June 23, 2023 | By J. Paul Spencer, CPC, COC
We all knew that these days were on the horizon.
Now that we find ourselves over a month after the expiration of the Public Health Emergency (PHE), audit activity from commercial and governmental payers, which picked up significantly in 2022, shows no signs of abating.
From Target, Probe & Educate (TPE) audits from your local MAC, to Unified Program Integrity Contractor (UPIC) audits to commercial insurance audits of all types, the audit landscape for providers has never been more of a minefield.
There are several ways that audits can come to a provider’s doorstep. While we tend to think of audits in the monolithic sense as a search for “fraud,” it’s not always specifically about the provider being targeted. In many cases, audits tend to be an extension of previous findings with a service or within the same specialty.
With that in mind, I’d like to share with the reader some details behind services that appear to be within the current sights of carriers of all types:
Psychotherapy Services – MACs are beginning to focus on the documentary details behind psychotherapy services. Some things to consider with psychotherapy services are:
- The treatment plan of care should outline the diagnoses requiring treatment, treatment goals, and must include the type, amount frequency and expected duration of treatment;
- While no LCD states specifically that a start and stop time for psychotherapy services in mandated, multiple education sessions with MAC, educators are showing a pattern of start and stop times being recommended for proper documentation of total time for psychotherapy services.
- The medical necessity for continuing treatment must be an ongoing part of psychotherapy documentation.
Pain Management Services – This particular specialty has seen an unprecedented level of scrutiny. While it is generally understood that the country finds itself deep in the throes of an opioid epidemic, law-abiding pain management practices across the country are being audited at the hands of sometimes overzealous assistant U. S. attorneys seeking to shift blame from the pharmaceuticals and the companies who manufacture them, to the prescribers. As part of this aggressive standing, the following areas have been particularly targeted:
- Urine drug testing and screening is one of the most likely areas of audit in the pain management arena. Medicare managed care groups have been deliberately misinterpreting LCD guidance in order to deny payment for higher level “G” codes used for definitive testing. There is wide incongruity between LCD guidance and individual state laws with regard to the frequency of both presumptive and definitive testing, which is being exploited for retrospective denials by carriers. Laboratories are also having services denied, based on insufficient documentation of medical necessity of the type and frequency of testing by the ordering pain management provider.
- More concerning is the trend to question pain management on a clinical basis. High level established E/M services (levels 4 and, based on utilization, level 5) are continuously being questioned. This is mostly based on outdated EMR templates that do not consistently and clearly provide the patient’s current response to treatment at the time of the encounter.
Telehealth Services – The OIG Work Plan continues to list documentation issues related to telehealth services as a current issue. In September of 2022, the OIG identified over 1,700 providers as a risk to the Medicare Program based on their performance and documentation of telehealth services.
This led the OIG to release a toolkit for Medicare Advantage plan to assess risks based around telehealth. In turn, this has led to commercial carriers to begin critical reviews of telehealth documentation. While the PHE can be used to argue the necessity of telehealth services during the pandemic, it is important that documentation state the reasons for telehealth services, patient consent to telehealth services, and reflect a realistic encounter of such services (for example, templates showing a multi-system physical examination being performed via telehealth, which is largely impossible).
These are but three issues that are gaining audit traction as we reach the halfway mark thru 2023. It is recommended that all providers take a look at your local MAC website for indications of what was found in your jurisdiction as part of Comprehensive Error Rate Testing (CERT) audits. This can provide a window into possible future TPE audit activity, at the very least.
It is also recommended that you pay attention to carrier medical policy bulletins from your largest commercial carriers. Many commercial audits have their genesis in updates to medical policy that goes unheeded due to low visibility to changes on the practice level. If your practice is offering unique services, it is best to know how all carriers consider reimbursement of those services.
Your next steps:
- Contact NAMAS to discuss your organization’s coding and documentation practices.
- Read more blog posts to stay updated on the 2023 Revisions to the 2021 E&M Guidelines.
- Subscribe to the NAMAS YouTube channel for more auditing and compliance tips.
- Register to attend the 15th Annual NAMAS Auditing & Compliance Conference to learn more from experts like Paul!
NAMAS is a division of DoctorsManagement, LLC, a premier full-service medical consulting firm since 1956. With a team of experienced auditors and educators boasting a minimum of a CPC and CPMA certification and 10+ years of auditing-specific experience, NAMAS offers a vast range of auditing education, resources, training, and services. As the original creator of the now AAPC-affiliated CPMA credential, NAMAS instructors continue to be the go-to authorities in auditing. From DOJ and RAC auditors to CMS and Medicare Advantage Auditors to physician and hospital-based auditing professionals, our team has educated them all. We are proud to have helped so many grow and excel in the auditing and compliance field.
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