
SRVCS SRVCS
4542 - VARICOSE VEINS OF LOWER EXTREMITIES
TOP PLACE OF SERVICE
9%
NBR PATS
% OF
TOTAL
ALLOWED
AMT
$2,262,529.21 $1,513,219.91 64.44%
$724,018.13 $535,778.12
22.81%
$336,653.28 $162,385.14
6.91%
$80,387.87
$48,357.79
2.06%
BILLED ALLWD
BILLED AMT
SRVCS SRVCS
7,549
4,714
1,583
277
7,549
4,714
1,583
277
ALLOWED
AMT
ALLOWED
AMT
TX Procedure Code 11044
by Allowed Dollars
Paid Dates:
April
2005 Makes the Difference
Education
Makes–
theSeptember
Difference
Education
TOP DIAGNOSES
Top Specialties
22%
42%
70715 - ULCER OF OTHER PART OF FOOT
70714 - ULCER OF HEEL AND MIDFOOT
99883 - NON-HEALING SURGICAL WOUND
TOP PLACE OF SERVICE
11 - OFFICE
22 - OUTPATIENT HOSPITAL
10%
BILLED ALLWD
NBR PATS
BILLED AMT
SRVCS SRVCS
287
56
50
150
67
14%
25 - Physical Medicine & Rehabilitation
02 - General Surgery
399
512
48 - Podiatry
11 - Internal Medicine
All Others
No Modifier Used
79 - UNRELATED PROCEDURE OR SERVICE BY T
TOP MODIFIERs 2
No Modifier Used
51 - MULTIPLE SURGERY
RT - PROCS PERFORMED ON RIGHT SIDE
562
554
284
256
239
BILLED ALLWD
NBR PATS
SRVCS SRVCS
TOP MODIFIERs 1
12%
562
554
284
256
239
1,968
1,225
1,968
1,225
$ 286,973.90
$ 121,887.03
$ 71,242.98
$ 131,413.99
$ 88,028.96
NBR PATS
1,149
202
155
71
2,030
664
224
270
$ 136,462.10
$ 120,816.31
$ 63,590.69
$ 61,171.09
$ 60,616.68
2,030
664
224
270
ALLOWED
AMT
% OF
TOTAL
ALLOWED
AMT
$644,871.95 $458,385.29 50.41%
$343,145.68 $175,115.81 19.26%
$115,188.85 $51,519.47
5.67%
$123,033.31 $44,195.47
4.86%
BILLED
AMT
2,544
812
233
90
ALLOWED
AMT
% OF
TOTAL
ALLOWED
AMT
$1,214,302.66 $663,335.54
72.95%
$184,722.03 $124,926.37
13.74%
$105,870.94 $31,718.58
3.49%
$65,913.17
$20,191.00
2.22%
BILLED ALLWD
BILLED AMT
SRVCS SRVCS
2,544
812
233
90
% OF
TOTAL
ALLOWED
AMT
15.01%
13.29%
6.99%
6.73%
6.67%
% OF
TOTAL
ALLOWED
AMT
$521,769.38 $450,521.46
49.55%
$667,774.05 $284,645.02
31.30%
BILLED
AMT
BILLED ALLWD
NBR PATS
SRVCS SRVCS
467
505
87
185
ALLOWED
AMT
ALLOWED
AMT
POINT #5
Unexpected provider specialty or types
Unexpected place(s) of service
Texas Ambulance (Specialty 59) BLS Non-Emergency Transport (Procedure Code A0428)
Trend of Maximum Potential Savings and Carrier-to-Nation Ratio
$40,000,000
2.50
$35,000,000
$30,000,000
$25,000,000
1.50
$20,000,000
1.00
$15,000,000
$10,000,000
0.50
$5,000,000
$0
0.00
Jan-Jun 2004
Jul-Dec 2004
Jan-Jun 2005
Jul-Dec 2005
Time Period
Maximum Potential Savings
Source: National BESS Data
Carrier-to-Nation Ratio
Jan-Jun 2006
Carrier to Nation Ratio
2.00
POINT #6
Dramatic utilization upturns
January – June 2006 BESS Data
Procedure Code A0428 – BLS Non-emergency
Ambulance service,
basic life support, non - emergency
transport
$40,000,000
2.5
$30,000,000
2
$25,000,000
$20,000,000
1.5
$15,000,000
$10,000,000
1
$5,000,000
$0
($5,000,000)
0.5
DC
DE
MD
TX
VA
($10,000,000)
0
$35,000,000
TX Scattergraph by UPIN
Procedure Code A0428 - BLS
Paid Dates: June – November 2006
A
l
l
o
w
e
d
S
e
r
v
i
c
e
s
3SD
2SD
Mean
160
140
120
P
a
t
i
e
n
t
100
3SD
80
2SD
60
40
P
e
r
Mean
20
0
$0
$500,000
$1,000,000
$1,500,000
$2,000,000
$2,500,000
Total Allowed Amount
There are 474 UPINs
Mean = $175,510.01 allowed amount and 16.64 allowed services per patient
2nd standard deviation = $670,743.14 allowed amount and 67.63 allowed services per patient (19 UPINs over 2nd standard deviation for allowed amount)
3rd standard deviation = $918,359.70 allowed amount and 93.13 allowed services per patient (6 UPINs over 3rd standard deviation for allowed amount)
Texas Ambulance (Specialty 59) BLS Non-Emergency Transport (Procedure Code A0428)
Trend of Carrier-to-Nation Ratio
2.5
Education
Makes the Difference
Carrier-to-Nation Ratio
2.0
1.5
1.0
0.5
0.0
Jan-Jun 2004
Jul-Dec 2004
Jan-Jun 2005
Time Period
Source: National BESS Data
Jul-Dec 2005
Jan-Jun 2006
POINT #7
Aberrancies in multiple data sources
•48% (26 of 54) of the providers are located in
the Houston area.
•11% (6 of 54) have fewer than 10 patients
•42% (23 of 54) have more than 7,000
services/100 patients.
POINT #8
Unusual business plans
Texas A0428 Modifiers RJ, JR
Dates of Service July – December 2007
Paid Dates July 2007 – January 2008
180
160
3 SD
140
2 SD
120
100
80
Mean
60
40
20
0
$0
$200,000
$400,000
$600,000
$800,000
Allowed Dollars
$1,000,000
$1,200,000
$1,400,000
$1,600,000
POINT #9
Birds of a feather flock together
POINT #10
There is no single data aberrancy to
indicate billing errors, fraud, or abuse with
100% specificity or 100% sensitivity
Claim Review
What’s Medicare Looking For?
• Validate the information on the face of the claim
• Verify that all Medicare benefit and medical necessity
requirements were met
•
Numerous medical review “probe audits” and pre-payment
audits last year.
•
Audits included numerous drugs and pharmacologic
administration services.
•
Significant error rates
•
Multiplex nature of errors
o Medical necessity
o “Incident to” violations
o Failure to document the services to have been performed.
o Provider identity/signature
Representative Errors From IVIG Audit
• Failure to meet one or more LCD requirement.
• Failure to demonstrate appropriate “Incident To”
reporting (i.e. absence of documentation indicating
the presence of the supervising physician on site
during the IVIG infusion).
• Documentation entries lacked legible signatures
identifying the performing/supervising persons.
• Errors associated with related infusion services
Services inherent to the cost of the infusion reported
separately.
 Normal saline (HCPCS codes J7040 and J7050) and used to
administer the drug.
 Heparin flush (HCPCS codes J1642 and J1644)
 Introduction of needle or intracatheter into a vein (CPT code
36000)
Failure to document infusions and/or push (CPT codes
96366, 96367 96368, 96373 and 96374) at the
quantity reported.
Failure to document administration of other
pharmacologic agents reported for payment:
 Metaclopramide (HCPCS code J2765), Dexamethasone
(HCPCS code J1110)
 Diphenhydramine (HCPCS code J1200)
 Methylprednisolone (HCPCS code J2930).
Failure to document Evaluation and Management
(E/M) Services (CPT codes 99213 and 99214)
 Failure to document a significant, separately identifiable E/M
service.
 Failure to document the level of E/M code level reported.
Failure to document miscellaneous reported services
 Portable pump maintenance (CPT 96521)
 Spirometry (CPT code 94010)
 Professional services for allergen immunotherapy (CPT code
95115).
Recent Local Policy Activities
Drafts To Be Presented To June 2010 CACs
• Computed Tomographic Coronary Arteriography
• Audiologic and Vestibular Function
• Cardiac Rehabilitation
• Pulmonary Rehabilitation
WHO
WHAT
Performing, supervising, and referring
practitioners
Services and quantities of services performed
WHERE
Place of service
WHEN
Date of service
WHY
Medical necessity and diagnosis
Performing, Supervising, and Referring
Practitioners
• Legible identity and signature*
• Appropriate professional
• Incident to
• (erstwhile) Consultations
Medicare Payment Requirements
Medicare assumes the following:
• Physicians and other providers of healthcare services who
report services for payment by Medicare know and have followed
the rules (“could have known, should have known”)
• Every item of information reported on every claim is true and
accurate and is supported by appropriate medical record
documentation
– That physicians and other providers of healthcare services understand
and correctly report CPT, HCPCS, and ICD-9 codes
– That the medical record demonstrates that the work of the CPT code
reported was performed by the reporting practitioner
Medicare Payment Requirements
Reported services must be:
• Performed in accordance with federal laws,
regulations, and Medicare national payment
rules
• Performed by a qualified practitioner
• Performed for a qualified beneficiary
• Medically reasonable and necessary
• Coded correctly
Medical Necessity In The Law
Social Security Act, Title XVIII
Section 1862 (a) (1) (A)
"Notwithstanding any other provision of this
title, no payment can be made under Part A
or Part B for any expenses incurred for items
or services which are not reasonable and
necessary for the diagnosis or treatment of
illness or injury or to improve the functioning
of a malformed body member.”
Medical Necessity Defined
Medical Necessity
• Statute
• National Coverage Decisions
• Local Coverage Determinations
Medical Necessity
•
•
•
•
Statute
National Coverage Decisions
Local Coverage Determinations
Clinician judgment considering the “rules”
– Safe and effective
– Not investigational
– Meet but not exceed patient’s medical need
– Accepted standard of medical practice
• Peer reviewed Medical literature
• Practice guidelines
• Respected textbooks
• Authoritative opinion
Medical Necessity
•
•
•
•
Statute
Medical Necessity
•
•
•
•
Statute
Medical Necessity
•
•
•
•
Statute
Medical Necessity
•
•
•
•
Statute
Miscellaneous Information
Miscellaneous Information
Medical Necessity – Beyond E/M
• Medical literature
Medical Necessity
• Clinician judgment considering the “rules”
• Peer reviewed medical literature
Teaching Physician Services
When documenting teaching physician
services remember
Part B does not pay physicians to teach
Part B payments for teaching physicians’
supervision of residents reimburses the
teaching physician for his personal service to
the patient
For E/M services performed by a resident and
teaching physician
•
The teaching physician may report to Medicare
for payment a service represented by the
combined documentation of the resident and the
teaching physician
•
The teaching physician’s personal documentation
must demonstrate
A face-to-face visit with the patient
Physical presence during the visit of the resident (when
applicable)
Participation in the management of the patient
Following are examples of unacceptable
documentation (physician attestation):
• “Agree with above.” followed by legible countersignature or
identity;
• “Rounded, Reviewed, Agree.” followed by legible
countersignature or identity;
• “Discussed with resident. Agree.” followed by legible
countersignature or identity;
• “Seen and agree.” followed by legible countersignature or
identity;
•Review the resident’s note in its entirety to assure
the resident included required elements necessary
to meet CPT defined physician key component
work
•Beware of notoriously missing History elements
( HPI and ROS)
•Beware inaccurate or conflicting HPI and ROS
•Beware of legibility issues
Documentation
Documentation Red Flags
• Patient’s medical condition not described or
described in very vague terms
Ambulance services
Physical therapy services
• Patient’s condition does not vary over time
Documentation
• Extensive, repetitious unnecessary
documentation
Unrelated to the presenting problem
“Blown in” records
Documentation by “exception”
• Records lack individualization
“Cloned” notes
Templates
Documentation
• CPT defined “work” not demonstrated
Procedures not documented
Level of effort not demonstrated
 E/M
 Surgical debridement
 Infusion services
Procedures do not meet any CPT code definition
and describe non-covered services
 “Electroceutical” services
 Nerve conduction studies
Documentation
•Circumstances described by modifiers not
demonstrated
Documentation
• Drugs/radiopharmaceuticals not documented
• Drug wastage not documented
Documentation
• Performing and/or record author not identified
“Incident to”
Scribing
Teaching physician
Documentation
• Failure to identify users
Electronic signatures
Passwords
Audit trail
• Need for clear EMR policies procedures
Documentation
• Documentation inconsistencies
Within the provider’s own record
Compared to records of other providers
Documentation
• Conclusions, impressions, and plans of care
not supported by the facts
• Subjective statements not supported by
objective information
“Trying is the first step towards failure.”
~Homer Simpson~
A CMS Contracted Intermediary and Carrier

TrailBlazer Medical Review Activities

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