Let’s face it: every payer—whether that be a commercial insurance company or a government health plan—employs or contracts with auditors. And an auditor’s job—their sole raison d'etre—is to find errors in your medical record documentation and/or claim submission. Most auditors are reputable and responsible and are paid based on a salary or fee per record reviewed. But there are some auditors who are paid based on a percentage of the money they are able to recover on behalf of their client. Recovery audit contractors (RAC auditors) are utilized by every Medicare administrative contractor (MAC) and by all 50 state Medicaid programs. These RAC auditors are financially incentivized to find mistakes in your record documentation, because they pocket a portion of the amount they say you owe back to the government.
With this in mind, it might be helpful for our readers to know the types of targeted audits that the government has been spearheading within the last year. Below are a few examples.
Kyphoplasty and Vertebroplasty
Performant Recovery, Inc. (PRI) is one of the Medicare RACs and is known to have been recently targeting kyphoplasties and vertebroplasties for audit. Several pain practices have received “additional documentation requests” (ADRs) to facilitate the conducting of these audits. As some of our chronic pain clients know, the Medicare policies, known as local coverage determinations or “LCDs,” that pertain to these procedures typically require the patient to have a pain score of five or greater. Due to this RAC focus, pain physicians who are performing these procedures should consider refamiliarizing themselves with their MAC’s LCD relating to kyphoplasty and vertebroplasty. The associated LCD for one of the MACs (Novitas) contains numerous medical necessity requirements in the "Clinical Indications" section, along with onerous documentation requirements. Remember that auditors will utilize LCDs in the review of your medical records, so you have to be rigorous in following the stipulations found therein.
Evaluation and Management Services
First Coast Service Options is the MAC for Florida. This Medicare contractor has recently been conducting “targeted probe and educate” (TPE) audits of evaluation and management (E/M) code 99204. Many of our readers may not be aware of the concerns associated with a TPE review. There can be up to three rounds of these audits, each involving perhaps 20 to 40 of your claims. If a provider fails all 3 rounds, your MAC will refer you to the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS), at which time you could be placed on a full prepayment review status. According to one compliance attorney, this means “you don’t get paid anything for any code unless an actual human being physically audits each claim and approves it, which takes an inordinate amount of time and will kill your cash flow.”
First Coast selected a certain Florida doctor for the 99204 audit, claiming the provider had “higher dollars per beneficiary over the jurisdictional average,” which is another way of saying he was billing a higher incidence of this code than what Medicare would expect. Medicare has found that interventional pain providers are billing 99204 at the rate of 68 percent of the time after the new E/M coding rules took effect in 2021. So, if you are coding 99204 in excess of 75 percent, for example, in your Medicare cases, that might trigger a TPE audit.
Modifier 25
As many of our readers know, modifier 25 allows you to bill an E/M visit on the same day as you bill a procedure, provided that the E/M visit is deemed to be significant and separately identifiable from the procedure billed on that date and does not act as part of the pre-procedure E/M service (H&P) built into the procedure. Whether the E/M meets these criteria and is separately billable will ultimately be up to the payer.
If you have a high percentage of procedures where modifier 25 is billed, Medicare tracks that and could initiate audits. A long-time compliance attorney has noted the following:
After dealing with Medicare auditors on this issue, it is obvious that there is a material disconnect between what clinicians believe is significant and separately identifiable as opposed to what Medicare coders think. So, word to the wise: if you believe you have a separately identifiable problem from the problem addressed by the procedure you are billing, it is incumbent upon you to “spoon feed” to the auditor its significance. You can do that by having something about that problem in the patient's complaint, the HPI, the exam, the assessment and the plan. Since medical decision-making (MDM) billing is primarily based on the assessment and plan, you will want to spend some time assessing that problem and documenting in your plan how to treat it.
Anesthesia for Chronic Pain
We know of at least one anesthesia group that has recently undergone a TPE audit due to submitting a large number of cases involving anesthesia for chronic pain injections, such as ESIs or facets. Medicare LCDs have indicated that receiving payment for such services is problematic, at best. The TPE “chief auditor” indicated that the extensive billing of anesthesia for these pain blocks is what triggers these audits and, if the providers do not pass the third round of such audits, they could lose their ability to smoothly submit any claims to Medicare. It is therefore incumbent upon all our clients to be extremely judicious when it comes to billing these services.
In summation, our readers would do well to consider the general implication woven throughout these paragraphs. Aside from the particulars of the auditors’ focus as listed above, here is the main takeaway: providers should assume that every service they perform and every record they complete is a potential target of some avid auditor’s intense scrutiny.