Medical Billing Forum

Coding => Coding => Topic started by: danielmanske on February 22, 2015, 09:29:08 PM

Title: Audit
Post by: danielmanske on February 22, 2015, 09:29:08 PM
I'm a physician who learned coding and billing from the ICD-9 and CPT books, not per the insurance company conventions which seem to be widely taught.
Our practice has been audited and the insurer is asking for money back.  There are 2 issues:
1.  We've used 99211 for single immunizations.  We've been paid, for several years.  It does meet all the criteria for a level 99211.  However the CPT book does specify the 90471-3 or 90460/90461 series of codes, thus trumping the conceptual use of 99211 for this purpose.  Although it is arguably defensible to use the concept of a 99211 applied to an immunization, the consensus in the billing community agrees with their interpretation.  So I agreed to negotiate a settlement of this issue for the prior 18 months, the maximum allowed take-back period for our state of NJ.  The exceptions to this time-limit are for fraud or abuse which are not issues.  The insurer wants to negotiate from 6 years back. 
2.  We have billed 99211 for such things as issuing referrals required by this insurer and for such things as medication refills, lab orders and other administrative purposes as per Appendix C in CPT.  Of course the patient is required to present in office; these are not for phone encounters.  We have used ICD-9 codes, V68.81, V68.1 and V68.09 for such things.  These are valid codes used in the sense of the Clinical Examples in Appendix C, the heading of which calls it an integral part of the coding/billing process.  This insurer states that these are invalid codes but yet have paid for 6 years and now want to take back payment.  They also argue, in case they can't prevail on that score, that the level of service is not sufficient.  However, in reviewing the CPT book in this regard, no requirements are given for this level of service for History, Exam or Medical Decision Making.  Since all other office visits require at least some of these, it follows that a description of the service provided is sufficient documentation.  On this issue I did not agree to negotiate and will vigorously defend our past billing, though going forward we may have to negotiate an agreement.   
Does anyone have any wisdom to share on these issues?  I know this is unconventional.  That's why we were audited, as an outlier.  But convention is not enforceable and if the AMA source books support it, then why should we yield to the opinion of the insurer?  I should note that this insurer is a Medicaid HMO that has a flat rate of $40 for all 99211 to 99215 office visits, meaning that a 99211 is paid the same as a 99215, quite unconventional.  Their rep says it evens out in the end, though it seems they didn't like how this worked for us.   
Title: Re: Audit
Post by: RichardP on February 24, 2015, 01:46:25 AM
We have billed 99211 for such things as issuing referrals required by this insurer and for such things as medication refills, lab orders and other administrative purposes as per Appendix C in CPT.

CPT Code 99211 is to be used for the Evaluation and Management of an established patient where the presence of a physician may not be required.  To trigger some thoughts/discussion - do "other administrative purposes" equal E/M services?  See 99211 at the first link and scroll down to "Basic Guidelines at the second link.  The third link also provides a good overview.
Title: Re: Audit
Post by: kristin on February 24, 2015, 08:03:07 PM
My two cents:

Richard posted the exact same links I was going to post, so thanks, Richard!

For the first issue, of using the 99211 in place of the injection codes that should have been used, that is the problem right have to code to the highest level of specificity/accuracy, and using an E/M code in place of the lower paying injection code that more accurately described the service rendered should not have been done.

For the second issue...while I understand that a few of the Appendix C examples of a 99211 involve administrative tasks, it is commonly "understood", at least with every doctor, biller, and coder I know, that you do not bill a 99211 for those things, because some of the examples in Appendix C are outdated, and need to be deleted. While the CPT/AMA may use those administrative task examples in their Appendix C, what the insurer wants trumps that, and starting with Medicare/Medicaid, and going straight on down the line, I don't know of any insurer that allows a 99211 for administrative tasks/paperwork. There ARE some codes for certain types of paperwork, but not the kind you are talking about. I am thinking specifically about HHA and some WC paperwork codes.

A 99211 is an E/M code, and the first DG for an E/M code with every insurer is you have to have a chief complaint. "Patient presents to the office today for a referral/Rx refill/lab order" is not a chief complaint. What some offices do is charge the patient for lengthier forms to be filled out, such as disability paperwork(Usually around $10 or so). Not lab orders, referrals, or Rx's, though, in most instances.

If you do want to charge patients for these administrative tasks, you certainly can, so long as it is not prohibited by any of your insurance contracts, and the charges are listed in your financial policy that every patient gets and signs. Understand, though, that most offices consider these tasks a part of the cost of doing business, and to charge for something like a lab order, or Rx, which takes all of two minutes or less to do, could be seen by patients as nickel and diming them. That costs you patients, in the end, as they will go somewhere else if they can. I know I would, if my doctor charged me for basic things such as Rx refills, etc.

While I am all about maximizing reimbursement for the doctors I bill for, and am no fan of most insurance companies(especially Medicaid and HMO's), and their low allowed amounts, etc, I have to side with the insurance company in this case, based on what you have said. Think about it from their perspective for a minute...what is to say that you aren't issuing lab orders and Rx refills that aren't actually medically necessary, just so you can bill a 99211 each time and collect your $40? I am NOT saying that is what you are doing, but THEY very well might think that, and there could be other doctors out there doing just that. It is a slippery slope.Ethically, I can't stand behind getting paid $40 to write an Rx, referral, or lab order, and would never bill a 99211 for such things, or allow my doctors to do so. 

And while I also understand that the insurance company in question pays $40 across the board for a 99211-99215, which I heartily feel is BS, my solution to that is to IMMEDIATELY get out of your contract with them, and never contract with an insurance company like that again, for those awful rates. Because what happens is exactly what happened try to "make up" the difference, and you are tagged as an outlier, and audited.
Title: Re: Audit
Post by: danielmanske on February 24, 2015, 11:55:05 PM
Thank you, Richard and Kristin for your kind replies.  I appreciate the input.  Some thoughts on the responses:
Should we do what is "commonly understood" simply because that's how it's been done, or should we follow the logic of the AMA coding/billing books.  When I started my solo practice 12 years ago I thought we would be paid fairly for taking good care of patients.  I found out that insurance companies will use any and every legal and sometimes illegal means to prevent paying what they should when they can get away with it.  It seemed that the playing field was tipped steeply to the advantage of the insurance companies.  They put great effort into preventing payment when there is any possibility they might be able to avoid it, with the onus then on the physician to run their gauntlet to get them to pay as they should.  Since I couldn't afford to pay someone to reliably take on this task, I learned it myself.  I concluded that insurance companies have to deal with a set of rules that really give physicians a fundamental advantage as the initiators of the coding/billing process.   Then they try to limit and control the payment process as reactors.  I suspect that one of the ways they do this is by imposing their version of the process on the medical billing establishment, by being a player in medical billing education.  If one deconstructs the AMA CPT and ICD-9 books to interpret them at face value, it does not always agree with the conventional logic of medical billing professionals, some of whom accept what the insurance industry espouses.  That's how I learned how to code and bill, by the books.  The heading for Appendix C and selected examples say:  (these are direct quotes):
AMA CPT 2013 Appendix C, Clinical Examples > As described in CPT 2013, clinical examples of the CPT codes for E/M services are intended to be an important element of the coding system.  The clinical examples, when used with the E/M descriptors contained in the full text of the CPT code set, provide a comprehensive and powerful tool for individuals to report the services provided to their patients. 

If it gives examples of a 99211 office visit such as:
  Office visit for an established patient who lost prescription for lichen planus. Returned for new copy.
  Office visit for an established patient, a Peace Corps enlistee, who requests documentation that third molars have been removed.
  Office visit for a 9-year-old, established patient, successfully treated for impetigo, requiring release to return to school.
  Office visit for an established patient requesting a return-to-work certificate for resolving contact dermatitis.
  Office visit for a 42-year-old, established patient, to read tuberculin test results.  (An experienced professional biller told me there was one global fee for PPD admin and reading.)
  Office visit with 31-year-old female, established patient, for return to work certificate.
  Office visit for a 45-year-old male, established patient, with chronic renal failure for the administration of erythropoietin.
  Office visit for an 82-year-old female, established patient, for a monthly B12 injection with documented Vitamin B12 deficiency.

How should one interpret these instructions in how to bill for these services?  As meaning something other than what they say?  That is the convention that insures would like and some billers commonly accept. I have followed the logic of these examples, erring only in the use of 99211 for immunizations, which I now accept as specified elsewhere.  To say that it could be abused is not to say it is not valid billing.  Fraudulent billing is not a viable practice; it should and will be discovered and prosecuted. 

Regarding the links, thank you Richard.  The CMS site is well known.  Government will increasingly be the policy maker in this process, unfortunately, in my opinion.  I actually did find the FP link in my search.  The third link is an insurance company website which is an example of the insurance industry promulgating their perspective.  So I'm left with the question of who is the final arbiter.  Going forward it has to be a negotiated agreement.  Looking back, I think it's a matter of contract.  I think we have good legal ground to stand on.  I'm just looking for perspective from the medical billing community.  Thanks.
Title: Re: Audit
Post by: RichardP on February 25, 2015, 11:27:34 AM
I'm left with the question of who is the final arbiter.  ... I think it's a matter of contract.

You are correct.  And here is how that truth falls out.  I'm cutting to the chase here.

Most of our clients have gotten out of Medicare and all insurances.  In doing this, the doctors have no contracts with any insurance carriers and can charge the patients whatever they want to.  We bill the insurances as a courtesy for the patients.  But we do business in a high-net-worth area, and the patients have the means to pay the doctor and wait for their insurance to pay them.

If you think your patients would likewise put up with the situation described in the first paragraph, cancel all of your contracts with your insurance carriers and charge your patients whatever you want.  If you think your patients won't or can't put up with this and would leave you for a doctor who accepts their insurance, then you have uncovered the only piece of information that is relevant to this conversation:  you need to accept payment from insurance companies in order to have enough patients to cover your cost of doing business plus give you a profit.

If you need to accept health insurance in order to have any patients, then you can only practice medicine in the way that your patients' health insurance carriers want you to.  To be a participating provider with an insurance carrier, you must sign a contract with them.  That contract binds you to bill them in whatever way they deem appropriate.  Your personal opinion no longer matters.  If you want your personal opinion to matter, get out of your contract with the insurance carrier.  That is the bottom line, and there is no other way to look at this.

If you still want to be a practicing physician, and you can't afford to not accept health insurance, then you need to learn to play the system the way the carriers want you to, not the way you want to.  That is an uncomfortable truth, perhaps.  But it is the governing truth for all doctors in private practice.  [edit:  Doctors who are employees are governed by the rules of their employers, who may be large enough to strike special deals with insurance carriers that individual doctors cannot obtain.  As it pertains to coding, tho, this may be a distinction without a diffence.]

An aside:  The AMA is its own governing body, and has put together the Diagnosis Codes and Procedure Codes for its own reasons.  Insurance carriers accept those codes for their own reasons.  But insurance carriers are not bound in any way by how the AMA binds itself.  Therefore, the AMA CPT 2013 Appendix C, Clinical Examples are not binding on any insurance carrier.  It is puzzling, therefore, that you point to AMA ... Appendix C as somehow relevant when an insurance carrier accuses you of violating their terms.  Your contract with that carrier rules the day with them, not whatever the AMA might say.

In your comments here you have pointed to the value of having an experienced biller who knows what the insurance carriers of your state require before they will pay for any claim.  Such a biller would have helped you avoid the situation you are in.
Title: Re: Audit
Post by: kristin on February 25, 2015, 11:43:53 AM
Agree with Richard, he said exactly what I was going to say.
Title: Re: Audit
Post by: RichardP on February 25, 2015, 11:58:28 AM
Title: Re: Audit
Post by: danielmanske on February 25, 2015, 10:55:39 PM
Thank you for your thoughtful response, Richard.  We live in a poor area and our mostly pediatric patients have Medicaid HMO coverage.  So if the contract does not spell out requirements that differ from the AMA coding/billing books then they apply, right.  They can't enforce something other than our contract or the AMA rule books looking back.  That's what they seem to want to do, enforce convention over the AMA books since it's not specified in our contract. 
Title: Re: Audit
Post by: RichardP on February 26, 2015, 12:02:01 AM
Medicaid is governed by both State and Federal law.  At this point, you would probably be wise to be asking questions of a HealthCare Attorney from your state rather than from this billing board.
Title: Re: Audit
Post by: danielmanske on February 26, 2015, 10:14:28 PM
Noted, thank you, Richard.  I think it's worthy of discussion as a challenge and to see what arguments might be in play.  I've seen nothing here to refute my interpretation.
Title: Re: Audit
Post by: RichardP on February 26, 2015, 11:41:26 PM
I've seen nothing here to refute my interpretation.

If you can provide answers to the following questions, that would be useful for those who pass by these parts in order to learn things.

1.  Do you, or the company you work for, have a contract with the Medicaid HMO in question?

2.  Have you discussed these issues with a HealthCare Attorney who knows your state's Medicaid laws?

3.  If the answer to Q2 is "Yes", does the Healthcare Attorney agree with your interpretation?

4.  If you lose on all points to the Medicaid HMO (assuming that they push it that far), do you or the company you work for stand to lose the ability to bill Medicaid for your state?

I'm curious to know how your situation gets resolved, whenever that happens.
Title: Re: Audit
Post by: PMRNC on February 28, 2015, 02:44:26 PM
Richard made excellent points.. all spot on.

My own take is that the AMA is no different than CMS..they have an "INVESTED" interest as well as a monopoly when it comes to CPT. You sure don't see us discussing a new PROCEDURE code system like we do diagnosis coding systems now do we?  :o ;) ;) 
Title: Re: Audit
Post by: danielmanske on March 11, 2015, 10:29:09 AM
Answer to Richard's questions 1-3, yes, Q4, unknown though not a likely scenario.
After last phone conference, they reduced their request for repayment by 70% after giving "credit" for agreeing that most of the charges conform to Appendix C, CPT.
They stated that they can go back beyond the 18 month limit imposed by NJ law because there was a "pattern of inappropriate billing" regarding the use of 99211 for immunizations.
This will be contested.  There is a conceptual basis for using this code for immunizations as it conforms to all aspects of a 99211 though I did admit that on review of CPT wording elsewhere it does state that a more specific code is available. 

Regarding the comparison of AMA to CMS, there is a distinct difference between the two.  CMS is an agent of the state, with the full enforcing powers of the federal government.  It is above the fray of commercial give and take and, as you well know, makes its own rules that trump any others.  And unless something changes, it will increasingly dictate health care delivery and payment.