How to Handle Medicare Documentation Audits

The Hospitalist. 2013 November;2013(11):

November 1, 2013 | The Hospitalist

Responding to Requests

When documentation is requested by the payor, take note of the date and the provider for whom the service is requested. Be certain to include all pertinent information in support of the claim. The payor request letter will typically include a generic list of items that should be submitted with the documentation request. Consider these particular items when submitting documentation for targeted services typically provided by hospitalists:

Initial Hospital Care (99223)
- Physician notes (including resident, nurse practitioner, or physician assistant notes);
- Identify any referenced sources of information (e.g., physician referencing a family history documented in the ED record);
- Dictations, when performed;
- Admitting orders; and
- Labs or diagnostic test reports performed on admission.

Subsequent Hospital Care (99233)
- Physician notes (including resident, nurse practitioner, or physician assistant notes);
- Identify multiple encounters/entries recorded on a given date;
- Physician orders; and
- Labs or diagnostic test reports performed on the requested date.

Documentation Tips

Because it is the primary communication tool for providers involved in the patient’s care, documentation must be entered in a timely manner and must be decipherable to members of the healthcare team as well as other individuals who may need to review the information (e.g., auditors). Proper credit cannot be given for documentation that is difficult to read.

Information should include historical review of past/interim events, a physical exam, medical decision-making as related to the patient’s progress/response to intervention, and modification of the care plan (as necessary). The reason for the encounter should be evident to support the medical necessity of the service. Because various specialists may participate in patient care, documentation for each provider’s encounter should demonstrate personalized and non-duplicative care.

Each individual provider must exhibit a personal contribution to the case to prevent payors from viewing the documentation as overlapping and indistinguishable from care already provided by another physician. Each entry should be dated and signed with a legible identifier (i.e., signature with a printed name).

The next several articles will address each of the key components (history, exam, and decision-making) and serve as a “documentation refresher” for providers who wish to compare their documentation to current standards.

Reader Question: Physician of Record for Hospice

Question: Your November 2012 article, “Hospice Care vs. Palliative Care” (p. 20), was very educational to me as a coder for a rural hospital. I have one other question, though. Would the AI modifier be appropriate to identify the primary physician of record for hospice (i.e., 99222-AI-GV)? Please advise, as I can’t find clear direction.

—A Conscientious Coder

Answer: Modifier AI would not be applicable for inpatient hospice services, as these services are considered under a different benefit and coverage criterion than acute inpatient stays. The hospice-attending physician is a doctor of medicine or osteopathy who is identified by the patient at the initiation of hospice care. This attending is responsible for having the most significant role in the determination and delivery of the individual’s medical care.⁸

If the patient does not have an attending physician who has provided primary care prior to or at the time of the terminal diagnosis, they may select a physician who is employed by the hospice. Payment for services by hospice-employed or hospice-contracted attending physicians is made to the hospice company. For these services, the hospice company establishes a charge and bills the Medicare contractor under the Medicare Part A benefit.⁸

The patient, however, may decide to use an “independent” attending physician (not employed by or contracted by the hospice to receive payment for professional services furnished to the patient). Professional care involving the hospice patient’s terminal condition provided by an independent attending physician is billed to the Medicare contractor through the Medicare Part B benefit. The Medicare contractor makes payment to the independent attending physician or beneficiary, as appropriate, based on the payment and deductible rules applicable to each covered service, if the provider alerts the payor that this service is not otherwise covered under the hospice Part A benefit.⁸

To distinguish as the hospice “attending of record” and receive separate payment for services, the independent attending physician must append modifier GV (Attending physician not employed or paid under arrangement by the patient’s hospice provider) to all services (initial and subsequent).

—Carol Pohlig