Do You Really Want to Put Your Practice At Risk for a RAC Audit

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Do You Really Want to Put Your Practice At Risk
for a RAC Audit?

• Cecile M. Katzoff, MGA, CGCS
• Vice President for Practice Management and
  Consulting Services
• American Gastroenterological Association

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The Consulting Physicians
The Works of William Hogarth In a Series of
Engravings With Descriptions, and a Comment on
Their Moral Tendency
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Billing New Patient Visits and Consultations as a
Shared Service

• Documentation identifies mid-level as providing
  the service
• Service billed under physicians provider number

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Incident to

• To qualify as incident to, services must be
  part of your patients normal course of
  treatment, during which a physician personally
  performed an initial service and remains actively
  involved in the course of treatment.

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Office/Clinic Setting

• When an E/M service is a shared/split encounter
  between a physician and a non-physician
  practitioner (NP, PA, CNS or CNM), the service is
  considered to have been performed incident to
  if the requirements for incident to are met and
  the patient is an established patient.
• If incident to requirements are not met for
  the shared/split E/M service, the service must be
  billed under the NPPs NPI.

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The Hospital Consultation
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Hospital Inpatient / Outpatient / Emergency
Department Setting

• When a hospital inpatient / outpatient or
  emergency department E/M is shared between a
  physician and a non-physician provider (NPP) from
  the same group practice,
• And the physician provides any face-to-face
  portion of the E/M encounter with the patient,
  then
• The service may be billed under either the
  physician's or the NPP's provider number

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Split/Shared E/M Service

• CMS Manual System Department of Health Human
  Services (DHHS)
• Pub. 100-04 Medicare Claims Processing Centers
  for Medicare
• Medicaid Services (CMS)
• Transmittal 178 Date MAY 14, 2004

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Incident To Services
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Other Services Billed Incident to

• Service (diagnostic test or infusions) billed
  under ordering physician rather then supervising
  physician.
• Service billed that is not part of a course of
  treatment prescribed by a physician in the group.

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Incident to

• You do not have to be physically present in the
  patients treatment room while these services are
  provided, but you must provide direct
  supervision, that is, you must be present in the
  office suite to render assistance, if necessary.

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Diagnostic Tests and Infusions

• The service must be billed under the name of the
  physician who is present in the office suite when
  the service is provided.
• If the supervising physician is not the ordering
  physician, the ordering physicians NPI number is
  inserted in the CMS 1500 as the referring
  physician.

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Revisions to Incident To

• Date AUGUST 28, 2002
• Allowed the provider of the service and the
  supervisor to be a leased or contracted employee.
• The incident to services or supplies must
  represent an expense incurred by the physician or
  legal entity billing for the services or
  supplies.

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Consultations Asking for an Audit

• No documentation of request for evaluation and
  opinion from another physician or NPP
• No letter back to the requesting physician

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Consultations

• The request for consultation does not have to
  come in writing but must be documented in
  consultants chart
• A copy of the chart notes does not meet the
  requirement for sending a separate letter
• You can initiate treatment or order diagnostic
  tests and still bill the initial encounter as a
  Consultation

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Consultations Educate Your Referral Sources

• If the initial intent of the referring physician
  is to transfer care or for a procedure, the
  service is a New Patient/Established Patient
  Visit.
• Thus
• Patient referred for evaluation of symptoms can
  be billed as a Consultation
• Patient referred for procedure must be billed
  as a New Patient or Established Patient Visit

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Clarification to Consultation Definition

• MLN Matters Number MM4215 Related Change
  Request (CR) 4215
• Related CR Release Date December 20, 2005
  Effective Date January 1, 2006
• Related CR Transmittal R788 Implementation
  Date January 17, 2006
• Consultation Services Current Procedural
  Terminology (CPT) Codes 99241 99255

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Billing for the Visit Preceding Screening
Colonoscopy

• The visit preceding a screening colonoscopy for a
  patient with no symptoms and no co-morbidities
  that require intervention is not billable as a
  Consultation, New Patient Visit, or Established
  Patient Visit.
• Medicare does not pay for services in the absence
  of signs or symptoms.

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E/M Services Audit Targets

• Level of service billed not supported by medical
  necessity
• Examination not appropriate given presenting
  problem
• Missing elements for the level of service billed
• Billing New Patient Visits when patient has been
  seen within the past 3 years.
• Billing a diagnosis that is not supported by
  documentation

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Procedures

• Upper Endoscopy (EGD) Documentation in
  procedure report does not specify that scope was
  advanced to the duodenum / jejunum.
• EGD with biopsy Documentation does not identify
  reason for biopsy.
• EGD with EUS of upper GI tract Documentation in
  procedure report does not specify that EUS was
  performed of the esophagus, stomach, and duodenum

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Prevention is the Best Protection

• Design and implement a Compliance Program.
• Perform internal audits at least once per year.
• Train all providers and staff on reimbursement
  regulations and documentation requirements.

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What to Do When the RAC Calls

• Make copies of all documentation requested.
• Respond by deadline identified in letter.
• If you can not get all materials together by
  deadline, ask for an extension in writing.
• Review all requests for refunds.
• If you feel the request is not justified, have
  the services reviewed by an independent auditor.
• If the auditor disagrees in your favor, appeal by
  the deadline.

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So Who Are You Going to Call?
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• Cecile M. Katzoff, MGA, CGCS
• American Gastroenterological Association
• 301-941-2639
• ckatzoff_at_gastro.org