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How to Develop and Use Physician Scorecards to Audit/MonitorScorecards to Audit/Monitor

Physician Compliance

A d i M C t ti MHA CHC CPC H CPCAndrei M. Costantino, MHA, CHC, CPC-H, CPCDirector of Organizational IntegrityTrinity HealthTrinity Health

AGENDAAGENDA

I. Trinity Health – Background (Who, What, Where)

II. Current Regulatory EnvironmentIII B h ki (U i D t )III. Benchmarking (Using Data)IV. Provider Scorecard Assessment GridV Auditing ProcessV. Auditing ProcessVI. ReportingVII. Lessons LearnedVIII. ChallengesIX. Wrap-up/Questions

Trinity Health• Fourth largest Catholic health system

in U.S. (based on operating revenue)• 45,000 FTEs

7 300 h i i• 7,300 physicians• 25 Ministry Organizations,

encompassing 44 hospitals (29 owned, 15 management agreements)

• Mostly community based facilities, but also rural access facilities, and some training & academic programs

• 379 outpatient clinics/facilitiesp• Numerous long-term care facilities,

home health and hospice programs, and senior housing communities in eight statesg

• Revenues of $6.3 billion (2008)• $432 million in Community Benefit

Ministry • 323 000 discharges• 323,000 discharges• 7,452,000 outpatient visits

Trinity HealthC li d I t l A dit R tiCompliance and Internal Audit Reporting

TH Organizational &Audit Committee of Board

President & CEO

• Coding professionals (RHIA RHIT CPC)

• All staff certified -CPAs CIAs CISA

SVPOI & Audit Services

(RHIA, RHIT, CPC), RNs

• Avg, 19 yrs experience

CPAs, CIAs, CISA• Avg. experience –

Managers – 13 years, seniors/supervisors - 8

DirectorAudit Services

DirectorOrganizational Integrity

DirectorHIPAA Privacy

23 FTES17 – Financial/operations5 – Information systems

12 FTEs5 – HIM/facility services3 – Professional services1 – PFS/CDM2 – Post-acute care services1 H tli d ti di ti

• Distributed staffing – 16

1.2 FTEs

1 – Hotline, education coordination, other program support

staff located at MO sites• 19 at Home Office

The “Big Picture”• A brief history of how we got here:

– Early 90s: Reports estimate 10% of health care spending lost to wastehealth care spending lost to waste, fraud and abuse

– Early investigations: home care, skilled nursing DMEnursing, DME

– Federal False Claims Act expanded– Mid-90s: Regulators begin requiring

licompliance programs– HIPAA and BBA: $s for health care

enforcement• Results: Over $21 billion recovered to-

date in False Claims Act cases• 15:1 return on government investment15:1 return on government investment

in health care fraud and abuse enforcement

The “Big Picture”g• Compliance efforts over last 12 years have yielded significant

improvement in Medicare payment error rates• 2008 CMS Medicare rate – 3 6% lowest on record• 2008 CMS Medicare rate – 3.6%, lowest on record• 2008 Medicaid rate = 10.5%

14 20%

16.00% Payment Error Rate14.20%

11.80%

10.10%

12.00%

14.00% Linear (PaymentError Rate)

2008 rate = $10.4 billion in estimated

payment “errors”

8.40% 8.60%9.40%

8.80%8.00%

5.20%

6.40%

6 00%

8.00%

10.00%errors

3.60%3.90%

4.40%

2.00%

4.00%

6.00%

Source: Centers for Medicare and Medicaid Services Report –“Improper Medicare FFS

0.00%1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Improper Medicare FFS Payments 2008” –11/17/08

The “Big Picture”• No slow-down or reduction in

health care regulatory

The Big Picture

g yenforcement expected

• New administration commitment to reducing health care coststo reducing health care costs

• Appointments to top positions in Justice Department have history in civil enforcementin civil enforcement

• Strong bi-partisan support in Congress

• Enforcement likely to intensify to fund to help support federal and state health care budgetsg

Current/Future Regulatory Environmentg y

• Data Mining / Transparency of Data– Medicare

• Recovery Audit Contractors (RACs)• Comprehensive Error Rate Testing (CERT)• Comprehensive Error Rate Testing (CERT)

Program

– Medicaid• Medicaid Integrity Program• Payment Error Rate Measurement (PERM)• Medicare – Medicaid Match Program (Medi-Medi)g ( )

– OIG• High dollar inpatient and outpatient demand letter

– Unprecedented level of scrutiny of organizations and their business practices

Who’s Who in Health Care Enforcement

• Recovery Audit Contractors (RACs) NewM di id I t it C t t (MIC ) N• Medicaid Integrity Contractors (MICs) New

• Medicare Administrative Contractors (MACs) New– Replacing Fiscal Intermediaries and Carriers– Responsible for both Part A and Part B claims– Accountable by CMS for reducing payment errors to

providers on front-end Z P I t it C t t (ZPIC ) N• Zone Program Integrity Contractors (ZPICs) New– Data mining and analytics

• Health Care Fraud Prevention and Enforcement Action Team (“HEAT”) New( HEAT ) New

• Medicare Fraud Strike Teams New• HHS - Office of Inspector General (OIG)

D t t f J ti (DOJ)• Department of Justice (DOJ)

Quote from the Movie Armageddon:

“You know we’re sitting on four million pounds of fuel one nuclearmillion pounds of fuel, one nuclear weapon and a thing that has 270 000 moving parts built by the270,000 moving parts built by the lowest bidder. Makes you feel good doesn’t it?”good, doesn’t it?”

Fraud Enforcement and Recovery Act of 2009 (FERA)2009 (FERA)

• Signed into law on May 21, 2009• Directed primarily at enforcement of mortgage, financial andDirected primarily at enforcement of mortgage, financial and

securities fraud. • Includes amendments to Civil False Claims Act (FCA), the primary

law used in health care enforcement• Key Points:

– Establishes clear liability under FCA for improper retention of government overpayments

– An entity violates the FCA if it “knowingly and improperly avoids or decreases an obligation” to pay money to the United States…including “an established duty arising from…the retention of any overpayment”of any overpayment

– Expands bar on retaliation against employees to include contractors or agents

– Expands statute of limitations for government to investigate FCAExpands statute of limitations for government to investigate FCA complaints

Current/Future Regulatory EnvironmentFi i l R l ti hi ith Ph i i• Financial Relationships with Physicians– Applicable Federal laws/regulations

• Stark LawStark Law• Anti-Kickback Statue• IRS Intermediate Sanctions

Fi i l l ti hi i l d Stark– Financial relationships include:• Employment• Professional services

StarkLaw

A i• Leases • Recruitment• Practice acquisitions

Intermediate Sanctions

Anti-Kickback Statute

• Practice acquisitions• Gifts and benefits

– Laws overlap in many areas, differ in others ki li ith ll 3 t lmaking compliance with all 3 extremely

challenging

Current/Future Regulatory Environment• Quality of Care and Compliance

– New Era: Pay for PerformanceQuality data and reporting– Quality data and reporting

– Quality → Payment → Compliance– Future compliance enforcement will

f di l itfocus on medical necessity, appropriateness of care

– False claims theory– Organization focus– Compliance program scope– Board oversightg

• Best Practice: periodically review the questions provided for di i ith i l d hidiscussion with senior leadership

Brown Dog AnalogyBrown Dog Analogy

B D A lBrown Dog Analogy

Brown Dog AnalogyBrown Dog Analogy

CERT – Types of Errors

• No Documentation • Insufficient Documentation Errors • Medically Unnecessary ServicesMedically Unnecessary Services • Incorrect Coding• Other Errors

Top 20 Services with Incorrect Coding Errors: Carriers/DMERCs/FIs/QIOs

CERT – Types of ErrorsTop 20 Services with Incorrect Coding Errors: Carriers/DMERCs/FIs/QIOs

C i (HCPCS) DMERC (HCPCS) FI

Incorrect Coding Errors

Projected 95%Carriers (HCPCS), DMERCs (HCPCS), FIs (Type of Bill), and QIOs (DRG)

Paid Claims Error Rate

Projected Improper Payments

95% Confidence Interval

Office/outpatient visit est (99214) 5 5% $244 047 384 5 0%-6 1%Office/outpatient visit, est (99214) 5.5% $244,047,384 5.0%-6.1%

Subsequent Hospital Care (99233) 16.8% $220,483,945 14.7 – 18.9%

Office/outpatient visit, est (99215) 18.6% $128,689,331 16.1% - 21.1%Office/outpatient visit, est (99215) 18.6% $128,689,331 16.1% 21.1%

Office Consultation (99244) 17.5% $120,385,360 14.2% - 20.8%

Office/outpatient visit, est (99213) 1.7% $75,715,227 1.4 – 1.9%

Office/outpatient visit, new (99204) 20.8% $66,046,693 16.8 – 24.8%

Office/outpatient visit new (99245) 19 1% $65 230 754 14 3 – 23 9%Office/outpatient visit, new (99245) 19.1% $65,230,754 14.3 23.9%

Office/outpatient visit, new (99203) 10.4% $42,348,998 7.9 – 12.9%Source: Centers for Medicare and Medicaid Services Report “Improper Fee-for-ServicePayments Report – May 2008.

CERT - Types of ErrorsCERT Types of Errors

Top 20 Services with Underpayment Coding Errors: Carriers/DMERCs/FIs

Underpayment Coding Errors

Carriers (HCPCS), DMERCs (HCPCS), and FIs (Type of Bill)

p y g



95% Confidence Interval

$Office/outpatient visit, est (99212) 5.6% $33,330,715 4.3 – 6.8%Office/outpatient visit, est (99213) 0.6% $28,360,087 0.5 – 0.8%Office/outpatient visit, est (99211) 6.3% $9,832,148 3.4% - 9.1%

Source: Centers for Medicare and Medicaid Services Report “Improper Fee-for-ServiceP t R t M 2008Payments Report – May 2008.

Impact of One Level E/M (Top 20)CERT - Types of Errors

Final E/M Code

Incorrect Coding Errors



95% Confidence Intervaly

Office/outpatient visit, est (99214) 5.0% $220,880,955 4.5% - 5.5%

Office/outpatient visit, est 1 6% $71 980 640 1 4% - 1 9%(99213) 1.6% $71,980,640 1.4% 1.9%

Office/outpatient visit, est (99215) 9.4% $65,134,620 7.9% - 10.9%

Office/outpatient visit estOffice/outpatient visit, est (99212) 4.8% $28,451,777 3.7% - 5.9%

Office/outpatient visit, new (99204) 8.9% $28,299,570 6.3% - 11.5%

Office consultation (99244) 4.1% $28,179,950 2.8% - 5.4%Office/outpatient visit, new (99203) 6.9% $28,099,040 5.2% - 8.6%

Office consultation (99243) 4.7% $23,554,867 3.3% - 6.1%Source: Centers for Medicare and Medicaid Services Report “Improper Fee-for-ServicePayments Report – November 2008.

Carrier - Comparative Billing Report

• Comparative Billing Report (CBR) – the CBR will compare individual provider data toCBR will compare individual provider data to jurisdictional group data.

• If errors are identified:• If errors are identified:– The provider may submit a corrected claim with

the appropriate billing and/orpp p g– Submit a voluntary refund to Medicare.

• If no significant change in the individual provider’s billing patterns, a provider-specific probe review may be performed.


Summary For Billing Provider XXXXXXand procedure codes 99211 99215

p g p

and procedure codes 99211 - 99215E/M

CODEBilling Provider's Percent

Allowed Of TotalPeer Groups' Percent

Allowed of Total

99211 5.77% 2.70%99212 5.98% 12.73%99213 24.79% 66.32%99214 54.06% 16.91%99215 9 40% 1 34%99215 9.40% 1.34%Total 100.00% 100.00%

Impact of Increased Government Attention on E/M Coding

• Many physicians are afraid to code correctly for fear that they lack the correct documentation or don’t quite understand the processdon t quite understand the process.

• A common response by physicians when shown the correct way to code and document is:the correct way to code and document is:

“What will happen when my profile shifts to reflect thesehigher levels of service? Won’t this attract greater scrutinyand maybe get me in trouble?”a d aybe get e t oub e

Impact of Increased Government Attention on E/M Coding

• Physicians may under code, particularly in the primary care areas in part as a response to documentation and compliance pressures. It is easy to comply with documentation and

li It i t l ithcompliance pressures. It is easy to comply with documentation requirements when reporting a code that reflects less work than actually performed.P id th i t ti t th i diti t• Provide the services to patients as their condition warrants, code the service correctly, document the service correctly, and invite any and all auditors, payers, and regulators to come inspect your workinspect your work.

• Medicare carrier pre-payment audits, post-payment audits, and private payer requests for supporting documentation should be viewed as an opportunity to demonstrate your good work on allviewed as an opportunity to demonstrate your good work on all fronts.

Benchmarking Physician PracticeBenchmarking – Physician Practice

• Use of Benchmark Data– See how your organization compares– See how your organization compares– Establish goals/targets– Make your case for additional resourcesMake your case for additional resources– Develop audit plans– Target risk areasTarget risk areas– Develop compliance scoring system

Benchmarking Physician PracticeBenchmarking – Physician Practice

• Goal of benchmarking is to determine where the physician practice or physician is based upon peers and to determinebased upon peers, and to determine whether additional focus or safeguards need to be implemented by the physician p y p ygroup.

Note: Just because a physician is outside of peer group does not necessarily mean a physician had done anything inappropriatedone anything inappropriate.

CMS Data• 100% summary of all Part B Carrier claims

processed through the Common Working Fil d t d i th N ti l Cl iFile and stored in the National Claims History Repository

• One year behind• One year behind • The file is arrayed by

– CarrierCarrier – Pricing locality– HCPCS– Modifier – Specialty– Type of serviceType of service– Place of service

CMS Data• Sources

– Various consulting companiesVarious consulting companies• Manipulated data• Workable format• Cost – up to $2,000.00

– CMSR d t• Raw data

• Requires advances database skills to manipulate• Cost - $250.00Cost $250.00• Request form available at:

http://www.cms.hhs.gov/NonIdentifiableDataFiles/06_PhysicianSupplierProcedureSummaryMasterFile.asp

CMS Data – What To Do With ItCMS Data What To Do With It• Developed a normal distribution graph (bell curve)

– National– Regional– Carrier

• Compiled internal physician data from all Trinity Health Physician Network practicesPhysician Network practices

• Developed a normal distribution graph (bell curve) by practice and by physician

• Compared Trinity data with CMS data• Analyze data to develop risk and audit strategies• Use data for physician scorecard

99211 99212 99213 99214 99215

Benchmarking

Carrier 2 6 64 25 3Physician 2 3 39 55 1Practice 1 2 74 23 0

BenchmarkingOffice Visit - Established Patient

All Data Points

80

50

60

70

age

Carrier

20

30

40

Perc

enta Carrier

PracticePhysician

0

10

99211 99212 99213 99214 99215

CPT CodeCPT Code

Provider Scorecard Assessment Grid

• The purpose is to see at-a-glance how an individual provider or practice is progressing with their E/Mprovider, or practice is progressing with their E/M coding and documentation. This tool offers several benefits including:

S ifi f di d d t ti th t d• Specific areas of coding and documentation that need attention.

• Assistance with knowing where to focus limited coding resourcesresources.

• Method for scheduling future provider coding education. • Establishing benchmarks across Trinity Health.

Good article to read for more information is: “A New Twist to Coding and Compliance Efforts: The Provider Ranking Assessment Summary “ by Michael P. Reiling, Principal and CEO, and Anne L Smith Principal Fredrikson Healthcare Consulting LTD contact information is:Anne L. Smith, Principal, Fredrikson Healthcare Consulting. LTD., contact information is: [email protected]

Provider Scorecard Assessment GridProvider Scorecard Assessment Grid

Th id d t id• The provider scorecard assessment grid ranks the provider into the following three areas:

– Net Reimbursement Results– E/M Bell Curve Analysis– Overall Documentation Quality

Category I: Net Reimbursement Resultsg y

• Points are assigned based on the net reimbursement results on E/M code assignmentresults on E/M code assignment.

• The net reimbursement results compares the actual billed reimbursement amount for E/M services to the derived

i b t t f th ditreimbursement amount from the audit. • By using net reimbursement it takes into account

overcoding, undercoding, unbilled services, unbillable g, g, ,services, and wrong category.

– 6 points = 90% or greater accuracy– 4 points = 80% or greater accuracyp g y– 2 points = 70% or greater accuracy– 0 points = less than 69% accuracy– The net reimbursement result analysis has a 50% weight.The net reimbursement result analysis has a 50% weight.

Category I: Net Reimbursement Results

ProviderBilled

ReimbursementDerived

Reimbursement Difference

Net Reimbursement

ResultsABC PracticeDr. Fine 794.77 212.46 582.31 26.73%Dr. Howard 595.33 573.61 21.72 96.35%Dr. Welby 238.13 238.13 0 100.00%Dr. Carter 191.44 191.44 0 100.00%P ti S bt t l 1 819 67 1 215 64 604 03 66 81%Practice Subtotal 1,819.67 1,215.64 604.03 66.81%

DEF PracticeDr. Burns 595.33 546.96 48.37 91.88%Dr. Seuss 646.68 408.54 238.14 63.17%Practice Subtotal 1,242.01 955.5 286.51 76.93%Practice Subtotal 1,242.01 955.5 286.51 76.93%

GHI PracticeDr. Hibbert 1,733.36 957.39 775.97 55.23%Dr. House 1,868.02 1,343.52 524.5 71.92%Practice Subtotal 3,601.38 2,300.91 1,300.47 63.89%

JKL PracticeDr. Doctor 595.33 549.92 45.41 92.37%Dr. Howser 646.68 623.97 22.71 96.49%Dr. King 646.68 501.94 144.74 77.62%Practice Subtotal 1 888 69 1 675 83 212 86 88 73%Practice Subtotal 1,888.69 1,675.83 212.86 88.73%

Category II: E/M Bell Curve Analysisg y y

• A comparison of each provider’s utilization of the CPT E/M codes in comparison to a peer group inCPT E/M codes in comparison to a peer group in the same specialty and region. Points are assigned based on how far a provider deviates onassigned based on how far a provider deviates on a percentage basis from the peer group’s norms that they are being measured against.

– 3 points = Less than a 15% deviation– 2 points = between 16% - 25% deviation– 1 point = between 26% - 44% deviation– 0 points = greater than a 45% deviation

The E/M bell curve analysis has a 25% weight– The E/M bell curve analysis has a 25% weight.

99211 99212 99213 99214 99215Fine 0 7 41 49 2National 4 8 59 26 3Region 3 8 62 25 2

99211 99212 99213 99214 99215Fine 0 7 41 49 2National 4 8 59 26 3Region 3 8 62 25 2

Percentage deviation calculation is:Region 3 8 62 25 2

Carrier 2 6 64 25 3Network 0 2 44 52 2

Region 3 8 62 25 2Carrier 2 6 64 25 3Network 0 2 44 52 2

calculation is:64% - 41% = 23%23% / 64% = 35.94%

BenchmarkingOffice Visit - Estblished Patient

Dr. Fine / Family Practice

50

60

70

Fine

20

30

40 NationalRegionCarrierNetwork

0

10

99211 99212 99213 99214 99215E/M CPT Codes

Category III: Overall Documentation Q litQuality

13 point scoring systemp g y1. Correct date-of-service (1pt)2. Legible (1pt)3. Correct diagnosis(es) reported on encounter form to documented g ( ) p

diagnosis(es) in medical record (1pt)4. Proper use of student and/or scribe documentation (2pts)5. Documentation present for a consult (2pts)p ( p )6. Percentage time spent documented for time based code or

counseling visit (2pts)7. Documentation authenticated by signature, stamp or electronically

(2 pts)8. Documentation present for ordered diagnostics or ancillaries (2pts)

The overall documentation quality analysis has a 25% weight.

Overall Score• After the provider scorecard assessment grid is

performed a summary form is completed toperformed a summary form is completed to provide an overall score. The scoring is as follows:

– Outstanding 11-12 points: Routine OI follow-up– Good 8 – 10 points: Internal follow-up audit with report

to LinC– Fair 4 – 7 points: Focused OI/internal audit in 6-9 p

months– Poor < 4 points: 100% pre-bill review or the review will

be placed under attorney client privilege (ACP)be placed under attorney client privilege (ACP)

Provider Scorecard Assessment Grid –Reporting

• Overall results for the Provider Network– Network scorecard in the executive summaryy

• Provider Network detailed findings with corrective actionscorrective actions

• Practice scorecardsIndividual provider scorecards with analysis• Individual provider scorecards with analysis

Practice ScorecardS d C t iScorecard Categories

Net E/M OverallReimbursement Bell Curve Documentation

Results Analysis Quality Scoring

Provider

Dr. Fine 6 3 1 10

Dr. Howard 0 3 0 3

Dr Welby 2 1 2 5Dr. Welby 2 1 2 5

Dr. Howser 0 3 0 3

Practice 2 3 1 6

SCORINGOutstanding 11-12 points Routine OI Follow-upGood 8 - 10 points Internal follow-up audit with report to LinCFair 4 - 7 points Focused OI/internal audit in 6-9 monthsPoor < 4 points 100% review/ACP

CATEGORY I: Net Reimbursement CATEGORY II: E/M Bell Curve CATEGORY III: OverallResults Analysis Documentation Quality6 points = 90% or > accuracy 3 points = < 15% deviation 3 points = 90% or > accuracy4 points = 80% - 89% accuracy 2 points = 16% - 25% deviation 2 points = 80% - 89% accuracy2 points = 70% - 79% accuracy 1 point = 26% - 44% deviation 1 point = 70% - 79% accuracy0 points = < 69% accuracy 0 points = > 45% deviation 0 points = <69% accuracy



70

10

20

30

40

50

60

Perc

enta

ge Dr. FineCarrier

Network

Net Reimbursement Results: 96.35% 6 pointsE/M B ll C A l i 50% 0 i t

Scorecard assessment:7 i t

099211 99212 99213 99214 99215

CPT Code

The overall results were fair/good. Dr. Fine is an outlier compared to his peers with regards to billing CPT 99214 in comparison to CPT code 99213, but the

E/M Bell Curve Analysis: 50% 0 pointsOverall Chart Documentation Quality: 74% 1 point

7 points = Fair Results

results of the record review showed that the documentation supports the E/M level billed. This is a good example of when a physician is considered an outlier in the eyes of CMS and will come under scrutiny by the Part B Carriers but the audit results support the level of coding.

Opportunities exist for improvement in the reporting of the diagnosis code on the encounter form to the documented diagnosis in the medical record.

We recommend periodic internal reviews of CPT code 99214 and education on th i t f ICD 9 dthe appropriate use of ICD-9 codes.

E/M Bell Curve Analysis

• If the provider is considered an outlier in comparison to his/heroutlier in comparison to his/her peers and the documentation supports the deviation from thesupports the deviation from the norm then the provider will receive th f ll th i tthe full three points.



70

10

20

30

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60

Perc

enta

ge Dr. FineCarrier

Network

Net Reimbursement Results: 96.35% 6 pointsE/M B ll C A l i 50% ( t d) 3 i t


099211 99212 99213 99214 99215

CPT Code

The overall results were good. Dr. Fine is an outlier compared to his peers with regards to billing CPT 99214 in comparison to CPT code 99213, but the results of

E/M Bell Curve Analysis: 50% (supported) 3 pointsOverall Chart Documentation Quality: 74% 1 point

10 points = Good Results

the record review showed that the documentation supports the E/M level billed. This is a good example of when a physician is considered an outlier in the eyes of CMS and will come under scrutiny by the Part B Carriers but the audit results support the level of coding.

Opportunities exist for improvement in the reporting of the diagnosis code on the encounter form to the documented diagnosis in the medical record.

We recommend periodic internal reviews of CPT code 99214 and education on th i t f ICD 9 dthe appropriate use of ICD-9 codes.


Dr. Howard / Family Practice

80

1020304050607080

Perc

enta

ge Dr. HowardCarrierNetwork

Net Reimbursement Results: 63.17% 0 pointsE/M B ll C A l i 50% ( t d) 3 i t


010

99211 99212 99213 99214 99215

CPT Code

The overall results are poor. Dr. Howard is an outlier based on her usage of E/M code 99214 in comparison to her peers. The results of our review show that the d t ti t th E/M d 99214 Th f D H d i d

E/M Bell Curve Analysis: 50% (supported) 3 pointsOverall Chart Documentation Quality: 58% 0 points

3 points = Poor Results

documentation supports the E/M code 99214. Therefore, Dr. Howard received the full three points in the E/M Bell Curve Analysis category. This is a good example of when a physician is considered an outlier in the eyes of CMS and will come under scrutiny by the Part B Carriers but the audit results support the level of coding.g

The poor results are attributed to an intern or student primarily documenting services without the appropriate supervision and documentation from Dr. Howard.

We recommend education on the correct way to document and supervise studentsWe recommend education on the correct way to document and supervise students and interns when a physician is acting as a teaching physician and education regarding the appropriate use of ICD-9 codes.


Dr. Welby / Internal Medicine

70

0

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Perc

enta

ge Dr. WelbyCarrierNetwork

Net Reimbursement Results: 71.92% 2 pointsE/M Bell Curve Analysis: 38% 1 point

Scorecard assessment:5 points =

99211 99212 99213 99214 99215

CPT Code

The overall results are fair to poor. Dr. Welby is an outlier based on his usage of E/M code 99214 in comparison to his peers. The results of our review show that

E/M Bell Curve Analysis: 38% 1 pointOverall Chart Documentation Quality: 86% 2 points

5 points Fair Results

the documentation does not support the E/M code 99214 in most cases. Since Dr. Welby is an outlier he will be under the scrutiny by the Part B Carriers and since the audit results do not support the level of coding the Carriers could perform a provider-specific probe review. Our results also showed that when a consultation was billed the documentation supported a subsequent hospital careconsultation was billed the documentation supported a subsequent hospital care E/M service.

We recommend internal periodic reviews of E/M codes 99214 and consultation E/M codes, education regarding the definition and requirements that must be documented to support billing consultations and education regarding the appropriate use of ICD-9 codes.


Dr. Howser / Family Practice

2030405060708090

Perc

enta

ge Howser

Carrier

Network

01020

99211 99212 99213 99214 99215

CPT Code

Th ll lt W f d dit CPT d 99215 d

Net Reimbursement Results: 26.73% 0 pointsE/M Bell Curve Analysis: (22%) 3 pointsOverall Chart Documentation Quality: 68% 0 points

Scorecard assessment:3 points = Poor Results

The overall results are poor. We focused our audit on CPT code 99215 and 99213 because of the unusually high volume in these codes. We reviewed five charts that were billed with CPT code 99215 and discovered that all five charts should have been billed using the preventive medicine CPT codes and in particular CPT code 99397 (Preventive Medicine 65 years and older). Three p ( y )out of the five charts reviewed billed with CPT code 99213 should have been billed with CPT code 99214.

We recommend a 100% internal review of CPT code 99215 and 99213.


Dr. No / Family Practice

100

2030405060708090

100

Perc

enta

ge ProviderCarrierNetwork

01020

99211 99212 99213 99214 99215

CPT Code

O ll lt t t di F b ll l i D N i billi

Net Reimbursement Results: 111% 6 pointsE/M Bell Curve Analysis: (48%) 3 pointsOverall Chart Documentation Quality: 100% 3 points

Scorecard assessment:12 points = Poor Results

Overall results are outstanding. From our bell-curve analysis, Dr. No is billing a significantly higher number of 99213s and fewer 99214s. We recommend periodic review and discussion with Dr. No to determine if this is a matter of under documentation when the acuity of his patients do indeed warrant the billing of more 99214s. g

Scorecard CategoriesNet E/M Overall

Reimbursement Bell Curve DocumentationReimbursement Bell Curve DocumentationResults Analysis Quality Scoring

Provider

Doolittle 2 3 1 6

McDreamy 6 *NA 3 *12

Grey 4 *NA 2 *8

Practice 4 3 2 9

SCORINGOutstanding 11-12 points Follow-up audit by OI every other yearGood 8 - 10 points Internal follow-up audit with report to LinCFair 4 - 7 points Focused OI/internal audit in 6-9 monthsPoor < 4 points 100% review/ACP

CATEGORY I: Net Reimbursement CATEGORY II: E&M Bell Curve CATEGORY III: OverallResults Analysis Documentation Quality6 points = 90% or > accuracy 3 points = < 15% deviation 3 points = 90% or > accuracy4 points = 80% - 89% accuracy 2 points = 16% - 25% deviation 2 points = 80% - 89% accuracy2 points = 70% - 79% accuracy 1 point = 26% - 44% deviation 1 point = 70% - 79% accuracy0 i 69% 0 i 45% d i i 0 i 69%

*E/M records were not reviewed for Dr. McDreamy or Dr. Grey. Therefore, the E/M bell curve analysis is not applicable to their overall score. Based on the 12-point scoring scale, the Net Reimbursement Results and the Overall Documentation

0 points = < 69% accuracy 0 points = > 45% deviation 0 points = <69% accuracy

g ,Quality scores were weighted accordingly to arrive at a comparable overall score (See individual physician analysis).

B e n c h m a r k in gO ff ic e V is it - E s ta b lis h e d P a t ie n t

M c D r e a m y / O b G yn

8 0

1 02 03 04 05 06 07 0

Perc

enta

ge P ro vid e r

C a rr ie r

N e tw o rk

Net Reimbursement Results 94% 6 points Scorecard assessment:

09 9 2 1 1 9 9 2 1 2 9 9 2 1 3 9 9 2 1 4 9 9 2 1 5

C P T C o d e

E/M Bell Curve Analysis: N/A*Overall Chart Documentation Quality: 91% 3 points

12 points* = Outstanding Results

Overall results are outstanding. Dr. McDreamy appears to be an outlier in the E/M bell-curve analysis in comparison to his OB/GYN peers. Due to his y p pOB/GYN specialty and our analysis of his reimbursement distribution across all billed CPT codes, focus was given to the review of obstetric services when choosing our sample. No E/M services were included in this review in order to validate supporting documentation.

*Therefore the E/M Bell Curve Analysis is not applicable to his overall score. The Net Reimbursement Results and the Overall Chart Documentation Quality were weighted based on the 12-point scale (score x 1.33) to arrive at a comparable overall score.

We recommend internal review of E/M codes 99212, 99213, and 99214 to validate supporting documentation for the billed codes.

BenchmarkingInpatient ConsultationsDr. Freud / Psychiatry

90

100

10

2030

40

50

60

7080

Perc

enta

ge Dr. Freud

Carrier

Netw ork

Net Reimbursement Results 46.80 0 points Scorecard assessment:

0

10

99251 99252 99253 99254 99255

CPT Code

E/M Bell Curve Analysis: (3)% 3 pointsOverall Chart Documentation Quality: 81% 2 points

5 Points = Outstanding Results

Overall results are fair. The net Reimbursement Results Score was lowered by under-documented Evaluation and Management services and services not y gbillable due to missing dates of service. The bell-curve analysis for inpatient consultations shows Dr. Freud to be an outlier in comparison to his peers in the billing of CPT code 99254. The medical record review of Dr. Freud’s documentation revealed that it does not consistently support billing that level of service Therefore Dr Freud’s may be subject to scrutiny by the Part Bof service. Therefore, Dr. Freud s may be subject to scrutiny by the Part B Carrier. Also, there are some opportunities for improvement in the documentation and reporting of diagnoses.

Recommendations included physician education, discussion with transcription to ensure documentation of dates of service and a internal audit in 6 monthsto ensure documentation of dates of service and a internal audit in 6 months.

The ProcessThe Process

• Gathering and manipulating data• Gathering and manipulating data– Filter, Sort, Subtotal

• Sampling Method– Before and AfterBefore and After

• Audit database– Reports

The Process: Gathering andThe Process: Gathering and Manipulating data

• Gathering and manipulating data– We receive physician data from all of the Trinity

Physician Network practicesPhysician Network practices• Encompasses previous year of billed professional

services• Sort by physician CPT codes• Sort by physician, CPT codes• Subtotal by reimbursement and count

– Compare Trinity data with CMS data– Develop a normal distribution graph (bell curve) by

practice and physician– Analyze data to develop risk and audit strategiesAnalyze data to develop risk and audit strategies

The Process: Sampling Method Before and After…• Prospective vs. Retrospective audit• Random vs. Judgmental sample

– Focus on Government payers– OIG Work Plan– Issues identified by Ministry Organization – Noted findings at other Organizations

Previous audit findings– Previous audit findings– Usually a few services account for 70% - 80% of net revenue– Goal is to review services that make up 60% to 80% of net

revenue• Ten records per provider vs. Limited sample sizes• There is a chance that not all physicians will be reviewed• Three year cycle review vs. Yearly follow-up

The Process: Sampling MethodT i it H lthTrinity Health Physician NetworkSample Selection

Number Medicare Medicare of

Population Audit Audit Sample RecordsPractice Physician Reimbursement Reimbursement Percentage Selection in Sample

Family Practice - Happy Valley

Doogie Howser $155,386 $125,067 80.49% 99213 499214 499215 3

Derek Pain $8 873 $0 0 00% NONE 0Derek Pain $8,873 $0 0.00% NONE 0

Marcus Welby $128,170 $104,599 81.61% 99213 499214 5

Larry Fine $60,343 $47,786 79.19% 99213 399214 3

Totals $352,772 $277,452 26

Total Audit % 78.65%

The Process: Audit Database

Reporting: Format

• Sections– Executive SummaryExecutive Summary– Table of Contents

Background– Background– Findings/Corrective Action

Sampling Techniq es– Sampling Techniques– Analysis of Sample

Reporting: Presentation of p gResults

• Discuss general findings• Network results

– Network scorecard• Practice results

P ti d– Practice scorecard• Provider results

– Provider scorecardsProvider scorecards• Recommendations for process improvement• Corrective actionsCorrective actions

Reporting: Follow upReporting: Follow-upSCORING

• Follow-up – Outstanding Results

F ll dit b OI th

Outstanding 11-12 pointsGood 8 - 10 pointsFair 4 - 7 pointsPoor < 4 points

• Follow-up audit by OI every other year– Good Results

• Internal follow-up– Fair Results

• Focused internal/OI audit in 6-9 months– Poor ResultsPoor Results

• 100% pre-billed review

Y ll d d ’ll i !• Yellow and red we’ll see again!

Lessons Learned

• Timing is everything– Requesting data

Ch i th l– Choosing the sample– Obtaining documentation

• Retrospective sample• Retrospective sample• Verbiage• Bell-curve deviation scoringBell curve deviation scoring• Specialties

– OB/GYN in Family Practicey

Challenges

• Size of network and sample• Potential payback issues• Potential payback issues• Follow-up education• New providers• Specialists• Specialists

Challenges: EMR• Check boxes and Templates• Cut and Paste• Cut and Paste• Cloning

Challenges: EMR• Education / Training

A diti• Auditing• Data Analysis CPT

CodeTypical Time fory

– Physician paid claims– CPT codes volume Date of

Code Time for Code

99212 10 minCPT codes, volume, Date of Service

– MGMA Visit Data 75th, 90th

99213 15 min

99214 25 min99215 40 min

– Outlier?– How many visits per day?

99215 40 min

Challenges: EMR - Example

ChargesTotal 99214 & % of CPT Code Distribution Percentageg

Physician Charges 99215 Total 99211 99212 99213 99214 99215

Dr. High Volume $1,278,062 $881,176 68.95% 0.01% 3.15% 5.01% 55.54% 36.29%

Port Huron - Physician Group Practice AnalysisFamily Practice - Dr. High Volume

70.00%

40.00%

50.00%

60.00%

PracticeCarrier

0 00%

10.00%

20.00%

30.00%CarrierDr. High Volume

0.00%99211 99212 99213 99214 99215

Challenges: EMR - Example(A)

Total (240 days) Total (240 days) (B)Visits Average 99214 & Average MGMA (A - B)

All Visits 99215 Visits 90th % DifferenceAll Visits 99215 Visits 90th % DifferenceLevels Per Day Visits Per Day Visits Visits

11,677 49 9,724 41 25 24

Port Huron - Physician Group Practice AnalysisFamily Practice - Dr. High Volume

70.00%

40.00%

50.00%

60.00%

PracticeCarrier

0 00%

10.00%

20.00%

30.00%CarrierDr. High Volume

0.00%99211 99212 99213 99214 99215

Challenges: Potential Payback Issues

• Inappropriate use of NPPsInappropriate use of NPPs– Billing “incident to” at a provider-based clinic– Billing services provided by NPPs as “incident to”

for new patient visits or new conditions• Wrong POS on claims – provider-based clinic

vs freestanding officevs. freestanding office• Inappropriate or no documentation for

supervision of residents when acting as a TPp g• Inappropriate use of student documentation• Billing services for one physician under g p y

another physician’s billing number

Challenges: Follow-up Education

• Providing cost-effective education– Trinity Health provides pre-recorded audio-

conferences (hcPro AHIMA and Decision Health)conferences (hcPro, AHIMA, and Decision Health) on the Trinity Health intranet website

• HealthStream• Other education

– Who performs• Internal vs External• One-on-one education

• Timeframee a e

Reality

Questions?

Questions/Discussion

• Thank-You for Your Attendance and Participation!p

• Follow-up questions can be directed to:

Andrei M. Costantino, MHA, CHC, CPC-H, CPCDirector, Organizational Integrity

Trinity Health(248) 324-8479

[email protected]

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