For all the challenges associated with compliance, perhaps the least understood -- yet potentially most important -- is the need to identify significant coding and billing patterns. To ignore the growing payer focus on statistical profiling and code utilization is to miss one of the fundamental developments in recent medical history: the enormous investment government and commercial payers have made in database management systems. At a recent ASA Practice Management Meeting, Jim Sheehan, chief prosecutor for the Eastern District of Pennsylvania, noted the government is spending the money it recoups from audits on physician profiling software. This should be of special concern to chronic pain management practitioners.

Despite the best intentions of those attempting to bring relief to 86 million Americans who suffer from chronic pain, from a government auditor’s perspective, the anesthesiologist turned chronic pain management specialist is becoming suspect of several unpardonable sins. The government views the migration of anesthesiologists into chronic pain as a direct result of declining revenues for intra-operative and obstetric anesthesia services. Such an interpretation automatically raises concerns about a physician’s motives and intent.

Chronic pain physicians perform services commonly considered over-utilized and of questionable clinical value -- namely the proliferation of Local Medical Review Policies (LMRPs) specifically focused on the most common chronic pain management services. A careful reading of policies intended to clarify billing guidelines for epidural steroid, trigger point and facet joint injections reveals an obvious prejudice. Such policies clearly were developed to reduce what is viewed as abusive utilization.

Even worse, chronic pain medicine billing relies heavily on Evaluation and Management (E/M) codes, the most widely used in medical billing. No other category of CPT codes is so clearly designed by and for the auditor, nor as closely scrutinized. An entire vocabulary has emerged from the careful analysis of E/M distribution patterns. Terms such as "upcoding," "default coding," and "over-utilization" have taken on new relevance since 1992.

Devising a defensive strategy to protect a practice from a payer or Office of Inspector General audit requires integration of at least three key elements: careful and complete documentation, compliance with government and third party billing guidelines and constant monitoring for "suspicious" behavior patterns. While the first two are essential prerequisites for a comprehensive plan, the average practice pays too little attention to the data requirements of ongoing monitoring and code utilization trends.

Seminars dedicated to chronic pain management billing tend to echo the auditor’s mantra, "not documented, not done." Every LMRP includes a section entitled, "documentation requirements," which should be mandatory reading for clinicians. Don’t make the common mistake of thinking if a payer reimbursed for a service, then receipt of the check is evidence of an appropriate claim. Not so. Medicare intermediaries make payment based on logical claim edits and always reserve the right to review supporting documentation after the fact. Unfortunately, no carrier or intermediary has yet addressed the question so often asked by specialists, "Must my report be dictated?" This ambiguity should not be interpreted as ambivalence. If questioned, the provider must be able to demonstrate the medical necessity and expected value of service.

When it comes to billing regulations, too many physicians try to hide behind the excuse, "the rules keep changing." While there may be some truth to the accusation, the changes are never as profound as some might believe. However arcane the criteria for selecting an appropriate E/M code, the rules are not impossible to decipher. A willingness to "see things from the payer’s perspective" goes a long way in making sense of codes. If a physician is confused, there are dozens of seminars that will help resolve coding questions. If in doubt, the practice should consider employing a Certified Professional Coder (CPC) trained in code selection.

Hiring a consultant to assess risk patterns, develop a set of written billing policies and a compliance plan is the easy part. Modification of physician behavior requires ongoing monitoring and intervention. Without regular feedback, physicians tend to default to patterns of code utilization which, however safe they may seem, actually can create more red flags and a higher risk of audit than the physician might have anticipated.

Consider two common scenarios. For years, Physician A performed epidural steroid injections on patients referred to him by orthopedic surgeons. On a busy day, he may perform three or four injections. Because he knows the referring physicians and performs the injections in the recovery room after completion of regularly scheduled cases, he does little more than a perfunctory work-up before performing the injection. Since there is no evaluation or fluoroscopy, billing is limited to a single code: 62311.

Physician B dedicates more time to chronic pain management, and conducts a cursory evaluation and assessment before performing a limited number of nerve block procedures, mainly epidural steroid, trigger point and occasional facet joint injections under fluoroscopy. While he knows he can bill for both the work-up and the procedure on the same day, because he is concerned about compliance, he bills only one E/M code: 99202, for a low-level outpatient evaluation of a new patient.

Interestingly, both physicians have a higher risk of an audit than colleagues who demonstrate more aggressive coding practices. In the case of physician A, the red flag is use of 62311 in the absence of any codes for evaluation and management. Because of his specialty, the use of 62311 is -- in and of itself -- a potential trigger for an audit. Issues for Physician B stem from reliance on a single code level for work-ups, a pattern referred to as default coding. Since it is statistically unlikely that all patient work-ups meet the criteria for a single code level, reliance on this code could trigger an audit based on the theory that he may not be doing a work-up at all. The government tends to view consistent use of low level codes as a way to get paid for services that are bundled into the primary service.

Both physicians would profit from a profile report that identifies their specific patterns of code usage. By examining code usage the way the carriers do, physicians have the opportunity to reassess their clinical and coding protocols in light of current guidelines. Some of the nation’s most advanced practices have developed fairly sophisticated monitoring mechanisms, allowing physicians to identify potentially risky billing practices long before they attract the attention of carriers or auditors.

Physicians often get hung up on the details of payers’ policies. Because they are so focused on technical decisions relating to code selection, ironically, they overlook basic patterns of code utilization, which result from such decisions. Fortunately, the problem is relatively easy to fix. For all the resources available to payers, the tools they use to identify potential fraud and abuse are not that sophisticated. A desire to understand the payer perspective and commitment to invest in necessary tools goes a long way toward protecting the average pain practice from a potentially disastrous audit.

ANESTHESIOLOGY PRACTICE MANAGEMENT EXPERT AVAILABLE

Expert Joseph (Jody) A. Locke is vice president of Anesthesiology Services for Per-Se Technologies, responsible for development and oversight of the company’s service offerings to anesthesiologists, CRNAs and pain management specialists. His responsibilities include new business development, employee education, client support and product development. With nearly 20 years of industry experience, he is a recognized expert on anesthesiology practice management issues and frequently speaks at physician and administrator meetings. He has published numerous articles about practice management-related issues and authored a book, "Mastering the Business of Chronic Pain Management," to be published during 2001 by United Communications. Locke holds a master’s degree from the University of Michigan, Ann Arbor, Mich., and a bachelor’s degree from Georgetown University, Washington, D.C.

 

Topics • Anesthesiology practice management