I have not posted for some time, largely because the flow of information from the federal government and commercial payers has slowed to a drip. But now things are heating up: CMS is poised to resume its audit and compliance operations on Aug. 3, even as cases of COVID-19 are rising again in many states. It seems that a second spate of shelter-in-place orders will be inevitable unless the trajectory of new infections changes. However, with cooler weather just a few short months away, bigger problems for our country seem to loom on the horizon! Please continue to take all necessary precautions to prevent the spread of COVID-19!
The audit landscape: CMS resumes audits
Regardless of the state of the pandemic on Aug. 3, 2020, CMS’ audit programs are going live on that date! CMS halted audits in March, when the scale of the pandemic became evident, for Recovery Audit Contractors (RACs), Supplemental Medical Review Contractors (SMRCs), the Targeted Probe and Educate (TPE) program, and most other pre- and post-payment audit entities. CMS has made it crystal clear these entities and the audits they conduct are critical to their program integrity efforts and that there will be no further extension of the enforcement discretion period that begin in March.
Sean’s takeaways for medical practices and health systems
- It is important to keep in mind these auditing groups must comply with any of the waivers put in place during the crisis and billed within that time frame.
- If a hardship applies to your situation, it is critical you communicate this to CMS as soon as possible.
- Prepare for a new onslaught of audits by preemptively auditing claims, implementing any corrective actions and/or making voluntary refunds to avoid aggressive actions by payer auditors.
- Make sure your staff is aware that CMS audits will soon ramp up and ensure that they are on the lookout for any CMS communications. The moment anything is received make sure they are flagged for your immediate review.
- Audit targets will most likely be in the following areas:
- COVID-19 screenings. This is based on the number of OIG Investigations and Settlement Actions during the past few months
- Application of COVID-19 diagnosis codes and documentation to support the use of these codes. Remember there are several ICD-10 codes applicable to COVID-19, so ranking and sequencing is important as are the secondary and tertiary diagnoses that you list.
- Telehealth services. We have audited a lot of these services for clients during the crisis and the lack of documentation we have found is troubling. Do not just rely on the time documented or the Medical Decision Making (MDM) to support these services. “Medical Necessity” is still the driving force for the level of service you select! Additionally, there still must be some form of history and exam to be able to bill for a 99201-99215. The problem we have seen is that a lot of the exams documented are highly improbable for visits conducted remotely via telehealth, so warn your providers to be careful and not over-document or falsify what exams they performed.
- In-person encounters with minor procedures (modifier 25) during the same visit. Again, you must have a significantly, separately identifiable E/M above and beyond the pre-service work-up that would normally be included in a minor procedure. I believe dermatology, primary care, urgent care, ENT, podiatry and orthopedics are at the highest risk.
- Surgical procedures. I believe there will be a focus on major surgery codes prior to the shelter-in-place orders issued in many states and the resumption of surgeries once the orders were lifted. I believe orthopedics is at the highest risk here.
Looking ahead
Many readers of this blog are already compliance clients and I will be reaching out to each of you to discuss planning for the remainder of 2020. If you are a past client or simply an interested reader, you can schedule a FREE consultation with me or another member of our compliance team to discuss how we can help with internal audits and audit response/appeal representation. You can contact me directly to discuss creating an audit action plan and implementation or updating of your compliance plan. My email address is [email protected].
What to do next…
- If you need help with an audit appeal or regulatory compliance concern, contact us at (800) 635-4040 or via email at [email protected].
- Read more about our: Total Compliance Solution
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