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This article first appeared in RACmonitor.
In anticipation of the inevitable RAC investigational expansion of complex reviews into physician services, experts in the industry, as well as CMS itself, have turned our attentions on the Comprehensive Error Rate Testing (CERT) Reports. These reports are a good indicator of what services require additional investigation, but there are a few stops in between a CERT and a RAC that further narrow the focus of the eventual RAC investigation. In my eternal quest for additional information, I came across one such type of study recently, the results of which illuminate the world of physician RAC audits like an H-bomb test on Bikini Atoll.
WPS, the current MAC for Jurisdiction 5 (covering Iowa, Kansas, Missouri and Nebraska) and the legacy MAC for Illinois, Michigan, Minnesota and Wisconsin, released the results of a Service Specific Probe of CPT code 99214 for the specialty of Family Practice. Overall, 100 such services were randomly selected for prepayment review. Of these, 52 were allowed as billed following documentation review. Based on the utilization of this code for Family Practice nationwide being somewhere between 37 and 38 percent of all established patient E/M services, that number appears low. With the internalized belief that we learn from our mistakes, I now present the results of the remaining 48 claims.
The Basics
11 claims were down-coded based on the documentation provided. To briefly review, a level 4 established patient visit requires that two of the following three elements be satisfied by the documentation:
- Detailed history
- Detailed examination
- Moderate medical decision making
While not specifically stated in the CMS E/M guidelines, with established visits, it is always a good idea to have medical decision making be one of the two elements selected. I recommend this based on medical necessity most often being defined based on treatment options selected for the condition being treated. Even in a patient with a list of co-morbidities written on a 3-foot scroll, if a patient has a bit of a rash, the greatest history ever taken and an examination and auscultation of every square inch of a patient is still treating a bit of a rash, and the E/M code selection needs to reflect this.
2 of the claims in the study were determined not to support the billing of an E/M service based on the documentation forwarded by the providers for review. If I had to venture a guess, I would say that these were related to encounters where a minor procedure was planned upon scheduling, the patient presented for the procedure, and the physicians in question billed both a procedure and an E/M service.
Poor Physician Response
The remaining 35 claims represent a different kind of hurdle for physician practices. These claims were denied outright because the providers did not provide the requested documentation for the services within the allotted 45-day period. This study included only 100 claims. If we expand that number out by a few zeroes, apply it to RAC documentation requests and then extrapolate that 35% of physician complex review requests will either be mishandled or ignored, the obvious conclusion is that by virtue of their internal practices, physicians are doing the RACs’ work for them. Who knew doctors had this level of time and altruism on their hands?
Previous Studies
It is important to note that this comes on the heels of two other service specific probes by WPS of CPT code 99233 (level 3 subsequent hospital visit) for the specialties of cardiology and internal medicine. In the cardiology probe, a stunning 97.24 percent of services were billed incorrectly based on the documentation for the service. Of the incorrect claims, 25.5 % were denied for insufficient or incomplete information in received documentation, 16.3% were re-coded to a lower level of service, and a whopping 54.6% of the services reviewed were denied for lack of response to the documentation request. The remaining 3.6% of claim errors in the cardiology study were not deemed to be subsequent hospital visits, but a completely different category of E/M service.
The internal medicine probe resulted in 75.7 percent of services reviewed being billed in error. Of the incorrect claims, 29.3 percent were denied for insufficient or incomplete information in received documentation and 5.5% were re-coded to a lower level of service. The percentage of services denied for lack of response to the documentation request topped out at 65.2 percent.
Part A providers knew the RAC’s were coming, and any facility worth its salt set up processes long ago to respond to RAC requests. It is my personal belief that a connection can be made between provider readiness for RAC audit requests and the so-far successful appeal rate of RAC decisions by Part A providers. A physician practice, in most cases, lacks the organizational infrastructure to prepare to respond in the same way as Part A providers. A solution to response readiness is not — and in many ways, cannot be — a one-size fits-all proposition. A good start would be educating administrative staff to be able to recognize a RAC request upon receipt.
With a 48% error rate in this limited probe, it is safe to say that high level established patient visits are now officially warming up in the RAC bullpen. A surprise occurs when you never see it coming. Like the relief pitcher who replaces the obviously tired starter, we saw them warming up. The RAC’s, in the same manner as the next pitcher jogging in from the outfield, are easy to see.
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The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.