Updates on Pre-Payment Audits, CPT codes and ICD-10 codes

New CPT Codes

The AMA CPT code committee will be reviewing the possibility of adding many new procedure codes. Three of them can part of a chiropractic practice in many states. Dry needling, trigger point acupuncture and low level laser therapy. Stay tuned.

New ICD-10 Codes

New ICD-10 codes become effective on October 1, 2018. Many codes were added, some deleted and some revised. Using the ICD-10 codes to the highest degree of specificity is more important now than ever before because of MACRA.

In my opinion, the only ICD-10 code that deserves attention as it relates to typical chiropractic care is M79.1 (myalgia/myofascial pain syndrome).

This 4-digit code now has the ability to add a 5th digit. Although M79.1 is still valid, it got more specific with the addition of 4 new codes:

  • M79.10: Myalgia, unspecified site
  • M79.11: Myalgia of mastication muscle
  • M79.12: Myalgia of auxiliary muscles, head and neck
  • M79.18: Myalgia, other site

Do not confuse the above codes with Fibromyalgia (M79.7) and Myositis (M60.88).

Pre-Payment Audits

Everyone has heard of POST-payment audits. They have been around for over 15 years. Many health plans such as Blue Cross/Blue Shield, Aetna, Cigna, United Healthcare and Medicare conduct them on a regular basis presently and will continue to do so in the future. Some plans are actually required by federal law to perform post-payment reviews as part of mandatory compliance.

PRE-payment audits are relatively new. After the implementation of a pre-payment audit (PPA) demonstration program in 2012 using recovery auditors in selected states, the CMS reported success in fighting fraud, waste and abuse. Private payers followed suit utilizing advancements in claims data analytics to identify irregularities in provider billing and coding practices to justify their use of PPAs. A pre-payment audit can be applied when there is a basis to suggest irregular or inappropriate services based on the claims submitted, referral tips from fraud hotlines or other means. Private payers conduct audits under the authority of anti-fraud statutes, through internal investigations and with the assistance of outside vendors.

Over the last 18 months, we have seen a dramatic increase in the amount of pre-payment audits. A reliable source just told me that one insurance company just hired 19 additional investigators to conduct for pre-payment reviews.

A pre-payment audit can cause chaos on a practice, creating cash flow problems and other issues that negatively impact the delivery of care. This process can be burdensome and frustrating. Staff members will need to spend hours preparing patient charts to be submitted to the insurance carrier. This delay in payment can have a significant impact on the practice because many providers rely on timely reimbursement in order to pay expenses and run their business. Reimbursement can be delayed for 90-120 days while your documentation is being reviewed to support medical necessity. Without a PPA, it normally takes only 15-30 days to get paid.

The PPA results could deny the claim for several reasons, including that the services billed do not match the patient records, the billed service lacks medical necessity, missing signature, no evidence of significant patient improvement, plus many more possible denial reasons. Pre-payment audits can last anywhere from 3 months to 2 years. Resolution of a PPA will come once the payer is satisfied with your billing and coding practices and the payer claims submission guidelines.

You do have rights. In some states, insurance companies must pay a claim or notify the provider that the claim is denied or contested within 20 days from receipt of the claim. If your claims are not being processed according to state law, contact an attorney as soon as possible and document all correspondence with the health plan investigator.

Compliance with an audit can be difficult because sometimes the payer will not communicate with the provider. The delays in reimbursement can go on for very long periods of time. In these instances, you may be left only with litigation as an option.

If you are placed in a PPA, hopefully you have been informed as to why. Being pro-active is the best way to never become subject of a PPA. In order to avoid this situation, implement simple, standard compliance regimes. Conduct formal staff trainings and have written policies and procedures. Many providers do not have the time or wherewithal to put together a simple policy manual. If that’s you, then contact us…we’ll do most of the “heavy-lifting” for you.

There is significant value in having the ability to generate documentation of accuracy in patient records supporting billing and coding. Since payers are analyzing claims submissions for what they view as abnormalities in coding and billing practices, conforming these practices to maximize compliance will reduce the risk of a payer implementing a PPA. Again, become pro-active. Don’t wait for the oil light to flash on your dashboard, get out of the car, lift open the hood and check it out.

As claims data analytics become more sophisticated and accessible, health plans are likely to implement PPAs with greater frequency. Providers and compliance teams should heed this trend and plan accordingly. If you are in presently in a pre-payment audit or about to start one, email or call us to schedule a free 15 minute consultation and we’ll show you how to conduct a self-audit. Target Coding OIG members, make sure you received our most recent chart audit tool and 12-point new patient exam. More on pre-payment audits coming soon.

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MIPS for PTs

In 2017 and 2018, physical therapists in private practice were not mandated to participate in MIPS. However, in 2019, this is all changing. CMS is proposing to add physical therapists as eligible professionals who would be required to participate in MIPS unless they meet at least one of the low-volume thresholds. Attend our webinar this November on MIPS for PTs to learn more.

For questions or for more info, please contact Dr. John Pecora @jpecoradc@wbcgp.com


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