Increase Your Revenue and Avoid Audits: Here's How

NEW YORK—Today's oncologists must maintain a balance between revenue and patient care, according to Mariana S-B Lamb, MS, founding senior partner and CEO of Efficient Physician, Inc., a health care management firm. "Practice viability can only be maintained by being flexible and open to change," Ms. Lamb said at the second annual Oncology Congress.

She stressed the need for proper coding "in order to preserve the health of your practice." If a physician spends 20 to 40 minutes with a patient and documents poorly (using CPT CODE 99203, for example), she said, Medicare pays only about $98.73. "You can double your legitimate reimbursement by bringing your documentation to an appropriate level," she said. Only a few extra minutes during the evaluation and management (E&M) might be required to bring the documentation up to a CPT 99204 ($139.52) or 99205 ($177.09), she commented, adding that, of course, the content of the service is the critical part.

"You get paid about $4.94 per minute for the first 20 minutes. You could potentially receive $6.98 to $8.85 per minute for the extra few minutes needed to properly complete the chart," Ms. Lamb said. Moreover, she stated that if physicians undercode or under-report levels of diagnosis and services, they are, in effect, driving down current and future levels of reimbursement and utilization.

Medical Necessity

She cautioned the audience about audits: "If you don't follow guidelines, you're vulnerable to ever-increasing audits. Document what you did and why you did it. It is vital that you assign codes according to medical necessity." The documentation of each patient visit should include the reason for the encounter and relevant history, exam findings, and prior diagnostic test results.

"Write down everything on your mind about your patient's condition and any potential concerns about treatment," she said, adding that the medical record should be complete and legible. To that end, she strongly advised that practices of all sizes move toward adopting electronic medical records systems.

'Incident to' Services

"Be sure you know your 'incident to' services billing requirements," Ms. Lamb said. These services will be fully reimbursed only under certain conditions:

• The service is rendered under the physician's direct personal supervision.

• The service is integral, although incidental, to a covered physician's service.

• The service is one that is commonly furnished in a physician's office.

• The service is included on the physician's bill.

• Code 99211 is used if the presenting problem is minimal, typically requiring only 5 minutes, and the service is rendered under the supervision of the physician.

• Chair rounds are properly documented in the practice's medical records.

Know Your OIG

"In today's challenging environment, risk of an audit makes us do strange things, such as having too much conformity in our levels of billing," Ms. Lamb said. She noted that of the top 10 specialties in the focus of the Office of Inspector General (OIG), medical oncology is ranked number 2, and hem/onc is number 3. Some special areas of concern for the OIG include:

• Too much single-level service (level 3) billing.

• Providing medically unnecessary services.

• Billing services or items prior to being rendered.

• Duplicate billing.

• Billing for noncovered services under a covered procedure code, incorrect place of service, and bundling.

To determine the risk of an audit, Ms. Lamb suggested that practices randomly select 20 to 30 claims from last year and check the levels of E&M services billed against documentation. "Check the diagnosis code on the claim for consistency with the medical record and the fee ticket documentation," she said. Ms. Lamb recommended that physicians thoroughly understand individual guidelines for E&M visits and their appropriate levels and required documentation.

The Three C's

"It is crucial that you understand all of the changes under MMA. Educate and train your entire staff. The health of your practice ultimately depends on the three C's—careful, complete, and correct coding and billing," Ms. Lamb said.

She encouraged the audience to consistently monitor drug costs and review all private payer contracts to ensure that reimbursement for drugs and services is adequate.

She emphasized that drug margins are a thing of the past; oncologists must now ensure adequate documentation and reimbursement for services, through benchmarking and monitoring.

"We're facing challenging economic times, but above all else, patient care should remain the focus of your practices in the new world of oncology," Ms. Lamb concluded.