As we begin 2021, the increased prevalence of Medical Reviews by Medicare Administrative Contractors (MACS) is appearing. The Targeted Probe and Educate (TPE) Medicare audit process was suspended during the pandemic but was re-instituted in August of 2020. Several MACs have started launching focused audits directed at therapy providers. We will discuss some of these reported findings below.
Let’s start by focusing on current active therapy specific audits and the upcoming post-payment medical reviews.
First Coast Services Options, Inc. lists the following active therapy-specific audits: Part A Outpatient Rehabilitation Facility, Inpatient Rehabilitation Facility, Skilled Nursing Facility, and Part B Rehabilitation Service providers.
Palmetto released a newsletter on January 22, 2021, announcing the upcoming post-payment medical reviews. The Part A list identified a focused audit on the following CPT Codes: 97110, 97112, and 97140 outpatient claims. Part A providers submitting these CPT codes should be on the lookout for additional documentation requests.
WPS, Novitas, and NGS have not published notice of active, therapy-specific, medical reviews in process as of the time of this blog.
Noridian Healthcare Solutions recently released therapy-specific findings of a focused audit on CPT 97530, therapeutic activities. The audit reviewed 118 claims spanning from September 1, 2020 through December 17, 2020. Noridian’s audit found zero percent compliance for claims submitting 97530 CPT Codes during this timeframe. This resulted in an overpayment being requested of the providers audited. The denial reason was reported that 97530 was not supported by the documentation. Providers do have the option to appeal these findings through the Noridian Appeals process.
Here is a summary of the findings:
- Initial Evaluations and Progress Notes were not signed by the provider.
- The documentation did not support the CPT Code submitted.
- Incomplete or Insufficient documentation.
- Plan of Care Certification physician signature non-compliance.
What is Your Best Defense?
The best defense when it comes to documentation, is to have a “great offense”. A great offense typically includes capturing skilled and timely documentation in support of the CPT codes submitted on claim forms.
A great offense involves the following:
- Clearly identify a lead person to respond to audit requests—sort of like having a quarterback. This person should understand the documents needed and unique needs of each payer’s documentation requests.
- Have a process in place to train newly hired staff on skilled documentation based upon the patient’s condition and appropriate CPT Codes. Newly hired staff pose a high risk to your practices successful audit. Look at your clinical staff as your offensive line. If your offensive line is not trained or is trained but cannot execute the plan, their documentation may not hold up to an audit. Thus, the quarterback or lead person is not protected.
- Identify the clinical staff who document well or have been successful when their documents come under an audit. These staff members can serve as your multi-purpose player, who can mentor and assist other teammates.
- Utilize external experts to assist you in improving your team’s performance. Having an external review of your team’s performance provides objectivity, such as having an external consultant conduct an audit of your documentation. This is one of the most important steps to having a great offense.
How LW Consulting, Inc. Can Help
- LW Consulting, Inc. (LWCI_ possesses over 100 years of therapy-specific auditing and appeals response experience collectively within the therapy field.
- LWCI offers a cloud-based therapy auditing product, ChartVerify®, which allows providers to routinely conduct audits and identify risks proactively. ChartVerify® is available to providers for a monthly fee and allows providers to download audit compliance reports within seconds.