SPEAKER_03 0:00

On this episode, Rack Got It. You picked in denials. Stay tuned. Today's episode is brought to you by ModMed. Do your EHR and PM adapt to your style of practice? The ModMed EHR and PM do, with benefits like remembering preferences and automatically suggesting documentation and billing codes. Urologist voted ModMed the number one urology-specific EHR and PM solution available. Built by Urologists with input from yours truly. Stop wasting 60 minutes and 200 for each of your open or no show slot. Go to modmed.com slash PRS Network, set up an appointment with the team at ModMed Urology, and shift your urology practice into high gear. Imagine a solution on a tablet or the web that works seamlessly with revenue cycle management, analytics, telehealth, payment processing, patient engagement tools, and much more. ModMed is transforming health care by placing doctors and patients at the center of care.

SPEAKER_02 1:08

Welcome to episode 305 of the Eurogy Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host, Mark Painter, Dr. Ray Painter, and we want to welcome back special guest Mary Ann DeSoyce. Mary Ann is the COO of PRS Managed Services, the PRS RCM arm, and she's in charge of hundreds and hundreds of urologist claims and all sorts of audits and just sees a lot of this stuff going on on a daily basis, and a lot of the things that are happening really has her finger on the pulse of what's happening in urology coding and reimbursement and billing. So, Marianne, thank you for joining us today.

SPEAKER_04 1:57

Thank you for having me.

SPEAKER_02 1:59

All right. Well, what's going on in the world of rack audits, UPICs, denials? Mark, Marianne, you wanna let us know what to do, how to deal with it, and what's going on.

SPEAKER_03 2:15

Yeah, so there's a couple of things that I'll let you know. I mean, this has increased recently. We're seeing it both with the number of revenue cycle folks that we work with, but also from urology groups around the country. There have been some specific focus areas that have been more, let's see, targeted than others. We are definitely seeing that the sacral neuromodulation 64561-64590 is not off the table yet. We've got a new set of focuses that seem to be hitting us as the, and I think we mentioned in one of our previous podcasts that the focus now that everybody's kind of got gotten down the requirements of the 50% improvement and the with the bladder diarrhea and making sure they've failed the conventional therapies and all that's documented well when it goes in. The newer focus seems to be on the making sure that the note includes that the sacral neuromodulation is being used to treat urgency or urge incontinence that is not secondary to bladder outlet obstruction, stress incontinence, or a neurologic condition like diabetic neuropathy. So it doesn't mean the patients can have these, but it does mean that clinically the physician is clearly making the decision to treat the urgency or the urge incontinence and that they feel clinically that it is going to be effective for that patient given the patient's overall condition. So you need to make sure that's in there. And of course, a reminder that not every reviewer has, in fact, very few reviewers have any urology education. So spoon feeding them that information is key as you deal with that. We're also seeing a lot of activity around PCRs. We've talked about this a little bit in the past, but PCR for UTI, which is not available in all states, certainly has some rules and regulations around it. We've been fighting this for years on whether or not PCR was medically necessary. We have encouraged everybody in the past to adopt really clear guidelines as to when a PCR test is should be run for that particular patient. It is not a substitute for a UA and shouldn't be run on every patient. It's only those that really need a diagnosis related to the organisms that are causing the symptoms, or the fact that you can't identify organisms that are causing the systems and which antibiotics will work to help treat the patient to deal with those systems. So you want to make sure, or symptoms. So you do want to make sure that you're very clear in your guidelines and that you follow those. I also, we've also talked about orders, making sure that your orders reflect the actual test you're running. All those things are important and need to be part of it. But our battle now seems to be focused on the CPT code. It's pretty interesting. That the entire PCR test should be billed with one 87801 code. That is really not the intention of 87801. If you look at the pricing in the clinical lab fee schedule, which is about $70, or the equivalent of two single organism tests, it really reflects what the AMA originally intended, which was that a test came or was done on more than one organism, but that it was a result that was positive or negative. It wasn't really drilled down to the organism itself. And CPT, in their instructions, say you should bill for each organism that was tested. So it's kind of a shift in the way Medicare is looking at how those codes should process. And of course, Medicare isn't looking at the methodology or kit. They're looking at the procedure, saying it's one test, so it's one procedure, and that's really not the way all of these tests are configured. So we've got a few different things that we're trying to look at in the back end relative to those. And those arguments go forward on some different grounds now, not just the medical necessity grounds, but on the coding grounds. We're also seeing UPIX and RACS look at some of your bigger surgeries and whether or not the patients had or qualified for that. Because remember, Medicare processes the claims typically based on a diagnosis and CPT code. And commercial payers typically look at things from the prior authorization, again, based on CPT codes and diagnosis. They don't look at the medical records for most of the payments. So the RACs and the UPICs are pulling the records and really looking behind the scenes to meet to see if all conditions are met, not just the conditions of CPT and ICD 10. And they're finding that a lot of that has been ignored. And that's, of course, stepping up the number of chart reviews that they're doing. So it's something that you want to keep in mind as you're providing services. Make sure that you understand the LCDs and the LCAs and the payer bulletins. Make sure your documentation has all of the information to meet those because they are also very strict now that addendums to the medical record are not allowed once those have been requested for a denial, a RAC, or a UPIC audit, or a Medicaid, or a Mac audit. So those are things that you're gonna have to be able to support. You met the LCD within the existing record. Now, that doesn't mean that you didn't, but and we see this quite frequently, but it is something that as you get into the Rack Mac side of the equation, especially in the UPICs, you're up against individuals that don't understand what's in the medical record clinically, so you may have to add cover letters and explain why the record supports this patient did meet the criteria that are required for that particular procedure. And then the last thing I will add is we've got some new technologies that are out there. And essentially what we're seeing is the payers are finding those areas that are of growth and starting to take a look at. Obviously, PAE is one of those. So we're starting to see some activity there. Quant UA, we're starting to see with denials. And with the focus of the OIG on particular codes or modifiers or combinations, like in PCR the 87798, the Always Modifier 25, these are going to be areas that get swept up in what's being addressed by the Macs, by the RACs, and by the UPIX. So you want to make sure that you are documenting well the first time through, checking all the boxes, build checklists for those things, and make sure you've got your medical protocols. I do see that quant UA is probably going to head the way that PCR is headed. So you better have a great protocol if you are running quant UAs or qualitative urinalysis. Those are going to get flagged for some of these things. We're looking at procedures that are being done fairly close together to treat BPH, like PAE and aquablation. Those are also going to be picked up very quickly for medical record reviews. So we don't have necessarily blocks, but I think it's important to understand that getting paid for a particular procedure is great. But with the ability for private payers and Medicare to reach back and take things back, keeping that revenue is also important. And in fact, probably one of those things that's more important because a lot of times those look backs come at a time when you can't go back and change or rebuild if you're doing things incorrectly. So I can't emphasize enough how important understanding that clinical requirement is important. It's not just about getting through that first level. Some practices are facing north of a million dollars in take backs for equipment that they have already committed. And it's some of it's just because Medicare changed the rules afterwards, but some of it is because those folks have not paid attention to the detail of the LCDs and LCAs. Marianne, what as we're looking at all of this and how this all happens, what do you what protocols do we have in place as individual groups? C denials or C rack audits or Mac documentation requests or UPIC audits. I mean, what's the process we go through here?

SPEAKER_04 13:29

We actually notify our clients to give us every single thing that comes in through identified with CMS on the top, anything that's referencing an audit, because sometimes those we've noticed end up on somebody's desk, possibly, and the time there's a timeline with them. So we ask anytime you see any documentation that comes in from a Medicare item that says CMS on the top, no matter what it is, send it over because oftentimes they're an office may not understand that it's a rack audit or you pick request. So we first of all ask that. Then when we get those items sent to us, we first look at the time, the date on that reference letter because there's usually a time span for when you have to turn those things around. So for example, if today I get something and it's dated already July 1st and I know that it's only at a 45-day turnaround, I know I'm facing a very quick turnaround for a rack audit that we need to process. So identifying the timeline that you have for turnaround of this request is the very first thing that we do. And then we go through the claims that are being requested and we find out what the target is on those. Usually you'll see that the claims sometimes they come with a couple of different reasons why they're pulling back or different codes, but oftentimes they're pretty standard in what they're requesting. You'll usually receive your inner stem on one, possibly your CyFlex on a different one. So we're identifying that item and then we're pulling up that protocol for those claims. We're sending that over to the person who we have identified to pull those records and pull the dates of service for which those records are. So what that means for when Mark was talking about identifying inner STEM, we know what that it's not just the visit that they are our auditors have to look at that is in question. We know that we usually have to pull records that are prior to that date of service as well, avoiding diaries, items noting the 50% or greater. We already identify those, key those up for the person who needs to review them. So when that person is going to pull those records, they know what they have to pull already, what they have to highlight for that auditor so that we already know what's probably missing at that point to go back and request to see if it's maybe somewhere else in the record. So that's the process that we take, and then those are reviewed, and then we send them up for a secondary review to make sure, hey, we're sending this back to the payer, usually CMS, with the documentation and knowing ahead of time if we believe this is going to pass or fail their rack audit or their UPIC review.

SPEAKER_03 16:11

And we usually have a point person at the office who's the actual submitter and somebody that we can go to for any records that are missing or any information we may need clarification from the physician for letters that we would append to the activity as well, as I remember.

SPEAKER_04 16:36

Correct. Correct. So that back piece of it is if we're identifying something that's possibly missing or we have questions on, or we know is not documented clearly in the documentation, that's when that follow-up loop comes back to the practice. When I was talking, when we talk about getting that education back to your provider or the person who's documenting that information or needs to follow up with that, that's when we're having those conversations because we're usually identifying a trend at that point that possibly could be for other records as well.

SPEAKER_03 17:07

Okay, and and translating that into an internal protocol in practice, it really does uh lend itself, and we've seen from the success side of the equation having somebody as point person that understands the timelines and the communication is step one, right? The somebody that can actually read through, get all those records, that's a that so that those things can be referred to the right person so that the game plan can be started and then executed, and that's kind of that supervisor that's out there. And what we've seen in a lot of groups, unfortunately, is that with a lot of this correspondence, if you have a lockbox, ends up coming in with the rest of the information, including EOBs and those types of things. And a lot of times the RCM staff is not identifying and passing those things in. So training your staff to identify and get these to the right person is key. So identifying, setting up the timeline is number one, and then having your support staff, those who have coding expertise, who have the ability to look at LCAs or LCDs for Medicare or NCDs in that case, to review those records before they go out the door, making checklists for each of the codes that are in question to make sure that you've answered every question from the LCD or the LCA, as well as any individual questions that came out of the demand letter from the RAC Mac or UPIC. All of those things are procedural driven. And you need to build that internal workflow. Who's gonna pull the records, who's gonna review the records, who's gonna submit the records, who's gonna sit on top of the timeline, who's originally gonna set up the timeline. That team needs to be in place in order to effectively and successfully fend off these rack audits.

SPEAKER_04 19:31

And the last part that that follow-up loop is if you've identified something in that audit review that was not completed in documentation, how do you circle back to ensure that is a process that is from this day forward that you've identified in your workflow checklists, all that, and also how do you possibly need to go back to previous claims and review those items as well for missing documentations for possible uh future rack audits. You were saying in the beginning, which I think is important to reiterate, once you guys get that rack audit, for example, the rack audit is the primary one, you can the addendums are not being accepted once that letter has been received by you. It's after they've actually notified you. So those those items should be reviewed before, if you know it's a high target item, you should be documenting correctly anyway, but you should know those qualifications that meet the medical necessity prior to another review coming.

SPEAKER_03 20:34

So what you're saying is if you find something and you realize that you didn't document it, but you actually did it, that pulling other records that had the same procedure and adding an addendum to explain what you did in each case to support the what was missing in the other ones, you would do that as soon as you identified that issue across the board in case another rack audit came in the door for the rest of those encounters that were decoded the same.

SPEAKER_04 21:08

Correct. And then you know, you take one item and you are able to review those, you already know ahead of time that if a rack audit comes for future claims that would be affected, you would already have reviewed it and you may already know you have a missing void voiding diary. That way, that person in that review already knows they don't have to ask anybody because it's already been reviewed. You already know it's missing, you're gonna just send that into the RAC. You know you're possibly not gonna have that item. Or you've identified that you do have it, you can place it in a space as well that's easily identifiable so that it meets the protocol and workflow that you did. So it's also making sure it's in your documentation and documented correctly, but also making it so that when that I'm gonna say when, because when that audit comes to you, you've already identified these things and that person in the review space that can actually send out your documentation that's all's already launched.

SPEAKER_03 22:04

Right. So both and so both future claims and claims that are past that are the same target. So fix it everything fix everything going forward, identify everything going backwards that you may have missed and add support for whatever you can. Yes that you actually did. Okay.

SPEAKER_04 22:25

Yeah. And always going back and having a monitoring process where you're reviewing your workflow because the workflows change and your targets may change. Or like you were talking about inner inner stem or something like that, a process, another item is added. They need to be a process of monitoring those workflows to make sure you're going back and review them quarterly. I would recommend quarterly or every six months because you do want to identify changes because A, you want to let your providers know that there's changes, what do you need to do at moving forward to documentation and your workflow? And also, has this effect affected any claims, this change since this change has been in place, has this affected any claims that possibly were not identified with the new workflow?

SPEAKER_02 23:07

How successful have you been?

SPEAKER_04 23:08

With rack audits?

SPEAKER_02 23:10

Yep.

SPEAKER_04 23:11

I believe that we have a success rate of about 86%. Usually when we have the documentation on the rack audit, where we're usually seeing those failures as new, like we were just talking about, new items that they placed into their review, or simply missing documentation that possibly wasn't identified through a medical necessity, like the checklist of what you need to have done for each of those procedures.

SPEAKER_02 23:41

Yeah.

SPEAKER_03 23:42

And I should point out that 86% win rate is not necessarily win one, but we're round two. Like you end up usually, I mean, the win rate in the first round is lower, and the win rate in the second round is higher. And then the last thing I'll put into that mix is the last step in all of this process is the ALJ. So as you put your information into the system, you want to make sure that you're focused on answering the question and you include everything that answers the question, but you're potentially headed to a legal proceeding. So you don't want to put in stuff that isn't supportive or gives anybody in the courtroom something else to look at that won't work that won't help you. So you want to be specific and comprehensive, but don't just grab the entire patient file and throw it out the door. That could lead to some other issues and problems. So stick to answering the question. You can always add information as you move up the change, but once you submitted documentation to either the RAC or the Mac as you go through the process, you cannot retract it. So be careful with what you put in. And it might be smart with some of these bigger ones. It's in fact it is smart to get some legal counsel so that you can have some attorney client interactions preparing for the potential eventuality of an ALJ review.

SPEAKER_04 25:32

Let me add to that too. This when I'm saying 86%, that's that are the those are the ones that you have received. You've gone through the timeline as well in the timeline that they have provided. So you've gotten a letter, you've addressed that letter right away when you have received it, you've sent them the records in their timeline. This does not count the items that we have seen practices who have actually not attended to the letters that have been received. Because once those timelines have expired, those are also harder to appeal and turn over once you guys have expired. Once you guys have received a notice, you have not responded to the request from a RAC or a UPIC, and it is now at a point where they've actually denied and made your decision unfavorable, those are harder as well and usually end up going to the level two or higher for reprocessing. So these are ones that have been attended to when they've been received, records have been sent, the review has happened, but also I want to make sure we see a significant amount of audits that have actually not been done and completed. They didn't understand the rack audit. They actually just thought they were notifications to the practice of a recoup that is coming. So we have seen this a numerous amount of times where the staff that's receiving those are just keeping those letters because they think it's a future recoup, not actually realizing that there's action on those letters.

SPEAKER_02 27:12

Wow, so important. Got to pay attention to all that stuff and really make sure you're on top of those things because time is tough. Those time frames are tough.

SPEAKER_04 27:22

They are tough and they are strict and they are, I mean, down to the day. So you the next day it's closed. You might be able to reopen that, but you can also ask for extensions. So let's just say you guys did notice today that you had a letter from a month ago and it's you're 15 days and you're not going to get to it. You can go on the sites and ask for extended time limits and let them know why. In addition, realizing that you those practices that have a practice and an ASC, remember that rack audit that might come for your practice and is unfavorable because there's not something will probably then affect the claim for the ASC as well at some point.

SPEAKER_02 28:02

That's a great point. Ray, comments, questions?

SPEAKER_00 28:08

No, I think that's all good information. I I think you've explained very well that you have to have the documentation, you have to understand the LCDs are the rules for each payer, but particularly with the high-ticket items. And once you have it and you know your claim was good, it makes the appeal much easier.

SPEAKER_04 28:36

I mean, I'd like to add, if you're working on a workflow of a new procedure, a new line of service that you guys are putting in your practice, this is kind of that workflow, that pathway is kind of actually setting it all up so that in that workflow, you can also say if we had a request for an audit, this is what we would be sending. So when you're starting to set up, if you're kind of trying being proactive, every new line of business should have that checklist marks what the medical necessity, what the LCDs, what the NCDs are, so that you guys have that all addressed. That way, also at the back side, when you guys do get a request for medical records or rack audit or UPIC, you guys know that workflow is already put in place. And then pro on your past stuff, then you guys can do workflows. But if you start doing this on new lines of service, I think it also allows you to educate your staff as well and let them know what this procedure is, how it's being done, it addresses all these items as well. And it allows you to know that you guys have been compliant in your protocols from the start of that new line of business. And then you can just put a workflow in to visit your past, your procedures that are already in place. But if you kind of just think of how do I implement this now, any new line of business, any new drug that you're putting in place, have that in mind of what needs to happen in that documentation. And then also having that checklist of what documentation would have to be sent for any medical records request or audit for each of those procedures and/or drugs that are being done in your practice.

SPEAKER_00 30:06

It sounds like you're making a point for having a protocol or a checklist for most anything you do.

SPEAKER_04 30:13

Yes, because it also makes it in a time that we're seeing staff shortages, where we're seeing people, you might have to have somebody take the place of somebody else. When those things are done, it's much easier to hand somebody a process to say, okay, we've got a rack audit here for 15 interstems. Here's what you're going to need to do. It's already in place, and you don't have to recreate the wheel, and you don't have to worry that something's being missed, because that is really where we're seeing those misses is that something gets handed off and it doesn't get handed off completely, and therefore you're you miss those timelines and you miss the data that's going out. Mark said this, and it's very important to say this again: sending the wrong documentation or too much documentation is not a great way to appeal those things and send that rack audit. Knowing exactly what you need to send in, what is there and what's missing is something that can help you greatly. So sending everything is not good, sending nothing, sending not enough isn't good either. And it causes time and money in your practice.

SPEAKER_02 31:16

Great points. All great points. All right. Gonna wrap this episode up here. We want to thank ModMed for supporting this episode. If you're in the market for an EHR or a practice management system, you can go to modmed.com forward slash PRS network for specials for our listening audience. All right, we want to get some final thoughts. And uh we're gonna start with Mark, then we're gonna go to Ray, and then we'll uh let Marianne have the last word. All right, Mark, final thoughts.

SPEAKER_03 31:44

Yeah, so again, I I think the the overall message here is that doing things right from top to bottom the first time is your best defense across the board. You don't want it to just get paid. You want to get paid and keep your money. The amount the ability of AI or computer assisted coding has given the payer community a new tool with which to harass the practice and to look deeper into what the practice has done and gotten paid for. So expect this under today's environment, expect this to increase just like we've seen with down coding. Every there's pressure monetarily on the payer community, on Medicare, on health care, as a system overall, and that pressure as many things do flows downhill and ends up in the physician's lap. And I think everybody knows what I'm talking about. So it's just one of those things that we have to prepare for up front. It's dotting the I's, crossing the T's, and taking the time to go through that. And then unfortunately, we've got the administrivia that is required to actually fight keeping our money for the racks, the UPICs, and the MAC denials that are out there. It's about the medical record at that point in time. The coding should reflect what's in the medical record. Yes, there are going to be occasions where Medicare changes its interpretation. That's also gonna be problematic. But you've got to remember the basics that you did what you did based on the knowledge that you had at the time and make your arguments for there, from there. And then we're gonna have to let the CHIPs fall where they f they may. But and sometimes the other part of this is we do need clinical support in these appeals. Remembering that MDs are the ones and the that are really responsible for what happens in the practice. APPs need to be well trained to document and follow the protocols and the clinical recommendations that are out there. All of that needs to be well governed, double checked on the compliance side. And when we get through all of that, if it's all there, that's a win, and that's something you can hold on to your money with. If it's not there, but it's implied, you may need to put some clarification in to the cover letter to point out why you made the decisions that were made. So you're gonna have to have some participation there. I know it's one of those areas where you're considering you're not practicing at the top of your license, but I would argue that in fact that is a case in the administrative side where you are practicing at your top of your license because we need that clinical support in those cases to go through. So don't shove it all down. You can certainly train and look for and work through some support staff and what they do, but spend the time to actually pay attention to what the arguments are and answer those questions. Build your protocols and make sure that you spend the time and the appropriate personnel at the right place to answer these to keep your money.

SPEAKER_02 35:41

Great suggestion. Great points. Ray, final thoughts.

SPEAKER_00 35:46

Well, my final thoughts is to keep the eye on the prize. All of this stuff can be very discouraging and etc. But the physician, you are the one that's in charge. You're making a you still have a successful practice, you just have to hire somebody to do it and be sure they do it. Maria, final thoughts.

SPEAKER_04 36:13

Just ensure that you guys have a process in place. If you are unsure of what a rack audit or a UPIC audit is, research that. Know that you have a process in place that not only identifies when you receive these notifications that they are high priority and the whole process, the workflow, Mark was talking about documentation. I'm talking about the workflow that happens to make sure that these are answered and responded to and that each item is sent back to the payer for any kind of review and that's followed up on. Make sure that's in place, make sure that's reviewed, and make sure that if you say you've never received a rack audit, that you actually might want to log into your Medicare portal and actually see you're able to look on there to see if you've ever gotten notifications and you're able to go through that. So if you have any question, if you've missed something or you haven't seen something like that, you can go on to your portals and you can look to see if those things have been sent to you before as well. But make sure you have a workflow. Don't ignore this. Don't think that you probably have aren't going to receive a letter of this nature and make sure that somebody who is regularly at your practice is the one who has this. So it's not somebody who's a part-time person who might have a stack of mail on their desk for more than a week. You want to make sure this is somebody in your practice that is actually able to look at this very quickly and process these claims.

SPEAKER_02 37:41

Great point.

SPEAKER_03 37:42

Yeah, I forgot to add one other thing. And that is check all your addresses. Um this has been one of the things that has tripped up a few folks. And that sometimes the payment address isn't the place that the CMS file goes to. There may be another address on file within your record, those go to. And don't assume that just because they sent one part of the request to one address that they're gonna use the same address for number two.

unknown 38:17

Yeah.

SPEAKER_03 38:17

So it's you gotta monitor all your mail and all your addresses for these things. We've seen a few people miss them because one of the notifications went to an address different from everything else.

SPEAKER_04 38:30

Correct. And that is a great point. You guys should regularly, every six months, at least a yearly look at your payer, especially Medicare, to make sure that you guys have your administrators labeled correctly. Your special address, correspondence address is correct. If you guys have moved, if you've got a had a provider that started the practice that was the email and the original requ uh credentialing that's changed, they might be getting that stuff. So you guys might want to go back in and look to make sure that all of your addresses are changed. An office manager that's been gone for a couple of years may be that person that you have on that you can't get access. So making sure you guys update those addresses is is extremely important.

SPEAKER_02 39:09

Yeah. That is critical. All right. We want to remind you that the urology advanced coding and reimbursement seminar registration is open. You can go to PRSnetwork.com, and right there on the homepage is a seminar registration button. You can check out that for more information, pricing, and registration. All right. We want to thank you all for listening, and we want to thank Marianne again for joining us today. We appreciate your time and all the great information that you have. That's all we have. Take it out, right?

SPEAKER_00 39:47

Every coding is doing.

SPEAKER_01 39:50

Thank you for your coding members podcast. Where we hope you're all just understand. That's my talk.