Cardiovascular Business - July/August 2008 - (Page 28)

Billing & Coding StrategieS › Recovery Audit Contractors ‘RAC’ Up Success By employing recovery audit contractors (raCs), Medicare has collected nearly $440 million in overpayments since the raC program began in 2005. last year, the raCs identified $371 million in improper payments from California, Florida and new York, the three states with the largest number of Medicare claims. the raCs are paid on contingency, so it’s no surprise that approximately 96 percent of the $371 million were overpayments to healthcare providers; the remaining 4 percent were underpayments. the cost to operate the program in 2007 was $77 million, which left a return of $247 million. CMS has decided to make the program permanent and will phase it in gradually over the next two years. Most of the improper payments that the raCs identified occurred when healthcare providers submitted claims that did not comply with Medicare’s coverage or coding rules. More than 85 percent of the overpayments collected and almost all underpayments refunded by the raCs were from claims submitted by inpatient hospitals. the types of errors leading to improper payments, found by the raCs, include: ■ Payments made for services coded incorrectly—for example Medicare is billed for a certain procedure but the medical record shows that a different procedure was actually provided; ■ a healthcare provider is paid twice because the provider submitted duplicate claims; or ■ a claim is paid using an outdated fee schedule. ordinary. One thing to check is coding ratios. For example, a coronary catheterization procedure involves a code for injecting the coronary arteries (93545), along with a corresponding supervision and interpretation code (93556). If those two codes are not close to a one-to-one ratio during an audit, something is not right, according to Marjorie A. Amato, MBA, director of the Business Office Coding Network at MedAxiom, a professional organization based in Neptune, Fla., specializing in helping cardiology practices perform at a higher level. “When we see that expected ratios aren’t met, we teach our clients to dig deeper,” Amato says. In order to be paid for what you do, you first have to ensure that you are billing for every code you can—and at the highest level of the code, Amato says. She culled data from 100 member cardiology practices to determine if they were coding at the proper level. She looked at the E&M (evaluation and management) levels for hospital admissions, hospital consultations, new office visits and office consultations—the four categories available for first-time patients. Each category has various code levels, each level representing a more comprehensive evaluation and, therefore, more reimbursement. Amato found that the 100 practices billed nearly 35,000 units of service for levels 1 and 2. At those levels, the management options are rest, gargling and elastic bandages, she said. She presented this data at a conference in Boston for MedAxiom members and challenged the audience to consider if they really saw 35,000 new cases—initial visits—last year where the conclusion was to gargle and sleep. Further analysis of the data from the same 100 practices indicated nearly 215,000 units of service billed for low level of complexity—again for first-time patients. These are patients, for example, with a stable chronic illness such as well-controlled hypertension. Management options include over-the-counter drugs or physical/occupational therapy. “I question whether or not we really did initial workups on that many people with that low level of acuity,” she says. “Some of them are valid, but I challenged the practices to review their documents to ensure they were making the right choices for the patients they see.” 28 Cardiovascular Business July/august 2008

Table of Contents Feed for the Digital Edition of Cardiovascular Business - July/August 2008

Cardiovascular Business - July/August 2008 Table of Contents First Word Cover Story: Planning for the Ideal Cath Lab Requires the Multidisciplinary Approach Clinical Study Digest: Cell Phone Technology Speeds Ecgs As Real-Time 3d Echo Matures, It Finds a Clinical Niche Ecg Image Management Brings Increased Productivity and Confidence Overcoming Barriers to Cath Lab Inventory Control Maximizing Reimbursement, Minimizing Penalties News & Views Calendar Reader Resources The Back Page

Cardiovascular Business - July/August 2008

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