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Introduction
This section summarizes how Mountain State conducts reviews of Evaluation and Management (E/M) services coding. Included is a copy of the auditors' worksheet that both nurse and/or coding reviewers and Mountain State medical directors use to document their findings. This section is included in the revised Mountain State Provider Manual.
Pre- and Post-Payment Reviews
Mountain State periodically performs audits of providers that have been selected based on their utilization and billing patterns, relative to their peers, of E/M codes for new and established patients. A statistically valid random sample of records for the questioned services is requested and reviewed by a Mountain State staff member.
Typically, a certified professional coder and/or registered nurse perform the initial record review. The medical director also reviews any cases contested by the Provider.
Similarly, Mountain State may on occasion pend and review a Provider's claims for E/M services on a pre-claims payment basis. A staff member will perform the review.
Criteria Used in Reviews
In the performance of E/M reviews (whether pre-
or post-payment of claims), the reviewer will use the following
criteria to assess adequacy of documentation of the level of
service billed:
- The applicable E/M Services Guidelines published by the
American Medical Association (AMA) in the Current Procedural
Terminology book (CPT book);
- The 1995/1997 Documentation Guidelines for E/M Services, published
by the Centers for Medicare & Medicaid Services (CMS). This
can also be found at the CMS web site at www.cms.hhs.gov;
and
- The requirement in Mountain State group and individual
Policies and Provider contracts that services be Medically
Necessary.
Documentation of Findings
To document their reviews of E/M services, Mountain
State reviewers use an E/M
Documentation Auditors' Worksheet, modeled on a CMS carrier
worksheet. Reviewers may supplement or annotate the worksheet
with written comments and specialty score sheets that incorporate
the elements of examination "bullets" from the 1997 E/M Documentation
Guidelines. Samples of the specialty score
sheets are included with the E/M Documentation Auditors'
Worksheet.
Providers may wish to use the worksheet and guidelines for self-audits to monitor their compliance with recognized documentation standards.
Treatment of Under Coding
E/M reviews will document determinations of both over coding and under coding. In the event Mountain State determines that documentation supports a higher E/M level than billed, Mountain State will adjust the claim and pay the appropriate higher level of reimbursement, and also give credit in the calculation of any extrapolated overpayment.
Modifier 25 Reviews
In addition to E/M reviews focused on the correctness of the level of service billed, Mountain State may also conduct retroactive audits to determine the appropriateness of the use of Modifier 25 and other modifiers related to E/M services. In performing such reviews, Mountain State will use as its primary review standards the descriptions of the modifiers set forth in the CPT book, as well as the E/M documentation criteria described above.
Review of Results with Providers; Provider Remedies
At the conclusion of a review, the results are shared with the Provider in writing. Copies of the audit worksheets are available upon written request. The Provider is afforded the opportunity to rebut audit findings. A Provider may also request that contested cases be reviewed specifically under either the 1995 or 1997 Documentation Guidelines. A face-to-face meeting with Mountain State is available to:
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Ensure the Provider understands the audit process and results;
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Answer any questions regarding correct billing or documentation standards;
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Afford the Provider an opportunity to furnish additional information; and
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Discuss repayment arrangements, if applicable.
Sampling and Extrapolation
Mountain State's procedures for auditing Providers
may include the use of statistically valid random sampling and
extrapolation. If sampling reveals a consistent pattern of overcharging
or other fiscal abuse by a Provider, the Provider will be required
to reimburse Mountain State for the projected total overpayment.
The calculations for computing such an overpayment are as follows:
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The total dollar overpayment in the audit sample is calculated;
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This total overpayment is divided by the total paid dollars of audited cases to determine the error rate;
- This error rate is multiplied by the total paid dollars
of applicable cases for which the Provider received payment
during an audit period to determine the total overpayment
.
If underpayments are found in an audit, they
are subtracted from any overpayments, and factored into calculation
of the error rate and total extrapolated overpayment or underpayment
amount.
The Provider will be notified in writing of the amount to be recovered with appropriate documentation to support the findings. After receipt of the notice of overpayment, the Provider may within 30 days request a conference to allow an opportunity to present additional information or discuss an extended repayment plan.
Audit Appeals
Challenges to audits set forth in Chapter 10
of the provider manual may be requested pursuant to the following
appeal process:
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Level I: A provider has 30 days from receipt of the audit findings in which to request an appeal. Typically, reviews will be conducted by a Certified Professional Coder or similarly qualified employee.
- Level II: If the audit is upheld and the provider
is still unsatisfied, he/she may request a second level appeal
within 30 days of the Level I decision. A Mountain State medical director will perform a review of a representative sample of the disputed findings.
- Level III: If after a Level II review the audit
is upheld, and the provider is still not satisfied with the
decision, he/she may request a third level appeal within 30
days of the Level II decision. During this Level III review,
records will be submitted to the Mountain State Medical Advisory
Committee (“MAC”). See Chapter 11 of the Provider Manual for
specific MAC procedures.
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Other: If the provider is still unsatisfied, Mountain State may, at its discretion, allow a fourth level appeal to an outside entity of its choosing, comprised of relevant medical professionals in like specialties, provided the provider agrees to share equally in the cost of the external review. Requests for a fourth level appeal shall be made in writing within 30 days of the final Level III appeal decision.
Retention of Records
Mountain State will maintain the worksheets and findings of E/M reviews for a period of at least three (3) years, in accordance with Mountain State's corporate record retention policies.
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