Enhancing Billing and Coding Compliance in a Physician Practice
The Challenge
A physician practice with concerns about the accuracy of their billing and coding practices. Leadership suspected that some doctors were not coding correctly, potentially leading to compliance risks. The practice faced several significant compliance issues:
Upcoding and Inappropriate Modifiers: Some physicians were billing higher-level services than provided and using incorrect coding modifiers.
Chronic Care Documentation: There were problems documenting chronic care, including distinguishing between complex and non-complex cases.
Medicare Requirements: Physicians struggled to differentiate between physical exams and annual wellness visits under Medicare guidelines.
Unsupported Diagnosis Codes: Diagnosis codes submitted were not always supported by patient records, resulting in inflated risk adjustment scores.
Medical Necessity Documentation: Although physicians could verbally justify medical necessity, the documentation was often lacking, making it appear as though unnecessary treatments were provided.
The Solution
Jessica Zeff, CEO for Simply Compliance, was engaged to audit the practice's billing records and address these issues. Her approach included several key steps:
Initial Audit:
Record Review: Conducted a comprehensive audit of billing records and identified instances of upcoding, inappropriate coding modifiers, and unsupported diagnosis codes.
Documentation Issues: Found significant gaps in the documentation of chronic care and medical necessity.
Reporting and Findings:
Detailed Report: Provided a detailed report of findings to practice leadership, highlighting areas of non-compliance and specific examples of coding errors.
Training and Education:
Billing and Coding Training: Developed and conducted training sessions for physicians and staff on correct billing, coding, and documentation practices.
Medicare Guidelines: Provided specific training on distinguishing between physical exams and annual wellness visits to ensure compliance with Medicare requirements.
Process Development:
60-Day Rule: Assisted the practice in developing a process for identifying and refunding overpayments within 60 days, in compliance with the 60-Day Rule.
Internal Monitoring and Audits: Created a sustainable internal audit program to regularly monitor billing practices and ensure ongoing compliance.
High-Risk Billing Practices: Developed materials and reminders for high-risk billing practices, making them easily accessible to practice staff.
The Results
Jessica's comprehensive intervention led to significant improvements in the practice's compliance:
Identified and Rectified Errors: The practice self-identified $127,000 worth of coding errors and took corrective action.
Avoided Regulatory Scrutiny: By proactively addressing these issues, the practice avoided allegations of fraud and false claims, as well as costly regulatory scrutiny and penalties.
Improved Documentation: Enhanced the accuracy and completeness of medical necessity documentation, reducing the risk of non-compliance.
Ongoing Compliance: Established robust training and audit processes to ensure sustained compliance with billing and coding regulations.
The Conclusion
Jessica Zeff's expertise in healthcare compliance was instrumental in transforming the physician practice's approach to billing and coding. Her comprehensive audit, targeted training, and development of sustainable processes helped the practice rectify significant errors, avoid severe penalties, and ensure ongoing compliance. This case study underscores the importance of proactive compliance measures and the value of expert guidance in navigating complex regulatory landscapes.