ACR 2011: Physician Practices Have to Live by the Code


All practices should perform self-audits of their medical and billing records to ensure that they are properly documenting care and receiving the maximum allowable reimbursement.

All practices should perform self-audits of their medical and billing records to ensure that they are properly documenting care and receiving the maximum allowable reimbursement.

Monday at the at the 2011 ACR/ARHP Annual Meeting Melesia Tillman, CPC-I, CRHC, CHA, coding and reimbursement specialist for the American College of Rheumatology, opened her presentation, titled “RAC and Roll: How to Perform Complex Chart Audits,” by explaining that coding is like baking a cake — even though you use the same basic ingredients each time, the recipe is never quite the same, as the cook tweaks and adds ingredients based on a range of variables.

She recommended that all practices should regularly schedule and perform self audits. Doing so “will help keep your practice compliant, identify coding errors, and assist physicians and staff with coding education. The more you audit, the more you understand the rules,” she said. The first step is to assign a compliance officer who understands the coding and appeals process.

Tillman reminded the audience that they can follow either the 1995 or 1997 E/M guidelines when documenting a patient visit, and can even switch from patient to patient, but they cannot switch versions within the notes of an individual visit. She also briefly reviewed the chief components that must be included in each note: documentation of a chief complaint, history of present illness (HPI), review of system, and past family and social history. “If you don’t do this last one, it will bring your visit down to lower level of coding,” Tillman told the audience. She also reminded them that the HPI is the only part of the history that must be completed by the treating physician; it cannot be entered by a staff member.

After reviewing the type and minimum number of data elements a record should include in order to comply with the 1995 and 1997 E/M guidelines, Tillman discussed the two types of recovery audit contractor (RAC) audits — automated and complex – and reminded the audience that RAC cannot audit claims for medical necessity; they only apply coding guidelines. During a complex audit, RAC auditors will request access to a practice’s medical records for review, and practices have 45 days in which to comply with this request. She said that there currently are four companies that are recognized recovery audit contractors, and are each responsible for conducting audits in specific region of the country.

However, Zone Program Integrity Contractors (ZPIC) can audit for medical necessity. They can also audit for high utilization rates of procedures. Tillman advised that all practices must document medical necessity when using new technologies (eg, they must explain why they used ultrasound guidance in the note; it’s not enough to merely document that the procedure was used). ZPICs also look for cloned medical records (ie, language reproduced verbatim from patient to patient, or for each visit for the same patient). Providers with EMRs must especially guard against this. Tillman said there are seven regional ZPIC zones in the US, with the regions containing California, Texas, and Florida having the highest rates of audits.

In the event a practice is audited and found to have been overpaid, it can file a written request for a redetermination within 120 days of the initial decision on a claim. Tillman suggested that these should be sent by certified mail so the practice has proof that an appeal was filed. If the practice is not satisfied with the redetermination, it can file an appeal within 180 days of the redetermination and have a qualified independent contractor (QIC) conduct a reconsideration of the decision. That decision may also be appealed and the practice can request a hearing before an administrative law judge within 60 days of QIC’s reconsideration. The judge’s decision can be appealed to the Medicare Appeals Council within 60 days. The final level of appeal would be a judicial review of the case in US district court.

Tillman concluded her presentation with several pieces of advice for physicians:

  • If it’s not documented and legible, it’s not billable
  • Make sure you and your staff understand the coding guidelines
  • Documentation must always support medical necessity
  • Perform scheduled self audits — auditors take this into consideration – and document this in your compliance plan
  • Physicians and staff need to know and understand their right to appeal and the appeals process
  • Don’t rely solely on vendors’ advice about what is billable for their product

This activity is not sanctioned by, nor a part of, the American College of Rheumatology.

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