A while back, we received information from a leading healthcare compliance law firm that focuses on anesthesia and chronic pain. They noted that several chronic pain practices across the country had been selected to undergo audits—audits of certain services, in particular. Below is a summation of what they encountered and what may be in store for some of our readers, as well.
Kyphoplasty and Vertebroplasty
As many of you will recall, federal payers, such as Medicare and Medicaid, work with organizations known as recovery audit contractors (RACs). Performant Recovery, Inc. is one such RAC. They implemented a large-scale auditing program involving two procedures in particular: kyphoplasties and vertebroplasties. Several chronic pain practices received additional documentation requests (ADRs) to conduct these audits.
Knowing that at least one RAC has targeted these specific services, it may behoove providers of such services to reacquaint themselves with the rules. Medicare’s local coverage determinations (LCDs) covering these procedures typically require the patient to have a pain score of 5 or greater. Novitas’ LCD, for example, is 23 pages long and contains numerous medical necessity requirements in the "Clinical Indications" section, along with onerous documentation requirements.
Whether the target is kyphoplasties, vertebroplasties or any other service or procedure, this is our recommendation: where it is known that a RAC is targeting a particular service or procedure that you are performing on a regular basis, you should do the following:
- Determine whether or not an applicable LCD exists
- If so, pull it and review it
- Determine whether or not you are currently meeting the LCD standards
- If not, adjust your practice/documentation to ensure you are meeting the standards going forward
The reason the above steps are necessary is that the auditor will scrupulously abide by the LCD, where extant, in determining whether or not payment for your service or procedure is justified.
Evaluation and Management
In Florida, First Coast Service Options—the Medicare administrative contractor (MAC) for that state—has conducted Targeted Probe & Educate (TPE) audits of CPT 99204 (new patient, office or outpatient visits). These audits can be problematic because there are up to 3 rounds of auditing, typically involving 20 to 40 provider claims. If you fail all 3 rounds, your MAC could refer you to the Office of Inspector General (OIG), an agency within the U.S. Department of Health and Human Services (HHS). Such a referral would lead to you being placed on a 100% prepayment review status. This means you won’t get paid for any service code unless an actual human being physically audits each claim and approves it. This, of course, would lead to a significant cash flow issue as it concerns your Medicare cases. One TPE auditor actually said such a referral could mean your right to bill Medicare cases is taken away.
Medicare has statistics showing that interventional pain providers have begun billing 99204 68% of the time after the new evaluation and management (E/M) coding rules took effect in 2021. So, if you are coding 99204 to Medicare in excess of 75%, for example, you could very well be targeted for an audit. It may be that you are perfectly justified in having such a high percentage of cases meeting this E/M level, but your documentation had better support it. Where the E/M level is determined by medical decision-making (MDM), providers should look carefully at the nuanced requirements of each MDM element (e.g., problems, data, risk) to ensure they are meeting the 99204 criteria. Where Coronis Health is under contract to perform the E/M coding, we will ensure the code on the claim is indeed supported by the provider’s documentation.
Modifier 25
Modifier 25 allows you to bill an E/M visit on the same day as you bill a procedure, provided that the visit: (a) is significant, (b) is separately identifiable from the procedure billed on that date, (c) is not part of the pre-procedure E/M service built into the procedure that you are also billing on that date, and (d) can stand on its own as a billable code if everything about the procedure were distinguishable from the visit note. Whether something is “significant” and “separately identifiable” is subjective, and Medicare auditors have historically taken a narrow view of that.
If you have a high percentage of procedures where modifier 25 is billed, Medicare tracks that and will audit outliers. 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 denoting something about that problem in the patient's complaints, the HPI, the exam, the assessment and the plan. Since 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 you propose to treat it.