The goal of this article is to help you gain an understanding of the various governmental auditing programs and help to ensure you and your RCM team are working together and can avoid an external audit.
Working with your revenue cycle management team is key to maintaining compliance with coding and billing requirements. The anesthesia record should tell the story of your encounter with the patient. It is the communication between the anesthesia provider and the coder. Not only are we looking for supporting documentation of the surgical procedure and diagnosis, but we are reviewing types of providers on the case and ensuring documentation supports various models such as medical direction and teaching. We are reviewing the documentation of your ancillary services and ensuring your services are authenticated with a signature.
Ask yourself, are you receiving requests for additional information from your coding team? What types of information are they requesting? Information requests are not only needed to ensure we can properly code and bill the service, but they should also be considered an opportunity for the provider to correct deficiencies, and volumes for such requests should be decreasing over time if providers remain aware.
The goal of audit programs processed through the Centers for Medicare and Medicaid Services (CMS) is to identify improper payments. Anesthesia providers are not immune from audits by CMS. Over the years we have seen specific audits that have targeted anesthesia services. Some of them include:
- The improper use of anesthesia payment modifiers to reflect personally performed cases vs. medically directed or supervised
- Anesthesia performed for pain management procedures
- Overuse of modifiers, specifically in chronic pain management and the use of modifier 25 for an evaluation & management service on the same date as a procedure
- Chronic pain management services
- Ultrasound guidance for needle placement
- Accurate reporting of anesthesia time
From a management perspective, we must remain informed of changes in coding and carrier policies. We review our resources to identify what may be on the audit horizon. Some of the resources include:
- The OIG Work Plan. The Office of Inspector General work plan includes active items of audits and evaluations as well as archived items. The site is updated monthly and is fairly easy to review. Work Plan | Office of Inspector General | U.S. Department of Health and Human Services
- Targeted Probe and Educate (TPE). CMS began the TPE program in 2014 and then in 2017 authorized the Medicare contractors (MACs) to conduct reviews utilizing a TPE review. Their goal is to identify errors and work with providers for improvement. They use data to identify providers that have high claim error rates or unusual billing practices. The TPE programs can be found on your MAC website. A simple understanding the program can be found here. IMPROVING THE MEDICARE CLAIMS REVIEW PROCESS
- Local Coverage Determinations. These are policies issued by CMS and their Medicare contractors outlining specific items or services to determine if they are a covered service. There are several LCDs related to anesthesia services, and they could vary depending on your Medicare contractor. Some include monitored anesthesia care, TEEs, pain management as well as anesthesia for pain management services. Local Coverage Determinations | CMS
- Medicaid and Commercial Carrier Policies. These would be specific to your state and Insurance plan. We dive into the requirements for anesthesia billing and documentation guidelines in place by your state carriers to ensure compliance with documentation, coding and billing requirements.
THE VARIOUS AUDIT PROGRAMS
MACs – Medicare Administrative Contractor
- MACs are private companies, usually subsidiaries of large insurance companies, that have contracted with CMS to administer the Medicare program.
RAC – Recovery Audit Contractor
- RACs are private companies contracted by CMS to identify Medicare overpayments and underpayments.
CERT – Comprehensive Error Rate Testing
- The CERT program was created by CMS to measure the paid claims error rate for claims submitted to Medicare. CERT Documentation Contractors (CDCs) are retained by CMS.
PERM – Payment Error Rate Measurement
- The PERM program measures improper payments in Medicaid and CHIP and produces error rates for each program
UPIC – Unified Program Integrity Contractor (Formerly ZPIC)
- UPICs are private companies contracted by CMS to conduct audits for Medicare and Medicaid overpayments to detect and then recover possible fraudulent activities.
It is important to maintain an action plan in the event of an audit.
- Audit letters are received via mail. Sometimes they may be sent to a providers’ physical location. Be sure to contact your RCM team immediately upon receipt. Dates identified for returning information are crucial.
- Work together with your RCM team to ensure all medical records are pulled at the facility.
- Track dates submitted and confirmation of receipt.
- Do a self-audit of the records in question. This review should not delay the submission of information for the audit.
Needless to say, it is not on anyone’s bucket list to go through a carrier audit. Therefore, partnering with your RCM team to understand any documentation deficiencies and cure them as well as having a plan to address an audit should one occur. Avoiding a CMS audit could be possible by ensuring you are actively engaged and understanding your data.
Lynn Cook, CHC serves as vice president of anesthesia practice management for Coronis Health. Ms. Cook has over 35 years’ experience in healthcare management with the majority devoted to anesthesia. Lynn is a high-performing business leader with substantial experience in anesthesia operations, regulatory compliance and education with the ability to analyze and address complex issues and implement workable solutions. She is certified in Compliance Healthcare through the Health Care Compliance Association. Lynn can be reached at lynn.cook@coronishealth.com