SAN DIEGO – If you or your emergency medicine group is audited, one strategy is to use the Marshfield Clinic Tool to help explain medical decision making – specifically how comorbidities, the differential diagnosis, and special studies affected the course of treatment.
This marks one of 10 audit defense strategies that Edward R. Gaines III, J.D., shared at a meeting on reimbursement and coding held by the American College of Emergency Physicians.
Edward Gaines III
The other nine are as follows:
• Do not assume that the auditors have ED coding knowledge. Use the Emergency Medical Treatment and Labor Act (EMTALA) to help explain medical necessity in the context of emergency medicine. "A lot of medical directors and coders employed by the CMS Medicare administrative contractors and the Recovery Audit contractor auditors have no idea about EMTALA," said Mr. Gaines, who is the chief compliance officer of the Greensboro, N.C.–based Medical Management Professionals.
• Explain why you code with the presenting symptoms instead of with the final diagnosis. "Your auditor may be from a hospital background, and they’re all about the final diagnosis because that is how hospitals train their coders based on [American Hospital Association] inpatient standards," he said. See the government’s final ruling on this topic.
• Be thorough about the "nature of the presenting problem." "Explain how it impacts not only initial presentation but also comorbidities and the differential diagnosis," advised Mr. Gaines, who is also cofounder of the Emergency Department Practice Management Association.
• Insist on providers being part of the audit defense process. Use the audit "as an opportunity to educate the auditor and the client," he said.
• Make sure your documentation is true, accurate, and complete. This includes signatures on the E/M documentation, orders, and supervisory notes regarding nonphysician-practitioner and Physicians-at-Teaching-Hospitals documentation for residents. A free documentation template is available.
• Consult with counsel as appropriate, especially when large amounts of money are involved.
• Prepare a prompt and thorough response. "After the redetermination or reconsideration stages, you cannot submit any additional documentation evidence in the appeal, so you don’t want to find yourself limited," Mr. Gaines noted. "Submit complete and thorough documentation at the initial stages of the appeal."
• Don’t argue for the sake of argument. "If you missed the coding, just punt and maintain an expert, polite, and professional demeanor," he said. "That’s the best way to go to maintain credibility for the cases that you really want to argue about in the audit."
Mr. Gaines offered meeting attendees an 11th tip, a concept from Medicare case law known as the Treating Physician Rule. This rule states that deference should be given to the treatment decisions of the treating physician. "While deference is supposed to be given under the rule in Medicare cases, the deference does not rise to a presumption that the physician’s treatment was medically necessary and appropriate," Mr. Gaines stated. "The provider still has the obligation to show that services were medically necessary."
Mr. Gaines said that he had no relevant financial conflicts except as noted above.