Medicare CERT Audits: The Physician

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Medicare CERT Audits The Physicians
Perspective

• Brian S. Parsley, MD
• 2nd Vice President AAHKS
• Clinical Associate Professor
• Baylor College of Medicine
• Houston, Texas

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Who 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!

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Medicare 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

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Why Are Audits Beneficial???
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Error Rates and Improper Payments
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Improper Payments vs. Fraud

• ALL FRAUDULENT CLAIMS ARE IMPROPER PAYMENTS BUT
  ALL IMPROPER PAYMENTS ARE NOT FRAUDULENT
  CLAIMS!!!!!
• MOST ARE DUE TO IMPROPER DOCUMENTATION!

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Is 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)

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Is 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

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DOCUMENTATION, 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.

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What 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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Advanced 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

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How Can I Help?
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Clear 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.

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Operative 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.

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Discharge 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.

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Tips to Avoid Denial of Claims Properly
Documenting Medical Necessity
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Tips 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!

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Do 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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If 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

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An Ounce of Prevention is Worth a Pound of Cure
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What 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!

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YOUR FEE IS NEXT!!!!!!!!!!!!
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Knee Case Audit Example
No discussion of level of knee pain, degree of
limitation, ambulation status, need for
assistive devices
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Knee Case Audit Example
No Discussion regarding function, ambulation,
assistive aids, crepitus, pain with ROM X-ray
reports somewhat limited
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Lessons 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.

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Lessons 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.

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Knee Case Audit Report
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Knee Case Audit Response Example
Payment Approved on Appeal!
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Hip Case Audit Example

• Short HP Form no longer allowed at the hospital

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Hip 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
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Hip Case Audit Clawback
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Hip 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

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Hip Case Level I Audit Appeal
More Detailed information provided regarding the
treatment history and failure of the
conservative management and degree of
difficulties.
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Hip 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.
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Again DENIED!!!
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Level 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

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Reasons for Denial Outlined
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Hip 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

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Second Appeal Payment Approved!
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If You Follow These Steps..

• You Can Show Me The Money!
• Thank You