American College of Cardiology

Create a Compliance Program
On its Web site, the College has posted—

• A model compliance guide,
• An evaluation and management services self-audit form, and
• A sample log for tracking compliance plan development.

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(FEBRUARY 2000) Larry Lehrner, MD, knows all too well what it feels like to get hit with a Medicare audit. A few years back, a Medicare carrier visited the office of the Las Vegas physician to scrutinize dozens of charts for "referrals" that the carrier insisted the group had incorrectly billed as "consultations."

To defend his group's coding practices, Dr. Lehrner sent the carrier reams of documentation, including letters the group had sent to the physicians who had requested consultations. Lengthy discussions and chart reviews finally convinced the carrier that there wasn't a problem.

"We went round and round. Finally, they backed off," said Dr. Lehrner. "It was a nightmare."

With the government's renewed emphasis on stamping out fraud and abuse, physicians everywhere worry that an honest billing mistake may lead to an audit from their Medicare carrier, fines, and, even worse, scrutiny from the Office of the Inspector General (OIG), the federal office charged with enforcing health care fraud and abuse laws.

Although the government has stepped up its investigations into fraud and abuse, experts say most billing problems are ironed out between physicians and their local Medicare carriers before they reach a critical stage. Of those cases that do reach the attention of the OIG, only a fraction involve physicians.

Still, even a small-scale audit by your local Medicare carrier is usually a painful process that you are better off avoiding. So, what can you do to make sure that your bills comply with Medicare regulations, or how can you better position yourself in case you are audited? Here are some tips from Medicare compliance experts:

Get the Codes Right
Make sure that your CPT codes (those that indicate services rendered) match the services rendered, and that your ICD-9-CM codes (those that indicate diagnosis) support any ancillary services you have ordered.

A common error is to bill all office visits at the same level. Experts say that nothing raises a red flag among auditors more than a physician who overuses one particular level of service.

To avoid coding errors, many consultants contend that only the physician should write down the appropriate code, in part because the physician is ultimately liable for any errors. "Generally speaking, when the doctor delegates coding to other people, you're going to have more mistakes in the system," said Neil B. Caesar, JD, president of the Health Law Center in Greenville, S.C.

Write Down Everything
A few words on a scratch pad will no longer suffice. You must be able to prove the scope of the medical history covered, the extent of the physical examination, and the complexity of your medical decision making. In other words, you should be prepared to prove to an auditor that the encounter you coded at level 4 really was a level 4.

In your progress notes, be sure to discuss assessments, diagnoses, and plans for care. If you asked for a family history, for example, then say so in the notes. "Document the negatives," said Alice G. Gosfield, JD, a health care lawyer in Philadelphia. "If you looked at some system and it was normal, write it down. For example: 'Heart rhythm and rate regular.'"

Some practices use template encounter forms that list various systems or procedures. Experts caution, however, that simply checking off all of the items on a template (or running your pen from the top of the form to the bottom to indicate that you covered all areas) may be as risky as not documenting at all. The government might assume that you simply check off such items routinely and conclude that your forms do not reflect specific encounters.

"I write a thousand things more than I know are medically needed in my chart," explained Dr. Lehrner. "Anyone who has any sense now is spending time and effort making sure there's enough black on the white page to impress the reviewers."

Demonstrate Medical Necessity
In addition to recording your encounters, carefully document the reasons for all ancillary services, including what you ordered and the diagnosis that prompted you to order them.

"A lot of physicians think the reason a test is ordered can be inferred from the progress note," said William A. Sarraille, JD, a partner with the Washington law firm Arent Fox. "Go the extra step, and make it explicit."

Include the results of all tests in the patient's record. When an auditor asks for information, Ms. Gosfield said, "Don't say, 'We just sent the progress notes; we didn't include the lab slips.'"

Audit Your Practice Regularly
A baseline audit can help uncover documentation problems. Mr. Caesar recommended sampling 20–50 charts per physician and having an outside reviewer interview key people at your practice.

Mr. Sarraille likes to examine practices from a patient's perspective, from reception to checkout. He notes how charge sheets are transferred from the physician to billing staff and whether staff members code visits based on information in the record or whether they return to the physician with questions.

Another strategy is to conduct regular smaller audits. Each physician, for example, might audit three of his partners' charts each month. "By making the sample small, you make this a manageable task," Mr. Sarraille said. "By doing it frequently, you keep issues in front of people on a constant basis."

Create a Compliance Program
An official compliance program that outlines policies and procedures in writing will help ensure that you follow through on training, audits, and other steps. It also shows a goodwill effort that the OIG may take into account in the event of an audit.

Although the OIG has yet to produce a model compliance program for physician offices, there are a number of models to follow. The publication Health Information Management Compliance: A Model Program for Healthcare Organizations suggests that compliance programs should include written policies that outline coding procedures (e.g., the steps a coder should take when reviewing a health record), a compliance officer responsible for monitoring the plan, and a formal system for filing complaints from patients and staff. (For more on this and other publications, visit http://www.ahima.org.)

Maintain Good Patient Relations
"The single best thing physicians can do to protect themselves from liability, assuming they are moderately competent at the technical dimension of the craft, is to stay on good terms with their patients," said M. Gregg Bloche, JD, professor of law at Georgetown University and co-director of a joint program in law and public health with The Johns Hopkins School of Medicine. Patients are more likely to complain to Medicare if they are upset with their doctors, he noted.

The Health Care Financing Administration (HCFA) requires physicians to educate patients about services Medicare does not cover. General internist Yul D. Ejnes, MD, publishes a practice newsletter that explains Medicare's position on specific areas of health care, such as HCFA's decision to cover cholesterol testing only for patients who have been diagnosed with high cholesterol.

"My point is to explain to the patients that this is Medicare's policy, that we're not miscoding or doing anything that's not medically sound, and that their insurance does not cover certain things," said Dr. Ejnes. "We state quite frankly that we're not going to commit fraud to get tests covered."

This column is an edited version of an article that originally appeared in the September issue (Vol. 19, No. 8) of ACP-ASIM Observer, which is published by the American College of Physicians-American Society of Internal Medicine in Philadelphia. The article is printed here with permission.

Get the Codes Right

Create a Compliance Program