Coding Corner Answers: An Audit Record Request Quiz

Take the challenge.

1. C—When an insurance carrier requests the medical record for a service performed, the practice should send all pertinent information to support the medical necessity of that service. For example, if the drug requires that a patient first be tested for tuberculosis and the patient should be on methotrexate or leflunomide, the note for that date of service should include the results of the TB test and an explanation of why the patient is or is not on methotrexate or leflunomide.
2. C—ZPIC is an entity established by the Centers for Medicare & Medicaid Services to combat fraud, waste and abuse in the Medicare program. If a ZPIC representative visits your practice, there is a suspicion of fraud. The process is started without notice to the provider. This does not mean the physician is committing fraud—only that a suspicion of fraud exists. It is very important to allow the ZPIC representative to review and copy any records in the original request. If there is any pushback or refusal to review the charts, the practice and/or the provider’s National Provider Identification (NPI) number will be suspended, which can have a negative impact on seeing patients and billing claims until the practice and/or the provider complies. The practice should assign an employee to shadow the ZPIC representative and make copies of everything that is reviewed or copied so the practice has a record. It is also important to verify the ZPIC representative reviews and makes copies of all pertinent documentation in the medical records that supports the medical necessity.
3. D—The OIG examines coding issues or errors by physicians as part of its fiscal year work plan and releases warnings for areas it believes involve program integrity. Fraudulent billing, whether intentional or an innocent mistake, can be costly. Not only can the OIG audit for overpayments but it can apply a civil monetary penalty (CMP) of $10,000 or more for each line item and include prison time. Per the AMA’s Principles of CPT Coding, 9th Ed.: “when it comes to medical coding errors, the broad categories of ‘fraud’ and ‘abuse’ have distinct meanings. Fraud involves intentional misrepresentation or willfully committing a crime. Abuse means ‘the falsification was an innocent mistake, but nonetheless representative of a coding error without malice or intent.’” Practices must comply with OIG requests. They should also retain a healthcare attorney, because a complex web of local, state and federal laws and regulations governs the business of healthcare and providers. Contacting the ACR ([email protected]; Administrative Support) is also a good idea because the practice management team is available to answer coding and billing questions, as well as provide auditing expertise.
4. Yes—An approved prior authorization is not a guarantee of payment, but an indication of the patient’s health plan’s intention to pay for a service or medication. When it comes to infusions, the prior authorization will be for medical necessity to ensure use is for FDA-approved indications, as well as for site-of-service administration. It simply means if the medical policy allows for a treatment or drug, then it is considered an allowable charge. But the medical necessity of the service must be documented with any explanation that will help the payer understand why a drug was used based on clinical guidelines. For example, if the patient’s outcome is not sufficient for continuing use, the drug could later be denied as not meeting medical necessity even though a prior authorization was given. When a prior authorization is given, a caveat always exists that the approval does not guarantee reimbursement of the service, because it may require further review.
5. Yes—Under federal law, drugs may not be purchased from another country unless the company in that country is the drug manufacturer. Practices should be wary of drug companies that state they can offer discounted rates on multiple drugs. The practice must do its due diligence to make sure the drugs being purchased are from the U.S. Ignorance of a company’s wrongdoing won’t protect your practice from liability in an OIG audit.

Whether you are dealing with a commercial payer, Medicare or Medicaid, improper claims should be avoided to reduce your risk of a medical coding audit. The OIG releases its annual work plan to help providers avoid medical billing fraud and abuse in the Medicare and Medicaid programs. Practices should review third-party payer contracts and review any policy updates on their websites.