Allergy practices and Audits

• Number of Test performed
• Number of Doses charged
• Medical Necessity for allergy testing and an E/M on the same calendar date
• Incident to services with mid levels

Incident To Guidelines

• Applicable to ALL government entities – medicare, medicaid, Champus, Federal employees ---
• Incident to - physician has established a plan of care for an employee to follow.
• Physician must be on site when the service is provided
• NP, PA may not supervise diagnostic test under incident to guidelines and bill the service under the physician. 

OIG Work plan for 2012-2013

1. Non-compliance with assignment guidelines
2. Incident to services
3. Place of Service errors
4. Evaluation and Management codes based on 2010 payments
5. E/M with modifiers
6. Claims with G modifiers
7. Payments for physician administered drugs and biologics
8. Medicare as a secondary payer

• RAC Reviews and Audits
• RAC scope includes pre-payment fraud, waste and abuse efforts not limited to credit balance audits, incorrect billing and processing errors, and lack of medical necessity.
• Post payment RAC work includes data mining, medical records review, identifying overpayments
• RAC Reviews and Audits – Connelly Consulting
• Incorrect billing of Evaluation and Management Claims
• Physician Evaluation and Management Services During Same Day Global Period
• Place of Service Errors for Physician claims for service performed in an ASC or outpatient Hospital
• Place of Service Errors for Physician claims for service performed in

Hospital Inpatient setting

• Duplicate Claims - Physician (Carrier) CMS
• Modifier 59 – Know when you can use it appropriately

*  Excessive Units-Untimed Codes  RAC and other payer audits

• Focusing on allergy doses and testing
• E/M on the same date as a testing –
• Some allergist have been reviewed back for three years from Medicaid or Medicare.
• Blue Cross in some states has reviewed most all allergists for E/M on the same day
• United is not paying in some states for E/M and testing on the same date unless notes are submitted.

ALLERGIST CODING CURVE National National

• 99201 -  .47 %    / 99241 - .52 %
• 99202 -  5.00 %  / 99242 - 3.48 %
• 99203 -  30.15% / 99243 - 30.42%
• 99204 -  51.32% / 99244 - 54.02%
• 99205 - 13.06%  / 99245 - 11.56%

ALLERGIST CODING CURVE

• National
• 99211 - 3.98 %
• 99212 - 6.77%
• 99213 - 55.25%
• 99214 - 31.09%
• 99215 - 2.91 %

Audit Response

• Know your risk
• Seek counsel if you are high risk
• Review your records
• Have a third set of unbiased eyes read the notes
• Respond in a timely manner
• Communicate with the payer performing the review.
• Negotiate