Will You Be Able to Keep Your Medicare Payment After An Audit?

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information. However, HMP Communications and the authors do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received. The ultimate responsibility for verifying coding, coverage, and payment information accuracy lies with the reader.

As this author has traveled around the country this year to provide reimbursement education to wound care professionals at local, regional, and national wound care workshops and symposiums, the following comments are often made by many wound care professionals, program directors, clinical managers, billers, and/or coders:

• “I always bill evaluation and management (E&M) visits/clinic visits on the same day as procedures because I always assess the wound before the procedure. I place modifier -25 on the visit code and always get paid. You are just trying to scare us by telling us about the rules surrounding reporting E&M visits/clinic visits on the same day as procedures.”

• “Our wound care and/or ostomy hospital-based outpatient department (HOPD) is staffed 100 percent by wound ostomy continence nurses (WOCNs). We receive orders from referring physicians and take care of the wound and/or ostomy because we are better trained in wound and/or ostomy care than the physicians.If we need assistance, we call the referring physician and take orders via the phone. You are just trying to scare us by saying we need direct physician supervision in HOPDs.”

• “The physicians who practice in our HOPD document a surgical debridement and report a surgical debridement code at each patient encounter, even when they only debride fibrin, slough, exudate, or biofilm from the wound. When we question them about this and recommend that they bill for selective debridement instead, they tell us ‘those codes are only for therapists and the Medicare allowable rate for those codes is too low.’ The HOPD is supposed to code and bill for the same procedure that the physician documented in the medical record, but the WOCN who assists with these procedures feels she/he should document the level of tissue removed, not the level of tissue that the physician sees in the base of the wound. Will you talk to our physicians about this issue?”

• “The surgeons send their postoperative patients to the HOPD with orders for the WOCNs to change their dressings. That service makes the surgeons happy and brings a lot of volume to the HOPD. You are just trying to scare us by telling us that simple postop dressing changes are typically not a medically necessary reason for an HOPD visit.”

• “Since Medicare now packages the payment for cellular- and/or tissue-based products for wounds (CTPs; [outdated term “skin substitute”) into the HOPD payment for the procedure to apply them, if our physicians want to use a CTP that is not covered by our Medicare Administrative Contractor (MAC), we simply use the Q-code for a CTP that is covered by Medicare, rather than the Healthcare Common Procedure Coding System code assigned to that CTP.  We get paid every time. Why do you keep telling the HOPDs that this coding and billing is incorrect?”

This author could fill every page of this month’s issue of Today’s Wound Clinic with additional misperceptions about wound care coding and billing practices, but the ones listed above are exemplary of practices that lead to claim denials and/or to large repayments. This author hopes that none of these situations pertain to you or to your wound care businesses. The estimated 2014 Medicare fee-for-service (FFS) improper payment rate (the percentage of Medicare dollars paid incorrectly) was 12.7%. This means Medicare overpaid an estimated $45.8 billion. The most common cause of improper payments (60.1%) was “lack of documentation” to support the services or supplies billed to Medicare. NOTE: Hospital outpatient services of all types contributed $3.5 billion to these improper payment rates.

Because all of the regulations that pertain to wound care businesses are publicly available, wound care professionals should have the “playbook” they need. In addition, many reimbursement seminars and webinars that review the pertinent coding, payment, and coverage changes that should be implemented by both HOPDs and qualified healthcare professionals (QHPs) are presented each year. Wound care professionals can also always count on this author to write timely articles about pertinent reimbursement issues. In fact, this author seeks to help wound care professionals to be paid fairly for their excellent work and to be able to keep their payments if/when they are audited. Now, let’s talk about this serious process known as auditing.

First, let’s think about how claims are paid and reviewed. Wound care professionals submit claims to their respective MACs for Medicare FFS payment. The primary goal of each MAC is to pay the correct amount for covered, medically necessary, and correctly coded services. MACs are also responsible for preventing improper Medicare FFS payments through their claims payment decisions and processes.  

Under the authority of the Social Security Act, the Centers for Medicare & Medicaid Services (CMS) employs a variety of contractors, including the MACs, to process and review claims according to Medicare rules and regulations. (See Table 1.)  The overall goal of these contractors is to reduce improper payments by identifying and addressing coding, billing, and coverage errors for all provider types. An improper payment is any payment made in error or in an incorrect amount (including overpayments and underpayments) under statutory, contractual, administrative, or other legally applicable requirements:

• to an ineligible recipient,
• for ineligible goods or services,
• for goods or services not received (except for such payments where authorized by law),
• that duplicates a payment, and/or
• that does not account for credit for applicable discounts. 

While all review contractors have a specific area of focus, each contractor conducting claims reviews must apply all Medicare policies to the claims under review. This is why wound care professionals must know and follow the pertinent Medicare policies when submitting claims to Medicare. NOTE: Once a claim is reviewed, a different contractor should not reopen it.  Therefore, it is important that contractors review each claim in its entirety when conducting claims review. The MACs and other Medicare review contractors perform two main types of claims reviews. Both of these review types can be performed either before or after payment is rendered (ie, pre-payment or post-payment reviews).

• Non-Complex Medical Review: The Medicare review contractor makes a claim determination without clinical review of medical documentation submitted by the wound care professional. This includes a review that requires some form of human intervention to verify claim information and a review that is automated (i.e., done by computer) and does not require human intervention. MACs use this type of review more frequently than complex medical review because of the large number of claims that they must process each year.

• Complex Medical Review: The Medicare review contractor makes a claim determination after reviewing additional documentation associated with the claim. Complex medical reviews for the purpose of making coverage determinations are performed by licensed nurses (registered nurses and licensed practical nurses) or physicians, unless the specific task is delegated to other licensed healthcare professionals. During a complex medical review, nurse and physician reviewers may call upon other healthcare professionals (eg, dietitians or physician specialists) for advice. The MACs cannot perform complex medical reviews on every claim submitted because of the large number of claims that they process. As stated above, some of the Medicare claim review programs review claims before they are processed (pre-payment) and some review the claims after they are processed (post-payment). Table 2 identifies the types of reviews that are conducted pre-payment and post-payment. 

Business Briefs readers are probably aware that this author is particularly concerned about the post-payment reviews that are performed after wound care professionals have been paid. As an example, let’s review the Comprehensive Error Rate Testing (CERT) Program, which is performed by CERT review contractors, CERT documentation contractors, and CERT statistical contractors. CERT contractors randomly select a statistically valid sample of processed Medicare FFS claims and request medical documentation from the wound care professional who submitted the sampled claim. CERT review professionals review the claim and the supporting documentation to determine whether the claim was paid appropriately according to Medicare coverage, payment, coding, and billing rules. Table 3 describes the 5 error categories that CERT contractors identify.  Wound care professionals should ensure their medical documentation and submitted claims do not contain the errors listed in Table 3 because claims selected for CERT review are subject to potential denials, payment adjustments, or other actions depending on the result of the review. 

NOTE: E&M services/clinic visits are one of the top three CERT errors ($4.5 billion) in the country. The type of service, place of service, patient’s status, content of the service, and the time required to provide the service determine the category of E&M/clinic visit service. High errors consisted of insufficient documentation, no documentation, lack of physician signature, and incorrect coding of E&M/clinic visit services to support medical necessity and accurate billing of E&M/clinic visit services. NOTE: Many improper payments for E&M services included those billed using physicians’ national provider identifiers (NPIs), but provided solely by non-physician practitioners (NPPs). Remember: NPPs must bill under their own NPIs if they provide an E&M service (in person) for a physician’s patient in the HOPD and the physician does not also perform (and document) a substantive part of an E&M visit face-to-face with the same beneficiary on the same date of service.

Normal appeal rights and processes apply to CERT reviews. However, in the past wound care providers were often frustrated when they requested a redetermination or reconsideration of claims denied during a post-payment audit. The reason for the frustration occurred when the redetermination or reconsideration found that the claims should not be denied, but the expanded review of the additional evidence or issues resulted in an unfavorable appeal decision for a different reason than the original post-payment denial. GOOD NEWS: CMS recently addressed this frustrating issue by providing direction to the MACs and the review contractors that limits their scope of review for redeterminations and reconsiderations of claims denied following a post-payment review or audit. CMS has instructed MACs and review contractors to limit their review to the reason(s) the claim or line item at issue was initially denied. This instruction applies to redetermination and reconsideration requests received by a MAC or a contractor on or after Aug. 1, 2015, and will not be applied retroactively. MORE GOOD NEWS: CMS goes out of its way to educate wound care professionals on how to comply with rules and regulations in order to avoid claim denials and/or repayments. For example, CMS targets insufficient documentation with the following education, which wound care professionals should incorporate into their personal wound care business education:

• Coordinates provider outreach and education taskforces. These taskforces consist of MAC medical review professionals who meet regularly to develop provider education strategies and materials addressing areas prone to improper payments. The taskforces hold open-door forums to discuss documentation requirements and answer provider questions and distribute informational articles as needed to improve documentation and to educate providers on Medicare policies. The articles are maintained online on the Medicare Learning Network (MLN)^® and can be accessed by the public on the MLN website at www.cms.gov.

• Conducts ongoing education to keep wound care professionals informed about the importance of submitting thorough and complete documentation. This education involves national training sessions, individual meetings with providers or suppliers with high improper payment rates, presentations at industry association meetings, and dissemination of educational materials.

• Publishes articles in the MLN Medicare Quarterly Provider Compliance Newsletter. The articles discuss documentation requirements, CERT findings, and common errors. 

• Publishes MLN’s MLN Matters^® and special edition articles to educate wound care professionals on how to avoid insufficient documentation errors.

• Revises medical record-request letters, as needed, to clarify the components of the medical record required for review. The letter serves as a checklist for wound care professionals to ensure their medical record submission is complete. Follow-up medical record-request letters have also been developed to explain the type of missing documentation needed to be submitted.

SUMMARY

CMS goes to great lengths to publish coding, payment, and coverage regulations and guidance documents. MACs work hard to properly pay submitted claims. MACs and other review contractors work hard to protect the Medicare Trust Fund from paying claims that do not comply with Medicare regulations and guidance. Wound care professionals must take the initiative to read these documents; to read journal articles pertaining to wound care reimbursement; to participate in wound care reimbursement webinars; to attend wound care reimbursement seminars; to attend wound care reimbursement-related sessions at local, regional, and national wound care symposia; and then to incorporate their learnings into their own wound care businesses.

This author gets very concerned when wound care professionals make the misstatements listed at the beginning of this article, do not know the wound care-related Medicare regulations, have not read the Medicare guidance documents, and say things like “we have always done it this way,” or “another wound care professional told me to do it this way,” or “it is not my job to know the coding, payment, and coverage guidelines – I went to college to be a medical professional.” This author encourages all wound care professionals to make it “their business” to know the coding, payment, and coverage regulations that pertain to them so that they can receive correct and adequate payment for the amazing wound care work they perform and so that they can retain that payment if/when they are audited. 

Kathleen D. Schaum & Associates Inc., Lake Worth, FL; and director, medical products, reimbursement, biotherapeutics at Smith & Nephew.)