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Health Care Provider Insights | 3rd Edition

July 11, 2017

Authors: John H. Jankoff, Heather M. Levine-Levy

In this month’s edition of Health Care Provider Insights, we provide the following insights to help you protect your practice.

Tip #1: How to Avoid Denials for New-Patient Codes

In the past several years, denial rates for the five new-patient Current Procedural Terminology (CPT) codes (99201 through 99205) have gone up. Denials may be caused by incomplete documentation that does not contain all exam elements. To avoid denials, you need to have a higher level of documentation for a new-patient visit than for an existing patient visit. CPT guidelines require three components for the new-patient codes: (1) a comprehensive history, (2) a comprehensive physical exam and (3) the level of complexity of medical decision making (straightforward, low, moderate, or high). Codes 99204 and 99205 require a review of at least nine organ systems, and so you must perform a full exam to be able to bill for these codes.

Denials also may be caused by inadvertently categorizing someone as a “new patient” who has been seen by a partner with the same specialty in the same practice within the past three years. To avoid denials for this reason, you should make sure that your front-desk staff, coders and billers communicate clearly, and advise front-desk staff to find out when the patient was last seen. In addition, you should make sure that you and any other doctors in your practice are registered correctly in PECOS (provider enrollment, chain and ownership system) according to your specialties. This is important for determining whether a patient is a new patient or an existing patient and for coding appropriately.

Tip#2: How to Avoid Employing Fraudulent Staff

One possible risk to your practice is the inadvertent employment of fraudulent staff. Recently, there was a case where a medical facility settled with the Office of Inspector General for allegedly violating the civil monetary penalties law by employing someone who falsely claimed to be a registered nurse.

To avoid employing fraudulent staff and incurring unnecessary charges, it is advisable that you take the following steps:

  • Be aware of the fact that fraud exists and that there are people who will engage in fraud to obtain employment.
  • Train your HR manager/staff in screening prospective employees and in obtaining the necessary documentation to prove that the prospective employee has the appropriate credentials for the position.
  • Make sure that you have sufficient HR staff to screen potential applicants thoroughly and that your HR staff has enough time to do so.
  • Contact or have your HR staff contact all references given by a prospective employee.

Tip #3: How to Properly Amend Medical Records

Through their review of medical records, Medicare administrative contractors (MACs) such as Noridian Medicare Portal have discovered improperly amended records. Examples of mistakes physicians make are (1) adding a note to a patient’s file with no new date or signature and (2) forgetting to put in a contemporaneous note and adding a note weeks or months later. Noridian has given the following guidance:

  • Late entries are defined as “additional information that was omitted from the original entry.”
  • Addenda are “used to provide information that was not available at the time of the original entry” and should “be timely and bear the current date and reason for the addition or clarification of information being added to the medical record and be signed by the person making the addendum.”
  • Corrections are made to rectify inadvertent errors in the original record.

To avoid making mistakes in amendments to medical records, it is advisable that you do the following:

  • When you amend a medical record, put in the date on which you are making the amendment, not the date of the original note.
  • Make sure that the amended medical record clearly identifies what was originally in the record and the amendment.
  • To identify who is making the amendment, be sure to include your initials on the amendment − if you are identifiable by your initials through a signature log or electronic health record (EHR) − or your full signature.

Contact Us:
Heather and John are available to answer any questions or concerns about your practice. Please note their contact information and links to their bios below.

John Jankoff - Of Counsel - Wilson Elser Health Care Newsletter
John H. Jankoff
Of Counsel - New York
Phone: 212.915.5507
Wilson Elser - Web Email
 Heather Levine-Levy - Associate - Wilson Elser Health Care Newsletter
Heather M. Levine-Levy
Associate - New York
Phone: 212.915.5464
Wilson Elser - Web Email

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