Surviving the Pitfalls

Aka Medicare fraud Two nationwide Hospitalist groups have been charged with Medicare Fraud for upcoding in the past few years Not a huge deal if you have tens of millions of dollars laying around to give to CMS and don’t mind committing a crime

How does this happen? Two ways: 1) Systemic to a group (i.e. Here’s how WE bill/code) 2) Individualized (i.e. Here how I bill/code)

Documenting to: support a charge Versus Documenting to: Support what was medically necessary and only able to be provided by you (a physician with multiple years of training and licensure)

Remember that there’s a difference between what the Insurer is paying us to do and what the Hospital is paying us to do For example, the hospital pays us for things like multi- disciplinary rounds, answering/documenting responses to queries, etc Insurer pays for medical care that is required for your expert medical care of their patient

Remember that we have internal audits to try to ensure our docs are billing/coding appropriately If you document what a patient told you, what you found on examination, what the medically necessary things were that you had to do in order to care for that patient and then billed them accordingly, you didn’t commit fraud

There are a lot of factors that go into this History of Present Illness (number of elements) Review of History (past medical/surgical, social, family) Review of Systems (number of systems) Physical Exam (number of systems) Review of Data (number of points) Assessment and Plan (number of points) Level of Complexity / Medical Decision Making (Low, Moderate, High)

There is no quick and easy metric for figuring this out Literally thousands of possible permutations to a note when accounting for these multiple factors For example, 3 HPI elements, 6 ROS, 3 Histories, 8 organ systems, 4 data points, 3 points in A&P, Moderate complexity vs…

However, document what you did/asked/discussed and what was necessary to your care of the patient An appropriately thorough and good evaluation and examination will generally be a Level II or Level III H&P or follow up What usually determines Level II vs Level III is the degree of complexity in medical decision making

Moderate Complexity vs High Complexity Short way to remember it is High Complexity generally means “threat to life and limb” Doesn’t have to be a critically ill patient, but… Day 3 on a Heparin gtt for PE or Day 4 on 2 liters O2 for pneumonia doesn’t make for a patient with threat to life and limb

Would be unusual to have threat to life and limb but no change to care Transition from med/surg tele to intermediate level of care Increasing nasal canula O2 to non-rebreather on intermediate floor Checking EKG to confirm a-fib with RVR and starting Cardizem gtt on 3 heart

Each problem that you bill for must be something that you are actively managing (different from actively reviewing) Critical Care patient with respiratory failure on a vent Acute Renal Failure requiring hemodialysis Post MI / Cardiac arrest with stent placed Day 3 of patient here for COPD exacerbation with known HTN but blood pressures well controlled and no change in meds

Note the difference in H&P vs Progress Note At time of admission, I may be managing the atrial fib because I’m starting a Cardizem gtt or Heparin gtt while the person is tachycardic However, on Day 2 or 3, Cardiology may now be managing this or I’m transitioning off Heparin to Pradaxa, but the patient is stable and has no other acute medical problems

Multiple (potential) confusing factors Difference (in insurers’ eyes) between Consult and Medical Management Consult is about a specific problem (e.g. OB consults us specifically for a postpartum patient’s elevated blood pressures) Medical Management is about general management of chronic medical problems (even if there is an acute issue or question, like elevated blood pressures or pre-op clearance)

Some insurers let you bill for Consults, others don’t Some insurers let you bill a MM Consult as an H&P (Level I), others don’t Some surgical patients are Inpatient, some are Observation Our coders will change an erroneous code to the appropriate code for us

If Medicare patient, you can bill as a Level I H&P (if appropriate) Post op left TKA with HLD vs post op left TKA with DM, HTN, chronic rate controlled a-fib Bill as Inpatient/Observation Follow up for all other patients according to usual standards for this

Using a Consult note versus a Progress Note Doesn’t affect billing My personal preference of Consult note is because info on the initial page (i.e. Past Medical History, Surgical History, Family History, Social History) is all carried forward for future admissions Reasons not to do it that way EPIC is coming in less than a year Consult note can take more time It really annoys Mary (maybe a reason TO do it?)

Billing and Coding is how you are paid, BUT… Don’t overthink it (go with the Don Deep “gut” test) Do not document solely to support a charge (it’s called fraud and we don’t have tens of millions to give to the government) We take care of sick patients, so many of them are Level II or III; high vs moderate complexity will usually determine which Generally will bill a consult the same way you would an average follow up patient you’re seeing for the first time