Medicare’s medical review process May 2013

Objectives Understand how Medicare’s Medical Review Program works Identify the types of services that are currently being reviewed by Medicare Become familiar with your role in the Medicare review process Learn more about the common errors from recent Medicare audits Take advantage of the resources available to you

Medicare’s Medical Review Process Medicare contractors are required to develop processes to help ensure appropriate billing and proper claim payment MR may request documentation to support billed services Providers must supply documentation Documentation must support medical necessity and codes billed Documentation must be legible and signed Providers benefit from this program by: Reducing the overall claims payment error rate Reduction in filing errors Increase in timely payments, and Increased educational opportunities

The Provider’s Role The purpose of the MR process is to make sure claims are paid correctly. You can help meet this goal by: Reviewing and reading all publications and LCDs so you are aware of coverage requirements Familiarizing office staff and billing vendors with filing rules Checking your records against billed claims Performing self audits

Medicare audit contractors Recovery Audit Contractors (RACs) Comprehensive Error Rate Testing (CERT) Zone Program Integrity Contractors (ZPICs) Medicare Administrative Contractors (MACs) September 20, 2018 © 2013 Copyright, CGS Administrators, LLC.

CGS MR Strategy - 2013 Drugs Hospital Visits – Initial and Subsequent Ambulance Nursing Home Visits Chiropractic Manipulative Treatment Physical Therapy Office Visits - Established Office Visits – New Emergency Room Visits Modifiers 24, 25, 57 Lab Tests New Providers Surveillance Medical Review Edits Currently Reviewing Drugs-Herceptin, Hospital Visits, Locum Tenens, Modifier 25, Nursing Home Visits, and Office Visits

Types of Review Widespread: When a particular kind of problem is identified (i.e., errors in billing a specific type of service) Provider-specific (probe): When atypical billing patterns are identified  

How the MR Process Works: Initiating Documentation Requests Postpayment Review: Providers receive record request letters directly from the CGS MR Department via standard mail. Widespread Prepayment Review: Notification of widespread prepayment review initiated by the CGS MR are posted on the CGS Website and ListServ. Provider Specific Prepayment Review: If the provider is undergoing a prepayment review initiated by CGS MR, the provider will receive a notification letter from the Medical Review Department.

Responding to Documentation Requests Providers have 30 days to respond to requests for medical records. If documentation is not received within 45 days, the claim will be reviewed based on information at hand. If medical records are necessary for a determination and not received, the services will be denied.

How the MR Process Works: Submitting Documentation Providers have three options for submitting documentation. Fax Mail Electronic Submission of Medical Documentation (esMD)

How the MR Process Works: Faxing Documentation A cover sheet is provided for all post-payment review record requests; complete the cover sheet provided. Place the cover sheet and a copy of the record request letter on top of the documentation, ensuring the cover sheet is the first page of your fax. Fax to 615.664.5920 Note: CGS can accept any volume of documents via fax. This mechanism delivers your documentation directly to MR without the need for human intervention or sorting, helping to ensure the timely processing of your claims.

How the MR Process Works: Mailing Documentation A cover sheet is provided for all postpayment review record requests; complete the cover sheet provided. Place the cover sheet and a copy of the record request letter on top of the documentation. Please ensure the cover sheet is the first page of your mailing. Mark the mail-piece “Confidential” and send to: Part B Correspondence Attention: Part B Medical Review CGS Administrators, LLC PO Box 20018 Nashville, TN 37202 Note: In accordance with safety precautions suggested by the United States Postal Service, please remember to include your return address on the mail-piece. We will not open any mail that does not clearly identify the sender.

How the MR Process Works: Sending Documentation via esMD A cover sheet is provided for all postpayment review record requests; complete the cover sheet provided. Create and complete one copy of the cover sheet per claim. Identify each claim’s documentation in esMD by entering the Documentation Case ID Number (Doc Case ID Num) found on the Medical Records Request list that accompanies the record request letter.

Electronic Submission of Medical Documentation (esMD) CGS Administrators, LLC. April 1, 2013 Electronic Submission of Medical Documentation (esMD) CMS established a new mechanism for submitting medical documentation to Review Contractors More info: www.cms.gov/esMD Background 2013 Copyright, CGS Administrators, LLC.

Progressive Corrective Action During a probe review (20-40 claims/provider) or a widespread review (100 claims/multiple providers), providers are notified that the review is being conducted and asked to provide documentation for the claims in question. Once the review is completed, providers are notified of their results. If a review verifies that errors exist, it is classified as minor, moderate, or significant. Results determine which corrective actions are needed: Provider education, Prepayment (review prior to payment) review, or Postpayment (review after payment) review, Both pre and post payment review require providers to submit documentation. Once providers have re-established correct billing, they are removed from review.

From recent Medicare audits Key Findings From recent Medicare audits

Signatures in the Medical Record Acceptable forms of signatures: Legible handwritten signatures Handwritten signatures should be legible and the reviewer must be able to determine whose signature is used If signature illegible, use the Attestation Statement: http://www.cgsmedicare.com/kyb/claims/cert/Attestation_form.pdf Or, include a signature log with your documentation Electronic signatures Should contain date and timestamps and include printed statements, e.g., “electronically signed by,” or “verified by,” followed by the practitioner’s name and preferably a professional designation. Digitized signatures An electronic image is an individual’s handwritten signature reproduced in its identical form using a pen tablet.

Signature Guidelines Additional Signature Guidelines CMS MLN Matters article SE1237, “Importance of Preparing/Maintaining Legible Medical Records”: http://www.cms.gov/Outreach-and-Education/Medicare-Learning- Network-MLN/MLNMattersArticles/Downloads/SE1237.pdf CMS MLN Matters article MM6698, “Signature Guidelines for Medical Review Purposes”: http://www.cms.gov/Outreach- and-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/mm6698.pdf

Evaluation & Management Services E/M Services Always bill the most appropriate level of E/M services Upcoding and downcoding are both counted as billing errors New Patient Visits Ensure the patient has not been seen by the same specialty within the same practice in the past 3 years. Know the Guidelines The 1995 E/M guidelines are more general The 1997 E/M guidelines provide more specialty-focused direction. Both sets of guidelines are available on the CMS website http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNEdWebGuide/EMDOC.html

General rules for Documenting E/M Services If it isn’t documented, it hasn’t been done. The medical record should be complete and legible. The documentation of each patient encounter should include: Reason for the encounter; Assessment, clinical impression or diagnosis; Plan of care; Legible identity of the observer along with the date of the signature; This is a common phrase heard in the health care setting. Documentation is an integral part of a patients care. Medical records report the care that a patient received and because of this it is always important to document everything that was involved in the patient’s care. The reason for the encounter should also include relevant history, physical exam findings and prior diagnostic tests. Discuss briefly a what is an acceptable signature and provide information where this information can be found.

General Rules for Documenting E/M Service The rationale for ordering diagnostic and other ancillary services should be clearly identifiable in the record; Health risk factors should be identified; The patient’s progress, response to and changes in treatment and revision of diagnosis should be documented; and The information in the medical documentation should support the diagnosis codes billed.

Selecting the Appropriate E/M Code These steps should be taken when selecting an E/M code: Identify the category or subcategory of the service provided. Review the reporting instructions for the selected category or subcategory according to the CPT book. Review the level of E/M service descriptors. Determine the extent of the history obtained. Determine the extent of the examination performed. Determine the complexity of MDM. Select the appropriate level of E/M service. For example, is this an office visit, an inpatient hospital visit, a skilled nursing facility visit? Then is the patient a new patient or established patient, is it an initial hospital visit or subsequent. All of these things are factors in determining the correct E/M code. When coding the service make sure that the code is reasonable for the nature of the presenting problem. Coding should be based on the nature of the presenting problem and the amount of work needed for the problem not the volume of documentation. For example, you probably would not want to bill a 99215 for a patient who presented with ear pain and has a diagnosis of otitis media even if the volume of documentation caused the code to score out to that.

Insufficient Documentation Medical necessity must always be clearly documented in the patient’s medical record. When documentation is requested, remember to send all relevant information, including orders, plans of care, etc. If documentation is missing a signature, have the provider complete an Attestation Statement, and include it with the documentation.

Other Documentation Issues Scribing: http://www.cgsmedicare.com/kyb/pubs/news/2012/0412/cope18560.html EHR Cloning: http://www.cgsmedicare.com/kyb/pubs/news/2012/0812/cope19795.html Amendments/ Corrections to Medical Records: http://www.cgsmedicare.com/kyb/pubs/news/2012/1212/cope20874.html

Resources

CGS Administrators, LLC. MR Articles April 1, 2013 CGS MR Initiatives Articles on new/ongoing initiatives http://www.cgsmedicare.com/kyb/coverage/mr/Articles.html Published PCA Results Articles KY – CPT code 88305 OH – CPT modifier 25 2013 Therapy Cap Process KY – New Patient Office Visits OH – New and established Home Visits ASC – Claims for Unlisted Codes and Codes Subject to Medical Review KY – Initial Hospital Care OH – Chiropractic Services Scribes KY – Established Office Visits KY/OH – Ambulance HCPCS code A0427 Rule-Out Diagnosis Codes KY – Chiropractic Services Radiology - Physician / Practitioner Order Required SE1123 http://www.cms.gov/MLNProducts/downloads/MCRP_Booklet.pdf 2013 Copyright, CGS Administrators, LLC.

CGS Documentation Checklists The CGS Documentation Checklists are useful tools to assist providers in preparing and submitting documentation. These checklists will help to guide you with the types of information that should be available in the patient's record. We have also included important reminders and citations for the recommended components of documentation in each checklist. http://www.cgsmedicare.com/kyb/coverage/mr/Checklists.html

CGS Documentation Checklists E/M Services Other Services CPT code 99205 CPT codes 99213 - 99215 CPT code 99222 CPT code 99223 CPT code 99232 CPT code 99233 CPT code 99285 CPT codes 99306 - 99310 Advanced Imaging Services Ambulance Services Blepharoplasty Chiropractic Services Home Dialysis Visits Radiation Therapy Services Outpatient Physician Dialysis Visits Physical Therapy Services http://www.cgsmedicare.com/kyb/coverage/mr/Checklists.html

Comparative Billing Reports CMS authorized SafeGuard Services to produce Comparative Billing Reports (CBRs) CBRs are documented analysis that shows a provider’s billing patterns and compares that billing to their peers The purpose of peer comparisons is to allow providers to proactively identify errors in their billing practices Data also available in the new Interactive Website Map Sample Topics Include Physical therapy/KX modifier Chiropractic services Ambulance Podiatry Sleep studies Cardiology services Evaluation & Management Services Advance diagnostic imaging Pain management http://www.safeguard-servicesllc.com/default.asp

Medicare Quarterly Provider Compliance Newsletter Addresses common billing errors and other claim review findings http://cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/ProviderCompliance.html

Questions?