MAKE SURE BILLING AND CODING OPINION IS BACKED UP WITH REFERENCES

ONE OF the saddest things I am involved with on a day-to-day basis are audits. After receiving the information from the doctor on what failed audit and why, the question typically comes up on why they did what they did to create the audit exposure.

Here’s the saddest part: Typically, the audited O.D. is following information he or she got from a chat room or a lecture from a supposed “expert,” but the information presented wasn’t supported by any documentation.

Here is an example:

An O.D. requests specific information about billing medical insurance for topography in a specific geographic location.

The “expert” replies with a CPT code and indicates the diagnosis code is whatever an insurance company is willing to pay for the test.

This expert advice is clearly wrong. One doesn’t manipulate a diagnosis just to get reimbursed from a carrier.

We all know this is wrong and, in fact, when done with intent, changes the aspect of an audit completely from waste and abuse to actual fraud. That is significant.

TECHNOLOGY CHANGES THINGS

The frequency of audits is certainly increasing; it really is a question of when — and not if — any longer, and the monetary demand amounts are skyrocketing as well.

Now, many think it is only CMS to fear on the audit side; that is simply not true. At least 40% of the audits I see involve managed vision care plans. The combination of advancing computer technology, the ICD-10 specificity, and electronic claims submission is making it very easy to identify doctors who are outliers and are billing inappropriately. EHR systems time and date stamp every entry; any auditor will know if the record has been purposely altered or if items were done out of sequence. For example, if the record indicates “ordered fundus photography” on a patient, which should be done after the examination, but the log file shows it was added before the O.D. saw the patient. Now, there is a problem.

KEY TO SUCCESS

The key to success in any of these situations is simple. Don’t follow the herd mentality. Know the rules of the CPT. Know the rules of the ICD. Know the rules of each and every carrier with which one’s practice does business. Don’t rely on some “expert’s” opinion, but make sure any advice is backed up with references for the information presented before employing any recommendations in practice. Not only is it required by law — the survival of one’s practice depends on it. OM

DR. RUMPAKIS is founder, president and CEO of Practice Resource Management, Inc., a consulting, appraisal and management firm for healthcare professionals. Email him at John@PRMI.com.