Auditing is a word almost nobody wants to hear, and yet it’s a crucial part—and requirement—of maintaining a healthy, successful otolaryngology practice. It’s also a smart idea if you want to catch problems before they become bigger issues.
Your options when it comes to otolaryngology auditing are to hire an external service to perform the audit or to implement internal audits. In her ProfEdOnDemand presentation, “Auditing and Modifiers for Otolaryngology,” otolaryngology compliance consultant Barbara Cobuzzi discusses the pros and cons of internal versus external audits in otolaryngology practices, as well as one key area where audits can unearth improvement opportunities: modifiers.
When Modifier 25 Cost an Extra $538 Million
Modifiers: Those two extra digits can make or break your reimbursement chances every time, so whether you’re a physician or a coder, it’s crucial that you understand what claims documentation is required to keep payers from balking.
One otolaryngology modifier that has seen a lot of controversy since at least 2005 is -25. In 2005, the Office of Inspector General (OIG) published a report stating that, out of $1.96 billion dollars reimbursed in 2002, approximately $538 million was paid improperly. This analysis also found that approximately 35% of Medicare claims with modifier 25 did not meet program requirements.
What these numbers demonstrate is how much confusion exists about how to report -25. Remember that -25 is used to report only “significant and separately identifiable” evaluation and management (E/M) services. That means the services must go above and beyond standard pre- and post-operative care.
Exceptions: As you know, any minor procedure—a laryngoscopy, for example—includes a history exam and medical decision making (MDM). So those elements can’t be included as a separate service. However, if a physician decides to perform a minor procedure, such as a laryngoscopy, because of inadequate visualization, then you can bill using -25. Essentially, there has to be a condition created that requires the additional service.
Don’t Use -25 Without These 3 Elements
Given the above parameters, it’s no small matter to get the -25 documentation right. And it’s critical. Payers can come back even years later to demand that you return money wrongly issued! So be sure you get things right the first time around.
In order to properly add -25 to a claim, you must have the following in the documentation (which the payer could always request to see):
- Evidence that both procedures/services were performed on the same day
- Indication that, on the day the initial procedure was performed, something about the patient’s condition required the 2nd service or procedure to be done
- Sufficient documentation of both procedures to support claims for these services
Pick One: Internal or External—It’s Your Choice
And now back to audits. Remember those numbers from the 2005 OIG report? By performing routine audits, you can help ensure those numbers don’t get quite that high again. When deciding how to audit, using an internal versus external process, consider the following points:
- External audits are more costly, but they give the members of your practice more time to focus on their actual work while the outside agency is performing the audit.
- An external perspective can be more objective and more likely to point out flaws and errors that could get missed from a subjective (internal) viewpoint.
- If your practice is looking to save money, internal audits are a smart option; just be sure you have proper audit protocol set and everyone is aware beforehand of said protocol.
- If your practice can afford it (both in terms of money and time), having internal and external audits could do the best job of pointing out flaws and bad practices, leading to better overall compliance.
Audits: Catch Modifier Issues Before They Grow
Otolaryngology auditing is no fun for anyone, but it’s a requirement. If you’re confused about audit best practices, the proper use of otolaryngology modifiers, and related coding and billing compliance issues, you’re not alone. Join Cobuzzi as she answers your most pressing questions and gives practical advice on how to get audits and modifier usage right.
