Billing and coding compliance helps prevent, detect and report errors related to regulations set forth in the U.S. government’s Centers for Medicare & Medicaid Services (CMS). This article serves as an introduction to key concepts of compliance issues and provides guidance in building a critical care audit program.
Fraud and Abuse
Providers and institutions submit claims for Medicare and Medicaid services, thereby becoming responsible for applicable rules and regulations. Training processes for providers should include education on billing and coding and compliance issues. Institutions should screen providers for exclusions and review compliance plans with them on a yearly basis to review expected conduct and to make sure they understand the implications of improper conduct.(1)
CMS considers fraud and abuse a significant threat, and the U.S. government has an interest in mitigating losses to the taxpayer. While the true cost of fraud and abuse is unknown, estimates place it at approximately 3%–10% of the federal plan, or roughly $20–60 billion dollars annually. As a result, the government has instituted measures to recoup losses and to hold individuals and institutions accountable for inappropriate claims, abuse and fraud.
Fraud is defined as knowingly billing for services not furnished or supplies not provided. It includes falsifying records to show delivery of items and billing Medicare for appointments that patients did not keep or services that were not provided. Other examples include knowingly billing for services at a higher level than the services provided or documented.(2)
Abuse is a practice that results in unnecessary costs. It includes practices not consistent with providing patients with services that are medically necessary, meet recognized standards and are priced fairly. Examples of abuse include billing for services that were not medically necessary, charging excessively for services or supplies, and misusing codes on a claim, such as upcoding or unbundling codes.(2)
Fraud and abuse can expose providers and entities to criminal and civil liability. This may include imprisonment, fines and other penalties, such as exclusion from participation in the Medicare/Medicaid programs and loss of professional licenses. In order to mitigate and prevent fraud and abuse, the U.S. government has enforcement and recovery capabilities and promotes self-reporting when errors occur. Federal laws governing fraud and abuse include the False Claims Act, Anti-Kickback Statute, Physician Self-Referral Law (Stark Law), Social Security Act and the United States Criminal Code.(3)
Improvements in decision support software, risk analysis and computer algorithms have helped the U.S. government focus on areas of potential abuse, fraud and billing inaccuracies. The Office of Inspector General of the U.S. Department of Health & Human Services develops work plans each year on areas of focus. One area that may impact critical care is the 2016 Work Plan, which includes a review of the diagnostic-related group of mechanical ventilation as an area of concern for billing inaccuracies.(4) CMS’ Recovery Audit Programs have been very successful in reviewing claims and recovering overpayments for services billed.(5) Providers, entities, individuals and even beneficiaries may also bring action on behalf of the government through qui tam, or whistleblower, provisions. Recovery of money by the U.S. government can result in large settlements with the filing party, potentially collecting 25% of the settlement. Provisions in the False Claims Act also have severe penalties and reimbursement for actions against those who file false claims. A recent case in the southeastern United States has a whistleblower potentially collecting nearly $20 million dollars for filing a suit regarding violations to the Stark Law and the Anti-Kickback Statute.(6)
Developing a Critical Care Audit Program
In order to help mitigate compliance issues, the development of a critical care audit program may be necessary. An important part of such a program is to monitor metrics. Critical care audit metrics involve comparisons across various divisions to look for outliers. One common indicator is a comparison of aggregate data between intensive care units (ICUs), known as inter-ICU comparison. By comparing the average amount of time documented in an ICU as well as the percentage of evaluation and management (E/M) versus critical care time
, deviations can be identified and examined in greater detail. Here, it is important to differentiate between severity of illness and billing differences. Norming with either the Sepsis-Related Organ Failure Assessment (SOFA) or the Acute Physiologic and Chronic Health Evaluation (APACHE) can help identify differences associated with illness versus billing patterns.
Intra-ICU comparisons (among providers within ICUs) are also helpful in differentiating abnormal billing patterns. Given a relatively similar patient population and similar practice style, billing should be relatively similar. A practitioner who bills a higher percentage of E/M or critical care may warrant examination to determine if that practitioner is using common billing rules. It is important to differentiate among practice parameters such as shifts and admission patterns. A nighttime provider may have a higher percentage of critical care time due to the emergent nature of nighttime admissions.
Another area of ICU billing that warrants observation is procedural billing. Procedural billing is complex; there are many procedures with similar descriptions. For example, the Current Procedural Terminology (CPT) code description for a central venous line and a peripherally inserted central catheter (PICC) are very similar. Running a list of procedural billing versus expected CPT codes might show discrepancies in procedures. If your service does not perform PICC insertion, but has providers billing CPT codes for PICCs, it is relatively simple to educate the providers on the correct codes. Depending on which billing software is being used, lists of common procedures can dramatically lower incorrect procedural billing.
Finally, monitoring each of these metrics longitudinally can provide more information. If the billing pattern of a particular provider or ICU is known, it is easier to observe deviations from the norm. Monthly or quarterly reporting of ICU metrics will help show trends and sudden aberrations from normal billing behavior. Overall, billing metrics provide a powerful tool to monitor individual and group behavior. Differences can be rapidly identified and used to target units or individuals for further billing education.(7)
Another important area in critical care reviews is individual chart audits. Chart audits are a necessary part of a compliance program. The primary goal is to ensure that documentation supports the bill submitted. Critical care billing is relatively straightforward, but has a number of required elements to support its use. E/M billing is more complex and has numerous documentation requirements to support correct coding.
One early question to ask is: Which group should do the billing? Using certified coding personnel either during the billing process or as part of an audit team can ensure clear expectations between the coders and the providers performing the documentation. In addition, training providers to perform spot audits has added benefit. Providers are more familiar with descriptive nomenclature and procedural terms. They are also more familiar with steps used to create notes and may identify systemic problems. The number of charts to audit in a given period is open to question. Generally, five to 10 charts will give an auditor a feel for the provider’s overall documentation habits. Both E/M and critical care documentation should be reviewed to make sure the different requirements for each code are met.
Finally, each provider should get feedback on his/her documentation. Providers with specific documentation issues should be provided education on those issues. Common documentation issues should be addressed to the group at large. Longitudinal studies of documentation will help organizations identify persistent weaknesses and better target educational opportunities.(8)
Critical care coding and billing remains a high-risk area of compliance. Understanding the issues surrounding compliance and building a strong internal compliance and audit structure can strengthen the group’s ability to provide good information for potential inquiries. A strong billing and coding compliance program also helps develop a foundation to ensure that the organization is following the law and billing appropriately for services.
1. Office of Inspector General, US Department of Health & Human Services. Health Care Compliance Program Tips. Washington, DC: US Department of Health & Human Services; May 16, 2011. http://oig.hhs.gov/compliance/provider-compliance-training/files/Compliance101tips508.pdf. Accessed February 17, 2018.
2. Centers for Medicare & Medicaid Services. Medicare Fraud and Abuse. Baltimore, MD: Centers for Medicare & Medicaid Services; August 2014. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Fraud_and_Abuse.pdf. Accessed February 18, 2016.
3. Office of Inspector General, US Department of Health & Human Services. A Roadmap for New Physicians: Fraud & Abuse Laws. Washington, DC: US Department of Health & Human Services; date unknown. http://oig.hhs.gov/compliance/physician-education/01laws.asp. Accessed February 18, 2016.
4. Office of Inspector General, US Department of Health & Human Services. Work Plan: Fiscal Year 2016. Washington, DC: US Department of Health & Human Services; 2015. http://oig.hhs.gov/reports-and-publications/archives/workplan/2016/oig-work-plan-2016.pdf. Accessed February 18, 2016.
5. Centers for Medicare & Medicaid Services. Recovery Audit Program. Baltimore, MD: Centers for Medicare & Medicaid Services; last modified November 10, 2015. https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/. Accessed February 18, 2016.
6. Becker S, Gamble M. The Growth of Healthcare Fraud Qui Tam Lawsuits. In: Becker’s Hospital Review. November 26, 2013. http://www.beckershospitalreview.com/legal-regulatory-issues/the-growth-of-healthcare-fraud-qui-tam-lawsuits.html. Accessed February 18, 2016.
7. Centers for Medicare & Medicaid Services. Self-Audit Toolkit: Conducting a Self-Audit: A Guide for Physicians and Other Health Care Professionals. Baltimore, MD: Centers for Medicare & Medicaid Services; February 2015. https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/audit-selfaudit-booklet[April-2015].pdf. Accessed February 18, 2016.
8. Gregory BH, Van Horn C, Kaprielian VS. Eight Steps to a Chart Audit for Quality. Fam Pract Manage. 2008 Jul-Aug;15(7):A3-A8.