Becker's ASC Review

40 CODING & BILLING Payers Increasing Scrutiny of Coding Compliance By Alison Kuley, CPC, Coder, National Medical Billing Services I n September 2014, the U.S. Dept. of Health and Human Services' Office of the Inspector General (OIG) published its audit of Tulare Regional Medical Center, an acute care hospital in California. In its findings, federal investigators determined the "hospital did not comply with Medicare billing requirements for all 10 of the outpa- tient surgery claims we reviewed, resulting in an overpayment of $178,647," according to the final OIG report. As a result of the coding mistakes, the Central Valley hospital gave back the $180,000 to Medicare, public filings show, and paid an un- disclosed amount to internally address the underlying revenue cycle management issues that caused the problem. And Tulare's woes are hardly unique among outpatient providers. Previous OIG investiga- tions during the past decade have uncovered widespread coding com- pliance issues in outpatient surgery facilities across the United States. In fact, in a 2010 OIG report focusing only on ambulatory surgery center (ASC) services for skilled nursing facility (SNF) patients, fed- eral auditors estimated that "Medicare contractors nationwide made at least $6.6 million in overpayments to ASCs for services subject to consolidated billing." "ASCs were either unaware of or did not fully understand consoli- dated billing requirements," the OIG concluded in its report on SNFs. "In some instances, ASC officials stated that they were unaware that the exclusion of certain intensive hospital outpatient procedures from consolidated billing requirements…does not apply if the services are performed in ASCs." With highly complex rules and requirements seemingly changing by the day, a widespread lack of awareness about coding compliance is a continual challenge for many ASCs. As referenced in the OIG's re- port, it's oen a simple lack of education; other times, it's having the right systems and processes in place to ensure a center is following the rules. Regardless, the penalties can be severe: Depending on the payer, ASCs risk claims denials, audits, fines, exclusion from federal payer programs and even prison time for failing to follow compliant coding practices at their facilities. Best practices: compliant coding "Trust, but verify." President Ronald Reagan's famous quote is the guiding principle of compliant coding: No matter what's listed in the superbill or charge- master, all bills should be checked against the operative note to guar- antee 100 percent compliance. In the event of a payer audit, any pro- cedure not documented in the operative notes cannot be supported or submitted for reimbursement. Unbundling, or breaking down procedure codes into individual codes, also is a red flag for payers. For example, facilities frequently overuse Modifier 59, which the U.S. Centers for Medicare and Medicaid Ser- vices (CMS) advises should be "used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances." "Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive inju- ries) not ordinarily encountered or performed on the same day by the same individual," CMS states. Upcoding, or listing procedure codes not performed or documented, also can land a provider in hot water. Just remember: If it's not documented, it's not billed. In cases where there is no specific code for a procedure, an unlisted procedure code from that body system should be reported, and the appropriate documentation should be provided. Be familiar with your payer guidelines when reporting unlisted codes and the supporting docu- mentation they would like submitted with the claim. Increased scrutiny Both Medicare and private payers have ramped up their scrutiny of ASC-based coding in recent years. At the same time, more and more difficult procedures are being performed in an outpatient setting, which has created industry-wide inconsistencies and uncertainty. In its 2016 Work Plan, the U.S. Dept. of Health and Human Services' OIG announced it was looking into a variety of ASC-related issues, including payment methodology, ICD-10 implementation and anesthesia service coding, specifically related to whether a physician or an advanced-practice nurse administered the anesthesia, which affects reimbursement. Cost-cutting measures also are forcing payers to look more closely at coding than perhaps they may have in the past. If issues arise, pay- ers oen deny a claim and may request an audit if they suspect wide- spread errors or abuse. While denials can be disruptive and hurt a facility's cash flow, Medicare's penalties are numerous and decidedly harsher than those handed down by insurance companies. "OIG also conducts investigations involving organized criminal activ- ity, including medical identity the and fraudulent medical schemes established for the sole purpose of stealing Medicare dollars," the OIG's 2016 work plan states. "Investigators are seeing an increase in individuals, including both healthcare providers and patients, engag- ing in these healthcare fraud schemes. ose who participate in these schemes may face heavy fines, jail time, and exclusion from participat- ing in federal healthcare programs." Collaborative approach Running afoul of coding rules, however, is not a foregone conclusion. Implementing best practices and fostering a collaborative work envi- ronment can eliminate many coding compliance risks. For example, if documentation is unclear, or there's something missing in the op- erative report, the physician should be consulted for confirmation. At times, the physician may need to provide an addendum to the opera- tive note before the case is coded and appropriately billed. is team-based approach also will help facilities position themselves to address coding compliance issues that inevitably will rise in the coming years. While its 2017 Work Plan was unavailable as of this publication's deadline, the OIG did indicate in a mid-year update that it expects to issue guidance in the new year on one issue of particular importance to ASC billing and coding operations: ICD-10. "We will review aspects of CMS' management of the implementa- tion of the 10th version of the International Classification of Diseases (ICD-10) codes in Medicare Parts A and B," the OIG wrote in April 2016. "is may include reviewing CMS' and its contractors' (e.g., MACs) assistance and guidance to hospitals and physicians and as- sessing how the transition to ICD-10 is affecting claims processing, including claims resubmissions, appeals, and medical reviews." n

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