Our http://www.healthtecsystems.info site has been up-dated to include “Free patient medical claim auditing services”.
You may have hear someone say, the doctor saw me of less then 10 minutes, and the patient benefited very little from the visit, but the patient gets a $250 bill.
HTS will provide basic free auditing services based on mandated coding guidelines.
As an example: The patient returned to the medical office and saw the doctor for 10 minutes. In that time the Doctor, checked their heart, examined the ears, eyes and mouth and lungs.
Asked the patient a few questions about their condition such as history of occurrence. The patient indicates, he has had a sore throat for 1 week, and he has a recurring head ack. The patient states he smokes 1/2 pack a day. He is a widow and lives along.
He tells the patient it appears he has a simple respiratory infection. Then writes a prescription for antibiotics for the throat and Tylenol #3 for the head pain. The patient is told to return in two weeks.
The Doctor’s bill submitted a claim for a 99205 Comprehensive visit $250.
Less first look at the definition of a Comprehensive visit. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and or family. Per Current procedure terminology coding guidelines published by the American Medical Association. Also the visit should offer elements in three components. History, Exam and medical decision making.
History – A. History of present illness (HPI)
___Location ___Severity ___Timing ___Modifying factors
___Quality ___ Duration ___Context ___ Associated sign and symptoms
B. History Review of systems
How many body systems examined _______
C. Past medical, family, social history (data collected_ _______
Examination- Limited to affected body area or organ system, or general muli-system exam 8 or more systems.
Body area examined ___________________________________________
Organ systems examined ________________________________________
Medical Decision Making – Made based on the problem or treatment option mentioned in the record. Risk of complications and or morbidity or mortality taken into consideration.
- Number of diagnosis or treatment options
- Highest risk
- Amount and complexity of data
- Type of decision making
Some services are based on time such as critical care, physical therapy and counseling.
Based on the patient listed above, the audit concluded the following for each of the above elements that were address and document in the progress note.
History of the problem, included location of the problem, timing, duration, the provider reviewed the eyes, nose, mouth, cardiac, and respiratory systems. If was documented that the patient had a social history of smoking. Based on our audit the history equaled a detailed visit
The examination of organ systems, covered the neuro systems, eyes, the digestive system and mouth, respiratory. The audit conclusion was a expanded problem focused exam was performed.
The medical decision making cover 2 diagnosis, the highest risk was low, and the amount and complexity of data reviewed, such as previous medical records and or lab or radiology test was minimal or low.
The results of the audit
Exam Expanded problem focus
Level III visit = procedure code 99213
The 99205 is a new patient visit code. The chart progress note indicated that the patient was a returning patient and an establish patient code should have been used. New patient visits are priced higher then established.
The original charge for a new patient visit was 99205 level 5 visit $250. Per audit patient is an established patient not new, and the service warranted at 99213 established patient level 3 visit. Charge $100. Savings $150.00. To the patient.
CMS requires that well patient annual visit include a personal patient prevention plan with follow-up. Providers must submit hard copy documentation within 45 days of claim or the claim will be denied.
HCPCS ® G0439 – Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit.
This service specific review is initiated based on the following:
- Annual wellness visit services have been identified as a known CERT error and HCPCS ® G0439 has been identified as a potential vulnerability through data analysis.
One-Time Notification to Providers
Your facility will be notified of the selected claims per the normal Automated Development System (ADS) process. The provider agreement to participate in the Medicare program requires the submission of all documentation necessary to support the services billed on the claim.
Submit all applicable documentation requested for each claim with a copy of the ADS as a coversheet. Records should be mailed (hardcopy or CD) or faxed to Noridian within 45 days of receipt or a claim denial will occur. Denials may result in future provider specific complex reviews and may be appealed through the normal appeal process. View references and required documentation on the Review Notifications and Findings webpage and detailed instructions on ADS submissions on the Automated Development System (ADS) Requests for Medical Record Submissions webpage.
$750,000 HIPAA SETTLEMENT CAUSES OCR TO UNDERSCORE NEED FOR ORGANIZATION WIDE RISK ANALYSIS
In a $750,000 HIPAA Settlement, the University of Washington Medicine (UWM) has agreed to settle charges that it potentially violated the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Security Rule by failing to implement policies and procedures to prevent, detect, contain, and correct security violations. UWM is an affiliated covered entity, which includes designated health care components and other entities under the control of the University of Washington, including University of Washington Medical Center, the primary teaching hospital of the University of Washington School of Medicine. Affiliated covered entities must have in place appropriate policies and processes to assure HIPAA compliance with respect to each of the entities that are part of the affiliated group. The settlement includes a monetary payment of $750,000, a corrective action plan, and annual reports on the organization’s compliance efforts.
You can review the complete notice on the HHS.gov website.
“Free Electronic Health Records Training” (classes)
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Email inquiries to Healthtecsystems@consultant.com
Overview of EHR Incentive
Programs Final Rule
The CMS rule is live here:
Federal Register – CMS
HealthTecSystems offers compliance audit services.
- E&M audits
- Continuing education training
- HIPAA security saftguards
- Compliance policies and procedures
Compliance requirements per CMS:
HIPAA Training Requirements
§ 164.308 Administrative safeguards. (a) A covered entity or business associate must, in accordance with § 164.306:
- (5)(i) Standard: Security awareness and training. Implement a security awareness and training program for all members of its workforce (including management).
- (5)(ii)(A) Security reminders (Addressable). Periodic security updates.
A new bill introduced into the US House of Representatives proposes a two-year “grace period” for accepting codes submitted in ICD-10-CM/PCS.
The bill, H.R. 2652, Protecting Patients and Physicians Against Coding Act of 2015, was introduced by Representative Gary Palmer (R-AL-6) on June 4.
The legislation is the third ICD-10-related bill to be introduced into the House of Representatives in the last five weeks. On May 12, H.R. 2247, the Increasing Clarity for Doctors by Transitioning Effectively Now Act (ICD-TEN Act) was introduced by Rep. Diane Black (R-TN-6) calling for an ICD-10 transition period. On April 30, H.R. 2126, the Cutting Costly Codes Act of 2015, was introduced by Rep. Ted Poe (R-TX-2) seeking to outright stop the replacement of ICD-9 with ICD-10. Neither bill has gained much traction since being introduced. Black’s bill currently has only five cosponsors, and Poe’s bill has nine—much lower than the 46 sponsors this same bill had when Poe first introduced it in 2013.
H.R.2652 would create a two-year grace period where healthcare providers’ ICD-10-based claims submitted to Medicare and Medicaid would not be denied due to coding errors. Implementing this grace period would ensure physicians are not negatively impacted while ICD-10 is “fully implemented within the healthcare system,” according to a letter sent by Palmer to fellow Congressmen asking for their support of the bill.
Similar to the Black bill, H.R. 2652 would not delay the October 1, 2015 implementation deadline for ICD-10 use, but would require the Centers for Medicare and Medicaid Services (CMS) to pay for claims even if inaccurately coded. Palmer states in the letter that this grace period would create a “true transition” to the new code set, and is needed in order to allow physicians “to grow accustomed to ICD-10 over a period of time without being penalized for unintentional errors.”
During the two-year grace period physicians would not be penalized and their payments would not be withheld by CMS due to “coding errors, mistakes, and/or malfunctions of the system,” according to the bill. The Department of Health and Human Services (HHS) would also be required to conduct a study on how the transition to ICD-10 has affected physicians and other healthcare providers, and state how well HHS has helped physicians transition to the new code set.
The bill is needed, Palmer said, because small and rural physicians have not had adequate time or resources to transition to ICD-10, and that learning to do so by October would harm their ability to provide quality patient care and receive proper reimbursement.
Other healthcare stakeholders have argued that the transition time from ICD-9 to ICD-10 has been ample enough. Also, ICD-10 advocates have pointed out that currently CMS offers numerous resources to help physicians and other providers with the transition, including fact sheets, checklists, guides, timelines, teleconferences, videos, and local training programs, through their Road to ICD-10 website located at www.cms.gov/Medicare/Coding/ICD10/index.html.
“Although another delay would assist many in the medical community, if ICD-10 is to be implemented on October 1, patient care should not suffer,” Palmer’s letter states.
This is not the first time Palmer has tried to stop ICD-10’s outright October 1 implementation. In March he unsuccessfully tried to introduce a delay amendment into the Sustainable Growth Rate replacement bill during the House Rules Committee process.
H.R. 2652 had 32 co-sponsors as of June 8, and has been referred to the House Committee on Energy and Commerce as well as the Committee on Ways and Means.
AHIMA Against H.R. 2652
AHIMA officials have said they are against this bill since the grace period would lead to inaccurate coding, improper payments, and potential medical billing fraud. With no official repercussions for inaccurate coding, AHIMA officials said they feel it would open the door to both intentional and unintentional coding errors—improperly paid claims at best and rampant fraud at worst—since proper payment of claims depends on accurate coding. Coverage determinations and validation of medical necessity of healthcare services also depend on codes submitted on claims, and would be impacted.
Also, claims data are used for many purposes beyond payment, including health policy decisions, assessment of quality of care, patient outcomes and safety, and evaluation of costs. Allowance of miscoding on claims will render claims data useless for any purpose, AHIMA officials said.
There are already appropriate mechanisms built into ICD-10-CM for reporting less specific codes when necessary and appropriate. There are “unspecified” codes in both ICD-9 and ICD-10, and unspecified ICD-9 codes are currently already allowed in Medicare fee-for-service payment systems, AHIMA officials said. There is no indication that allowance of unspecified codes will change under ICD-10.
While this bill implies that the increase in the number of codes in ICD-10 will cause hardship for physicians trying to find the right code, AHIMA officials counter that physicians and any other medical biller won’t need to learn every ICD-10 code in order to properly bill.
Just as no healthcare provider uses every code in ICD-9-CM today, physicians and other providers will not use all the codes in ICD-10-CM, AHIMA stated in an ICD-10 FAQ.
Physicians should use a subset of codes based on their practice and patient population. “The ICD-10-CM code set is like a dictionary that has thousands of words, but individuals use some words very commonly while other words are never used,” the FAQ states. “Also, laterality accounts for nearly half of the increase in the number of codes in ICD-10-CM–information that is typically already documented in patients’ medical records.
AHIMA officials have said the grace period is unnecessary since CMS end-to-end testing has shown that only two percent of claims were rejected due to ICD-10 coding errors during the most recent testing period, which ran April 27 to May 1. This is actually lower than the number of claims, 3 percent, currently rejected by CMS after annual ICD-9-CM code updates.