Tips for avoiding a Medicare Audit
Tips for avoiding a Medicare Audit
ACP-ASIM advice for avoiding trouble
It’s no secret that the government is paying much more attention to physician coding and billing practices in an effort to ferret out fraud and abuse.
This means it’s even more important than ever that practices pay close attention to their coding and claim filing procedures. As those practices that have been there will tell you, having to go through even a small-scale audit by a local Medicare carrier can be a painful process.
Here are some tips from the American College of Physicians-American Society of Internal Medicine (ACP-ASIM) on keys to avoiding the specter of a Medicare audit.
• Get the codes right. Make sure that your CPT codes indicating services rendered match the services actually rendered — and that your ICD-9-CM codes indicate diagnosis support of any ancillary services ordered.
• Don’t bill all office visits at the same level. Nothing raises a red flag for auditors like a physician who over uses one particular level of service.
Tip: Even intentionally under-coding patient visits in an effort to avoid scrutiny can attract the auditors, since they expect to see a variety of different codes being filed.
• Pinpoint responsibility. Many experts say only a physician should write down the appropriate code. This eliminates the hassle of having your staff guess what codes were intended based on sparse notes or past practice. Bottom line: When the doctor delegates coding to other people, you end up with more coding mistakes.
• Write everything down. A few words on a scratch pad won’t work when it comes to documentation. In today’s compliance climate, you must be able to prove the scope of the medical history covered, the extent of the physical exam, and the complexity of your medical decision making.
When making progress notes, for instance, you should discuss assessments, diagnoses, and plans for care. If you asked for a family history say so in the notes. "Document the negatives," says Alice G. Gosfield, a health care lawyer in Philadelphia. "If you looked at some system and it was normal, write it down. For example: Heart rhythm and rate regular.’"
• Beware of templates. Because they find the documentation requirements for HCFA’s evaluation and management (E/M) guidelines so burdensome, some practices use template encounter forms that list various systems or procedures.
Warning: Simply checking off all the items on a template — or running your pen from the top of the form to the bottom to indicate that you covered all areas — may be as risky as not documenting at all, advises the ACP-ASIM. In fact, a government auditor might even assume you just routinely check off such items and start wondering if your forms really reflect what happened in specific encounters.
That’s why it’s critical to add handwritten notes if you use a checklist. You don’t even have to use complete sentences. But it is critical that physicians actually hand write something at each of the locations on the template where they’re documenting the service, advise most experts.
• Demonstrate medical necessity. In addition to recording encounters, carefully document the reasons for all ancillary services, including what you ordered and the diagnosis that prompted you to order them, suggests the ACP-ASIM. You want to do this because you can’t assume your reasoning for ordering a particular test or service will be clear to an auditor who might be reading the file months, even years, later.
Spell it out
"A lot of physicians think the reason a test is ordered can be inferred from the progress note," says William A. Sarraille, a partner with the Washington law firm Arent Fox. "The reality is that the people doing the auditing have different backgrounds than physicians. What they will infer and what the doctor [implies may be] different things. Go the extra step and make it explicit."
Tip: Include the results of all tests in the patient’s record. If an auditor asks for information, send everything you have."
• Audit your practice regularly. A baseline audit — done internally or with the help of a consultant — can help uncover documentation problems.
• Create a compliance program. Now that the OIG has issued its compliance guidance for solo and small practices, there’s no excuse for not using these guidelines to start an organized in-house compliance program.
• Maintain good patient relations. Outside of knowing their specialties, one of the best things physicians can do to protect themselves is to stay on good terms with their patients, says M. Gregg Bloche, professor of law at Georgetown University. A patient who is upset with his or her doctor is more likely to complain to Medicare about their treatment, he says.
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