That stipulation assumes that a professional service was provided by the physician on the patient’s initial visit for that particular medical problem, otherwise the incident-to provision cannot be implemented on a subsequent visit. As Phillips points out, the incident-to billing rule “is certainly not nebulous, but it is confusing to people.”
Consider the case of a regular patient who presents for follow-up on his/her diabetes. “How often do you hear, ‘Oh, by the way…’ and it’s a whole new issue? That just blows incident-to out of the water. There isn’t a patient who sticks to any script. They don’t read the rules,” Phillips says with a laugh.
Technology may, in some ways, exacerbate billing and coding issues that can provoke suspicion on the part of Medicare authorities. Electronic medical records (EMRs) have introduced cloning into a clinician’s documentation process—and that’s not always a good thing.
“People are just reusing the same note over and over, and they’re not necessarily catching the changes, so it looks like a recycled note,” Phillips says. “If I don’t make sure to go in and update every single area, it may look like the same note. If [the patient encounter] is the same, it’s the same, but you’ve really got to watch what you’re documenting and make sure you are following the guidelines.”
Powe also cautions against allowing the cut-and-paste mentality to distract a clinician from doing proper documentation. He adds, “Some of the EMR systems will also prompt health care professionals ‘Did you do this? Did you do that?’ with the idea of trying to attain a higher level of code. That’s fine—as long as what you put on the record that you did really meets the test of medical necessity.”
“Make sure you are actually doing the work,” Phillips advises. “And don’t go looking for things that aren’t necessarily there, just to fill in the chart.”
Accurate and adequate documentation is part of Health Care 101, but not all education programs provide extensive training in billing and coding. While NPs and PAs may need to seek this expertise on their own, the opportunities are plentiful. The syllabus for nearly every professional conference usually includes at least one or two courses in coding. There are also a variety of online resources and Webinars that clinicians can review at their leisure; Phillips recommends the free video course offered by EMUniversity
.com. Buppert has developed training modules that are available for purchase by individuals or institutions, but also notes that local Medicare administrative contractors often conduct teleconferences and “lunch and learn” sessions.
“You can get the training,” she says. “It does take time, but the access is there.”
THE COST IS HIGH
Clinicians have to decide what is more important: finding time to bring themselves up to speed or paying the consequences of a potential investigation by Medicare (or another authority) if any violations occur. Even if an intention to commit fraud is not found, the costs to a health care provider and his/her practice can be substantial.
“I would suggest that Medicare does understand an honest mistake, and when those are made, they typically take back the reimbursement and call it a day,” Powe says. “Now, it’s also possible that if Medicare sees a long-term pattern of inappropriate or mistaken billing, that could very well trigger a practice audit.”
At that point, Phillips says, “the burden of having to prove what you did or did not do becomes incumbent on you. Often, you’re going to need to get an attorney, particularly one who is familiar with health care and audits and this whole issue of the Recovery Act.”
Buppert has been contacted by clinicians who have been audited and subsequently required to pay back sums ranging from $25,000 to $80,000. Typically, 5% to 10% of charts are reviewed, with findings extrapolated to the clinician’s or the practice’s total billing. For example, if medical necessity is not adequately documented on 50% of the audited charts, the fine is assessed to half of the submitted bills. If the auditors find a problem with 100% of the charts reviewed, they can deny payment for all submitted bills.
Buppert recently had a client who was going to be denied payment for 100% of her bills, due to what the auditors determined was poor documentation of the necessity for home visits. The clinician was ultimately cleared of wrongdoing, but not until she’d consulted two attorneys and had her case presented before administrative law judges. “It was an honest mistake, and it was resolved,” Buppert says, “but she had a large legal bill, so it was not a tremendously good result.”