finished reviewing the documentation, he and Dr. Wood will set another informal review with the agency to discuss OIG’s final findings. Dr. Wood’s ordeal with OIG is taking a tremendous emo- tional and financial toll on him. He describes it as “going through all the stages of grief” and says he’s ready to move forward and resolve the case. Dr. Wood is grateful for TMA’s help during a trying time. “I shared the records in question with TMA and gave the Of-
fice of General Counsel a copy of our documentation and the independent coder’s assessment. TMA then routed the infor- mation to two pediatricians and another specialist for review. All three of them responded by saying they found some minor coding mistakes but nothing to suggest fraud,” he said. TMA’s Patient-Physician Ad- vocacy Committee reviewed Dr. Wood’s documentation and recommended the association support Carousel Pediatrics in an effort to ensure fair treat- ment of physicians subject to the OIG’s Medicaid fraud in- vestigation process. Mr. Chouteau says he and
Dr. Wood hope to resolve OIG’s case against Carousel Pediat- rics soon.
Ms. Goodman says HHSC
can’t comment on it because the investigation is still open.
DEDICATED TO MEDICAID PATIENTS Dr. Lewis’ experience with OIG mirrors that of Dr. Wood. Be- ginning in 2005, he struggled to keep his office open after his billing practices caught OIG’s attention.
In its investigation of Dr.
Lewis, OIG reviewed only 30 records out of tens of thou- sands of his patients’ files and concluded he’d overbilled Med- icaid $146,396.89 for 2004 and 2005. After OIG factored in administrative penalties, Dr. Lewis potentially owed the state $439,109.67. Confident he hadn’t inten-
tionally defrauded Medicaid, Dr. Lewis requested a formal hearing with the State Office of Administrative Hearings. Dur- ing the four months leading up
to the hearing, the state withheld 25 percent of his Medicaid payments. At the 2006 hearing, a medical coding expert testi- fied that he examined the same 30 files and found Dr. Lewis’ charges to be in line. Judge Shannon Kilgore ruled in Dr. Lewis’ favor and told the state it couldn’t withhold the payments. Even so, OIG or- dered him to file all Medicaid claims by paper, instead of elec- tronically. At the time, Dr. Lewis says the state denied more than $500,000 in traditional Medicaid claims. Parkland Commu- nity Health Plan Medicaid HMO did pay his claims, however. Facing potential financial ruin and the threat of having to shut down, Dr. Lewis ran his practice out of his own pocket.
CODING ANXIETY? TMA CAN HELP
TMA Practice Consulting offers evaluation and management (E&M) cod- ing and documentation help that includes a review of claims, coding, and medical record documentation to determine whether a practice follows coding guidelines for appropriate billing. An abbreviated checkup and a full review are available. TMA Practice Consulting reviews a practice’s documentation for:
• Accurate CPT coding, appropriate application of CPT coding guide- lines, E&M coding guidelines, and the correct use of modifiers;
• Accurate ICD-9 coding, appropriate application of ICD-9 coding guidelines, and documentation of medical necessity; and
• Encounter forms, claims, and corresponding explanations of benefits to ensure accurate billing and reimbursement levels.
TMA also offers an E&M coding and documentation training program
for practices that need help understanding documentation guidelines or identifying inappropriate or inaccurate coding and weaknesses in medi- cal record documentation. The two-hour session covers a review of 1995 and 1997 E&M documentation guidelines, time-based coding, modifiers, audit triggers, prolonged services, preventive medicine, and E&M utiliza- tion patterns, among other topics. Services are available for a fee based on a practice’s needs. For more information, call TMA Practice Consulting at (800) 523-8776,
email
practice.consulting@
texmed.org, or visit
www.texmed.org/Practice Help to access all of TMA’s billing and coding resources. TMA Practice E-Tips Greatest Hits, Vol. 3: Coding is available free of charge online,
www.texmed.org/template.aspx?id=1492.
December 2012 TEXAS MEDICINE 21
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