Performance Metrics for Mitigating Post Payment Audit Risk- Mike Miscoe

Hello everyone. My name is Michael Miscoe with Miscoe Health Law. I’m a healthcare attorney and I’m happy to present today on behalf of Carver Secure. Our topic is, performance metrics and how we look at those to mitigate post payment audit risk. Pairs use a number of data analytic type activities to identify providers who are outliers and that is who they end up selecting for post payment analysis, and I’ve also noticed that some payers are implementing proactive programs trying to drive analytics downward, relative to chiropractic and physical medicine care, focusing on things like frequency of visits, number of visits per patient and condition pre-auth and things of that nature.

So this is going to be, I think the coming new norm with physical medicine all designed on the proactive side to minimize the likelihood that they would ever need to audit anybody but pending implementation of those programs, data analytics are used to identify providers that they they believe potentially received overpayment.

So looking at some of these issues, some of the key things that I see in post payment analysis coming up over and over again. First being evaluation management service utilization. A lot of misconceptions about when you can and cannot bill an evaluation management service in addition to a chiropractic manipulative treatment or therapy. The rules are somewhat complex from both the coding of medical necessity perspective, but essentially from a data metric perspective, you need to look at your E&M utilization per visit.

So essentially, if you’re thinking, doing the routine one and 12 every 30 days, from a data metric perspective that maybe makes sense, but E&M should be performed or re-evaluation should be performed when it’s appropriate based upon changes in the patient’s condition. You certainly want to avoid doing evaluation management services more frequently than one in nine visits.

So basically the way you figure that out is total visits within a period divided by the number of E&Ms performed in that period and you’ll get your ratio. The second thing is looking at your CMT utilization profile. It amazes me as long as the CMT codes have been in place, many providers tend to cluster code and basically what that means is that 99, if not 100% of the time, they’ll bill 9941.

Many providers manipulate full spine, get it. They don’t bill 9942 because they’re concerned about what it would look like if they’re billing the highest level of code all the time. So they back off and bill 9941 because it’s in the middle. We call that cluster coding. Regardless, data analytics don’t care what code you bill. They look for unusual patterns of billing a particular code.

So if you think you’re going to fly under the radar by billing 9940, the lowest level of CMT code all the time, you’re just as likely to get hit if you always bill four one or if you always bill four, two. You have to recognize that when billing third party payers, while you may manipulate full spine, you need to be very focused. They will only pay for manipulations performed in the areas of active symptomatology where there’s subluxation and an associated conditions similar to Medicare and with a patient who has neck pain and headaches. I certainly understand and they do too. While you might be manipulating the low back, the sacrum, the pelvis, but it just isn’t compensable under their standards of medical necessity.

So be also cautious about condition creep, where a patient comes in with neck pain and headaches and then you start asking questions, well what about your mid-back, what about your lower back. They report some complaints and you go ding, ding, ding and every case becomes a four one or four two.

So if you focus on the condition that brought the patient to your office, even if you’re trained full spine, I get that and you’re going to treat these other areas, you have to delineate which areas are directly related to the complaint and that you’re going to bill for and document those, and then in the additional areas, not directly related to the complaint, you document those separately and you don’t bill for those but if you do that, then you’ll get a natural diversion in your utilization pattern with respect to four two.

Don’t be afraid of it but if you have patients with full spine complaints, it’s okay to start out in your treatment plan with a four two but understand some of those complaints are going to drop out more quickly than others, in which case your code level should go down across the course of treatment.

So be cautious that when you look at your CMT utilization, you should see probably anywhere from 45 to 55%, four, O. Same thing for four one although it would be vice versa in a very low utilization percentage, 5% or less for four two. While we’re talking about manipulation, you also have to watch billing extremity manipulation. You can bill that if a patient has an extremity source complaint. I don’t mean radiation to an extremity, I mean an injury in an extremity with active symptomatology of an extremity HPI, history or present illness, examination, diagnosis, plan of care and it needs to exist separate and distinct from whatever’s going on in spinally.

If they only have an extremity complaint, only treat the extremity, but if you routinely bill extremity manipulation in addition to spinal manipulation, you’re going to be targeted for post payment review and in my experience, the documentation rarely supports the need for the extremity care and we have to give up on that issue.

Another highly audited code pairing is a spinal CMT or extremity CMT and manual therapy with a 59 modifier. While there’s a very hyper technical explanation of why the 59 modifier, depending on the technique utilized might be justified. More often than not, we don’t have time for it today, but you have to understand that payers don’t necessarily subscribe to that analysis in that opinion and generally consider that billing manual therapy in addition to manipulation is fundamentally wrong.

It’s permissible in very isolated circumstances, so you need to very carefully watch your utilization. If you’re going to do it, you need to justify three things, where the spinal manipulation is being performed, the condition it’s being performed, have an area of separation between the region you’re manipulating. So if you’re manipulating the neck, you’re doing manual therapy, same manual traction in the low back and in that, so you have the different regions separated by at least a region, and then in the region where you’re doing manual therapy, document why manipulation was contra indicated.

Otherwise, it might be more cost effective for you to manipulate, say the cervical region and the lumbar region. It’s still 98940, and they don’t have to pay any more money. So that’s just how they look at it. So be very cautious with that code pair. Another one is, if you’re doing for any therapeutic procedures, anything from 97110 through 97546. All of those codes, with the exception of group therapy, CPT 97150 require direct one on one contact and they’re all time-based. So if you’re always billing one-on-one contact codes, and let’s say you’re a solo practitioner, I mean they can do the math just as well as anybody and you get into what are called these impossible day scenarios.

Now if you’re using assistance, you need to be very cautious there. Some payers are okay with it, some payers aren’t. It depends on what the rules are in your state, and even if it’s legitimate for you to use unlicensed assistance to assist you in rehab and provide that contact, some payers still don’t allow it. So be very cautious about your utilization of one-on-one codes to make sure you don’t look like it would be impossible for you to do all that work.

Then they look at a number of other metrics, visits per patient, visits per patient per year, visits per condition and essentially what they do is they stack you up against other providers treating similar conditions. So what you need to do here, to insulate yourself is, don’t wimp out when you get the diagnosis and do subluxation and neck pain.

Neck pain doesn’t take a lot of treatment. Cervical radiculitis causing neck pain however, potentially does. So make sure that you accurately diagnose the condition causing the symptoms, which is required in ICD 10 anyway, and then be mindful of some of the guidelines and evidence-based stuff that payers rely on Milliman and whatnot to determine what are reasonable protocols of care.

The other one is, visit frequency and you might be surprised to figure out that I’m less concerned about too much as I am not enough. If your average visit frequency is point something visits per week, that’s bad, even if it’s one per week. Optimal frequency for physical medicine has traditionally, and this goes back to an old Medicare rule, two to three times a week. So when you’re treating less than that, it’s an indicator that your care is not likely to achieve significant improvements in the patient’s condition or capacity to function.

Keyword being, significant. Yeah, it’ll certainly help them, maybe palliatively if nothing else, but unfortunately those types of care are not covered. So payers look for visit frequency averages that are relatively low, one treatment per week or less, and then they tend to isolate those patients where they identify a predictable pattern of treatment once a week, once every two weeks, once a month, because those are cases that they can pretty much assume, do not meet their standards of medically necessary and they can deny and request a refund.

Final metric that I think is important is the number of services per visit. Some payers have very strict guidance that you cannot bill more than four units of anything in a physical medicine encounter and there is some theory behind that and I wish we had time to explain it, but be very, very cautious.

If you’re billing, five, six, seven, eight units of treatment, whether it’s in time units or multiple services leading up to a total of eight units, you’re probably going to be in a little bit of trouble. You’re likely to get audited and then dollars per visit is another metric. You know, if you’re just much more expensive for a visit, you’re not pounding out and I’m looking at allowed dollars, I mean if you charge $1000 for every treatment, that’s fine, but I’m more concerned about allowed dollars.

So if you charge $1000 for a manipulation, that’s not going to impact you, but it’s allowed charges per visit. So if you’re allowed charges per visit are significantly higher than your peers, likely because you’re doing more services per visit than your peers, then you could expect to be challenged at some point in time just because you’re more expensive than everybody else and therefore they have a motivation to either take you off the table through post payment audit, put you into prepayment review, things of that nature is how they negatively influence providers out of those patterns of care.

So I realize that was a whirlwind. I hope it was helpful and be sure next week to tune in. Sam Collins will be doing a presentation. I’m sure you’ll get lots of information out of that, and hopefully this will help you avoid post payment risk so that you’ll never find yourself in the position of needing someone like me to defend you against the payer who’s asking for a bunch of money back. Thanks everybody and have a great day.

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