Compliance is Front and Center for OIG

Compliance is Front and Center for OIG

  • 25 Apr Off
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While attending HealthCon 2016 this month, sponsored by the American Academy of Professional Coders, I was struck by several facts and trends and want to pass these on to our PACE community friends.  Most of these have to do with compliance issues related to documentation, coding and payment.  As mentioned previously, I’ve selected compliance our dominant theme in 2016, and much of what I heard at HealthCon reinforces this.

First is the completeness and accuracy of risk adjustment data.  The Office of Inspector General (OIG) for HHS 2016 Work Plan points to fresh emphasis on accurate payments by CMS across the spectrum of payment models, and specifically targets compliance with Part C requirements.  As you probably know, PACE plans are considered Part C plans along with Medicare Advantage plans and are held to the same standards of completeness and accuracy in their data integrity.  Our audit activities across many PACE programs reveal very significant lapses of completeness in diagnosis coding and coding data management that put programs at risk.  More disturbingly, many reviews have shown that medical record documentation does not always support the diagnoses submitted to CMS by PACE organizations.  

 Second, with the impending increased requirements of reporting in-house encounter data, PACE programs must understand complex procedural coding rules.  Basic procedure coding for provider office visits is complicated and even expert coders disagree on how some encounters should be coded.  Most providers have some previous experience in Evaluation and Management visit coding, but many have not and many other PACE professionals have never experienced coding their procedures.  In spite of the fact that encounter data does not currently drive Medicare payment for PACE, this may ultimately be an area of compliance risk for PACE and is already a major focus in other payment models.

 Many other compliance issues were presented at discussed at HealthCon, but I want to single out one more for emphasis, which the issue of cloning records.  Sometimes known as copy/paste, this practice is widespread and has become a favorite target of auditors, especially in terms of CPT coding, when adding additional information to a note creates the appearance of higher complexity.  We have previously issued guidance on this, but want to say it again:  if your providers resort to copy/paste, they must also edit the content to fit the existing situation on that encounter date.  We strongly encourage self-audits of your providers to detect and correct practices that could be interpreted as false documentation, inadvertent upcoding or inappropriate copy/paste without updates.  Make sure your clinical staff understands the risks of copy/paste/cloned notes and that these should always be edited, if used at all.

 As always, if we can assist you in any way to assess or reduce your compliance risks, please don’t hesitate to contact us.