“The most common outliers are those physicians who upcode in high volume. If a physician is three standard deviations from the mean, he or she will be on an audit program’s radar.”
profiles based on that information. At that point, Medicare can see who stands out in terms of overpayment and under- payment.
“The most common outliers are those physicians who upcode in high volume. If a physician is three standard devia- tions from the mean, he or she will be on an audit program’s radar,” Mr. Chou- teau said. Keep in mind, however, that under-
coding doesn’t mean a physician is im- mune to an audit. Mr. Chouteau says this is one of the common coding myths. Such myths may contribute to revenue loss and risk of a formal audit in physi- cian practices. Here are three other common coding
myths:
1. Receipt of insurance payment verifies correct coding.
2. Practices that don’t accept Medicare payments are not audited.
3. The targets of audits are large group practices; small, solo practices are not audited.
2. Submit a request for reconsideration of the MAC decision to the qualified independent contractor.
3. File an appeal for the case to be heard by an administrative law judge (ALJ).
4. If you lose, request a review by the Appeals Council within 60 days of receipt of the ALJ’s decision. Be sure to specify the issues and findings you are contesting.
5. Request judicial review before a U.S. District Court judge if at least $1,300 is still in controversy following the Appeals Council’s decision.
For more information on the ZPIC ap- peals, visit the CMS website at
www.cms .gov/MLNproducts/downloads/Medi careAppealsProcess.pdf. At press time, some of Mr. Chouteau’s clients had advanced as far as the third step in the appeal process. He explains physicians have been experiencing de- lays in having their cases heard before ALJs due to a backlog in appeals.
24 TEXAS MEDICINE September 2011
“It’s taking well over a year, even up to two years, before a physician can get an ALJ hearing,” he said.
Don’t take ZPIC lightly Why the ZPIC program honed in on Dr. Clark isn’t clear. But he has a theory. “I think it boils down to the fact that I’m one of few doctors in the area dedi- cated to the practice of treatment for venous disorders. I’ve been totally sur- prised by all the patients from McAllen, Rio Grande City, and Corpus Christi, making the clinic much busier than I ex- pected. I’m sure the fact that my clinic performs a large number of procedures per year makes me stand out,” he said. ZPICs do sophisticated data min-
ing, Mr. Chouteau says. OIG and CMS have created large databases of claims submissions. Medicare uses them to scour claims data to identify the most frequently billed codes and to compare that information across specialty areas. The databanks then generate physician
Inaccurate coding can signal the CMS about irregularities in a practice and may trigger a formal audit. Because CMS uses profiling to identify practices for audits, if your coding varies from other physicians in your specialty, you will stand out. The result may be recoup- ment of payment. Contact TMA Practice Consulting at
(800) 523-8766, or email
practice.con
sulting@texmed.org for more informa- tion about coding and documentation auditing and training services. When a ZPIC targets a medical prac- tice, a documentation problem is almost always the culprit, Mr. Chouteau says. He adds that in many instances, records simply aren’t properly signed and dated. “Physicians need to be diligent in documentation, and they need to have someone qualified getting their hands on those charts to ensure they’re coded and documented correctly. If you let problems go, when they come to a head with an audit, it will result in a lot of expense and hassle for the practice.” Indeed, ZPICs can have a devastating impact on a medical practice. Mr. Chou-
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