Why is the government ramping up RAC audits? Health care fraud costs US Taxpayers $60 Billion a year. Federal Agents charged close to 1,500 people last year alone.
Ever wonder why the government is spending more and more money on RAC audits and other fraud detection and deterrence initiatives? Each year it seems the Department of Justice and Office of Inspector General uncover more and more shocking examples of fraud and abuse. In the last year alone the feds have arrested con artists who steal Medicare numbers from the elderly in order to submit false claims, doctors that prescribe excessive amounts of controlled substances so they can sell them on the streets, even some who steal federal grant money intended for cancer or autism research. Not only are these acts deplorable and morally reprehensible because they steal money that is intended for the disadvantaged, the poor, and the sick - these criminals cost US Taxpayers $60 Billion (with a B) a year. Tom Costello contributed this report this morning on the Today Show. Be sure to assess your practice for any compliance risks, implement a strong compliance policy, and maintain it. If you uncover any concerns about fraud or abuse, be sure to contact a compliance expert and consider self-disclosure. With the amount of federal dollars being recouped each year (last year alone the federal government recouped $4.5 Billion in fines, penalties, and restitution) you can rest assured that the government will be ramping up its efforts.
Nancy M Enos, FACMPE, CPMA, CPC-I, CEMC
The benefits of Electronic Health Records – a coder’s perspective
Many physicians have been taught to fear a coding audit, and intentionally undercode in an effort to stay under the radar. This leaves the physician two problems: lower reimbursement, and incorrectly coded claims.
The use of an electronic health record provides structured notes, eliminating the risk of omission of documentation required for higher level Evaluation and Management (E/M) Codes. For example, a new patient visit with a new problem, resulting in a moderate risk (two or more stable chronic illnesses, an undiagnosed new problem with an uncertain prognosis or an acute illness or complicated injury) should be reported as a 99204. The American Medical Association (AMA) promotes “risk based coding”, where the Medical Decision Making matches the level of the code reported. For many new patient visits, this means a level 99203 for low risk and 99304 for moderate risk.
How does a physician ensure that the History and Exam components meet the criteria for the level of medical decision making, and code correctly? An Electronic Health Record is the answer. The templates offered by an EHR guide the physician to capture the required information. The History of Present illness is the most important statement, as it sets the stage for justification of the extent of the exam. The Review of Systems should also be supported by the chief complaint. Past, Family and Social History are easily captured or confirmed in the EHR.
The level of exam can be documented by the 1995 (general) or 1997 (specialty) guidelines. It is easier for pertinent negatives to be documented electronically. Beware of overdocumenting using an “auto-negative” feature if all areas are not examined.
Calculating the type if decision making is often confusing. By providing a template field to capture assessments and diagnostic statements, orders and a plan, the “points” can be calculated and the type of medical decision making can be selected.
In addition to the coding values, the EHR also eliminates illegible handwriting which counts against a physician in an audit. If it wasn’t documented, it wasn’t done. If it cannot be read, then it was not documented.
Mike and Nancy are independent consultants and coding educators. They are a mother/son team who are active in local and regional professional organizations.