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Marilyn Hammon

Publications and source records attributed to Marilyn Hammon.

17 recordsLinked to original sources
PubMed2006

A compliance focus on the 2006 OIG Work Plan.

To determine which areas of professional billing present the highest risk to your practice, it is recommended that physicians and their office staff review the Office of Inspector General's (OIG) annual Work Plan. The Work Plan details areas for increased scrutiny by the federal government due to a high rate of inappropriate billing, which has cost the Medicare program millions of dollars. The OIG's Work Plan for Fiscal Year 2006 identifies several new areas of investigation, but what is more curious is what is not on the OIG Work Plan for 2006. For the first time in several years, this year's Work Plan does not include investigations into evaluation and management services (E/M), including the controversial consultation codes. But don't let your guard down on E/M documentation as our local Medicare carrier has stated they will begin a widespread probe review into the hospital admit CPT code 99222. Documentation to support the billing of CPT 99222 must include a comprehensive history (including ten review of systems); a comprehensive examination of eight or more organ systems for the 1995 guidelines or two elements from each of nine systems of a 1997 multisystem exam; and moderate decision making. Medicare will also be requesting reviews on subsequent inpatient hospital care codes, CPT 99231, 99232 and 99233.

Fees, Medical↗
PubMed2006

Physician documentation essential for accurate coding and billing of excision of skin lesions.

Clear and precise documentation is essential to accurately code and bill for excision of benign or malignant skin lesions. Detailed documentation is crucial for capturing the full allowable reimbursement when the procedure involves more than a simple closure. For each lesion, only one type of removal may be reported, whether it is destruction, debridement, paring, curettement, shaving or excision. If an initial attempt to remove a lesion by a less invasive procedure is immediately followed by a more invasive lesion removal, only the more complex, definitive procedure may be billed. According to the Current Procedure Terminology manual (CPT), an excision of a skin lesion is defined as "full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure when performed." Changes in recent years now allow code selection based on the greatest clinical diameter of the lesion plus the narrowest margin required for adequately excising the lesion, "based on the physician's judgment." According to CPT, the "measurement of lesion plus margin is made prior to excision".

Current Procedural Terminology↗
PubMed2005

New coding and billing opportunities for 2005--Part I.

Part I of this series will highlight several changes in coding and billing for 2005. Medicare has established new preventive medicine services and screening tests for beneficiaries, but they have certain qualifications and documentation rules that must be followed. New codes have been established for using the Internet or similar electronic communications in response to a patient's request. There are additional revisions for pediatricians, orthopedists, endoscopists and surgeons performing transplants and bariatric surgery. All new CPT codes must be activated and deleted codes must be discontinued effective January 1, 2005. From that date forward, the patient's date of service must reflect current diagnosis (ICD-9) and procedure/services (CPT and HCPCS) codes. The Health Insurance Portability and Accountability Act (HIPAA) mandated a January 1, 2005, date compliance for all new and deleted diagnosis (ICD-9-CM) and physician service codes (CPT and HCPCS). Physicians no longer are allowed the 90-day grace period to update their coding systems to reflect the changes. The new 2005 CPT book contains many revisions within the codes themselves along with revisions found in the specific "guidelines" at the beginning of many sections. The CPT codes for 2005 contain 26 deleted codes and 130 new codes, thus providing a challenge to update all coding systems by the January 1, 2005, compliance date for CPT codes.

Current Procedural Terminology↗
PubMed2005

New coding and billing opportunities for 2005--Part II.

Part I of this series highlighted several changes in preventative care services and additional revisions for pediatricians, orthopedists, endoscopist and surgeons performing transplants and bariatric surgery. Part II addresses several new codes in gynecology, orthopedics, neurosurgery, and ophthalmology. It also includes wound care along with many revisions within chemotherapy for Medicare patients. All new CPT codes should have been activated and deleted codes discontinued effective for dates of service on or after January 1, 2005. From that date forward the patient's date of service must reflect current diagnosis (ICD-9) and procedure/services (CPT and HCPCS) codes.

Current Procedural Terminology↗
PubMed2005

Why should your practice perform compliance audits based on the latest OIG Work Plan?

Why have compliance audits, or medical record reviews, become an essential part of many progressive medical facilities? Because medical record reviews are known to improve reimbursement, documentation, and internally identify compliance issues that should to be promptly addressed, in order to protect the organization from substantial monetary penalties and legal sanctions by the federal government. This article discusses the importance of auditing based on the areas of focus recently identified in the OIG Work Plan. These include VA physician billing, pathology/clinical laboratory services, identifying referring physicians in Oklahoma that are sanctioned, high level E/M services, consultations, and red flags that are raised due to overuse of modifier -25 and -59.

Fees, Medical↗
PubMed2005

Compliance update--valid types of signatures in this modern era.

Proper signatures in the medical record is an area of concern because they are included in the Office of Inspector General (OIG) Compliance Guidance as a potential risk area effecting physician practices. One of the four areas identified by OIG is timely, accurate and complete documentation, which includes "date and legible identity of the observer." Federal auditors deny claims and require refunds if signatures are omitted from documentation of services. The vision of the current President is for all Americans to have Electronic Health Records (EHR) within a decade; this implies a growing use of electronic signatures. What constitutes a valid signature, and what regulations affect the use and type of signature? Businesses require signatures on many forms and documents. However, what if a check is not signed; can it be cashed? If a contract is not signed, is it binding? Similarly, if the medical record is not signed, will it withstand scrutiny in court? What is the significance of a signature? How important is it to authenticate or sign a report? To authenticate means to verify that the message/report comes from its stated source; therefore the author stands behind the documentation as written. The type of signature that is acceptable is variable, depending on the facility and the form payer requires.

Documentation↗
PubMed2005

Understand the "fine print" when selecting the correct codes for patient admissions from clinic to hospital.

How should a physician code and bill for services when a patient is seen in the clinic and then is directly admitted to the hospital? The correct answer is not as straightforward as it might at first seem because of needing to understand what amounts to the "fine print" in the Current Procedural Terminology (CPT) book code description. It also depends on whether or not the physician subsequently had face-to-face contact with the patient in the hospital. According to the CPT book, "When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (e.g. physician's office) all evaluation and management services (E/M) provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission. The inpatient care level of service reported by the admitting physician should include the services related to the admission s/he provided in the other sites of service as well as in the inpatient setting." At first, this wording could lead physicians and coders to conclude that their only recourse is to "roll up" the level of service provided in the clinic with the additional documentation necessary to admit a patient to the hospital to determine the code for "Initial Hospital Care", CPT 99221-99223. However, it has been noted that the description in the CPT book under initial hospital care has "fine print" in the statement the "codes are used to report the first hospital inpatient encounter with the patient by the admitting physician." "Encounter" is commonly understood to mean a "face to face" encounter between the physician and patient in the hospital setting. But, what if the physician does not go to the hospital to see the patient on the same date that s/he saw the patient in the clinic? Because a face to face encounter in the hospital did not occur, it would be inappropriate to use any of the "Initial Hospital Care" CPT 99221-99223 codes. Rather, the services of the clinic visit should be billed as "new" or "established" patient office visit on the date seen and the initial hospital service would be billed on a following date when the physician actually sees the patient in the hospital setting.

Ambulatory Care Facilities↗
PubMed2005

Benefiting from the government CERT audits.

In order to minimize the risk of submitting improper or false claims, one important component of a compliance program is performing medical chart audits to make certain that all of the essential elements of the billed codes are present in the physician's documentation. The federal government has a program know as the Comprehensive Error Rate Testing (CERT) program which is responsible for auditing the frequency of errors committed by 1) Medicare providers and 2) Medicare carriers and then publishing those results in a report. The CERT report can be a useful guide for auditing charts because it identifies areas that have been particularly problematic and are more likely to be closely scrutinized by governmental auditors.

Current Procedural Terminology↗
PubMed2005

When is it appropriate to bill physician services using modifier -59?

Accurate coding of medical services is a constant challenge for physicians and could jeopardize a practice if not taken seriously. Insurance carriers use sophisticated claims-processing software that easily identifies coding trends by physicians and flags outliers within specialties. The Office of Inspector General (OIG) and the Center for Medicare and Medicaid Services (CMS) hire auditors to identify areas for review which are commonly miscoded. One area that has been flagged for review is billing with modifier -59 because misuse of this modifier has increased inappropriate reimbursement. Be cautious when using this modifier, due to the legal and compliance ramifications when documentation does not adequately support the "distinct procedural service" to justify the use of modifier -59.

Current Procedural Terminology↗
PubMed2005

Physician documentation in support of appropriate billing with modifier '-25'.

What is one of the surest ways for a practice to lose revenue and invite the unwanted attention of government auditors? By failing to select and document the appropriate use of modifiers to code for services provided. For example, the Office of Inspector General (OIG) has made it known that they will closely review professional billing with the use of modifier '-25.' The use of this particular modifier appeared on their radar screen, because in one recent year Medicare paid approximately 1.7 billion dollars for Evaluation and Management (E/M) services billed with modifier '-25'. The OIG feels an increase of this amount warrants further investigation to determine if these claims were billed and reimbursed appropriately. Additionally, Oklahoma Medicaid auditors are actively scrutinizing the use of modifier '-25' to a degree even more stringent than Medicare and the CPT code book's description allow. Therefore, it is important that physicians be knowledgeable in determining when it is appropriate to bill using this modifier.

Current Procedural Terminology↗
PubMedDate not supplied

Admitting a patient "to" observation or "for" observation--what is the difference?

Coding and billing of a patient placed in "observation" status can be confusing, especially in a busy Emergency Department. If physicians know the rules related to observation status, they can avoid denials or accusations of false claims. Documenting either "admit to observation" or "admit for observation" can be interpreted differently for admission status and billing services. From a billing prospective, writing "admit for observation" would be interpreted as an inpatient admission (if the documentation throughout the medical record is consistent with inpatient status). If the order states "admit to observation," this normally would be interpreted as an order for outpatient observation. Physicians are encouraged to write admission orders that clearly state the level of services intended; for example, wording such as "place in outpatient observation" or "admit as inpatient," to clearly convey the physician's intent.

Humans↗