One doesn't generally think of ambulatory surgery facilities as hotbeds for criminal activity. And in general, surgery facility staff do everything they can to stay compliant with reimbursement requirements - in fact, performance scores on external audits are much better than in physicians' offices. On occasion, however, we have been surprised to discover major failings caused by ignorance, laziness and, in one case, malicious deception that would put Tony Soprano to shame. We've unearthed three real-life cases to show you how careless coding can sink a facility fast.

Case #1
The Unwitting Unbundlers
When reviewing a sample of typical cases for one of our ASC clients, we were shocked to discover repeated violations of Medicare's National Correct Coding Initiative (NCCI). This facility was charging separately for anterior vitrectomies performed with cataract surgery, but according to the NCCI, 67010 (anterior vitrectomy) is bundled with 66984 (cataract surgery with IOL) and should only rarely be paid separately. We explained to the staff that when a surgical misadventure requires anterior vitrectomy, there is no justifiable reason to unbundle that service; only the cataract surgery should be billed. Once in a while, anterior vitrectomy is warranted by pre-existing vitreous prolapse, in cases involving Marfan's syndrome, traumatic cataract or the like. Then, the ?59 modifier is appended to the 67010 CPT code to signify a "distinct" procedure.

The ASC's billing staff pleaded ignorance. They had erroneously believed that any surgical procedure identified on the operative report should be billed and the third-party payer would sort out the eligible and ineligible services for reimbursement.

The director of the ASC subsequently alerted the surgeons of his intention to rectify the identified errors. (Such notice obligated the surgeons to make similar restitution of their overpayments, as well.) All claims with that combination of codes were examined and appropriate refunds made. To ensure that this mistake wouldn't happen again, we provided the staff of the billing office with additional training and added new reference books describing the NCCI bundles to the ASC's library of management resources.

Did You Know? A facility can be held liable for the actions of every surgeon and every staff member.

Case #2
The Disappearing Operative Reports
When Medicare started investigating an ASC for potential overpayment on claims for oculoplastic surgery, the facility's attorney asked us to review the medical records and associated Explanation of Medicare Benefits (EOMBs) for the paid claims. We soon discovered that the CPT codes selected for the claims were chosen to maximize reimbursement but did not accurately portray the surgery. For example, repair of ectropion (67917) was described on the claim as repair of eyelid (67966) with concurrent canthoplasty (67950).

Upon further investigation, we found that the billing staff hardly ever examined the operative reports before submitting the claim to the payer - in fact, the op reports were usually tardy and sometimes missing altogether.

Clearly, it is a lot easier to read the title of the operative report and skip the narrative. Unfortunately, the title may be deceptive or misleading. Parsing the narrative to select the optimal code to report the procedure(s) is an art that takes practice and skill, as well as familiarity with pathology, anatomy, surgical technique and instrumentation as well as coding.

Immediately after receiving our report, the director of the ASC, who is a savvy RN with a wealth of experience, mandated operative reports prior to any claim for reimbursement. She asked us to establish a small reference library of archetype oculoplastic operative reports with annotations and appropriate coding for the billing staff. For the most common oculoplastic surgeries, this was readily done. For extraordinary cases, we agreed to create the claims from the operative reports.

The attorney for our client helped to establish a compliance plan so that corrective measures could begin. The Medicare investigators were informed of the new compliance plan before their investigation was completed.

Warning Signs of Improper Billing Tardy, incomplete or cribbed operative reports Coding claims from the description in the surgical schedule No verification of coding on encounter forms submitted by the surgeon Claims with multiple procedures Indignant and uncooperative surgeons Untrained, inexperienced but well-meaning billing staff with minimal supervision Outdated reference materials for billing and coding

Case #3
The Obfuscating Ophthalmologist
One of our clients had an independent contractor relationship with an itinerant ophthalmologist who visited his rural clinic once a month to do oculoplastic surgery. During the client's annual quality assurance review of chart documentation and claims, we found that a significant proportion of the blepharoplasties performed by the visiting surgeon were cosmetic procedures.

Cosmetic surgery is specifically excluded from Medicare coverage. Medicare carriers and other third party payers are especially skeptical about claims for eyelid surgery because so many problem cases have been identified. The ophthalmologist knew this, but he deliberately tried to trick Medicare by using contrived preoperative photographs in the medical charts that gave the impression of severe eyelid ptosis by artfully positioning the patient looking downward.

There were other clues that tipped us off. For example, the preoperative visual fields were insufficient to document field defects due to ptosis and the patients' complaints were consistently phrased in the same way. What sealed our case, however, was an eyewitness - one of the OR nurses told us that she observed eyelid surgery that was reported in a patient's operative report as a different ophthalmic procedure.

The ASC was obliged to make refunds to payers; unfortunately, the facility strained relations with its patients by holding them responsible for previously paid claims. The visiting surgeon denied any wrongdoing, but the ASC owner summarily ended their relationship.

Weeding out the bad apples
The human failings described in these cases are all too familiar. Tardiness, carelessness, greed and obfuscation all played a part. If you suspect a problem in your facility, start a quiet investigation immediately. That may lead to more questions or uncover weaknesses in your infrastructure, policies and procedures, training programs or quality assurance systems. Don't hesitate to blow the whistle and get help.

In today's climate of public outrage at corporate malfeasance, regulators function in an atmosphere where investigations and prosecutions for overpayments are deemed to be manifestations of vigilance and responsiveness. There is more activity of this sort motivated by more distrust than at any time in the history of the Medicare program. Fortunately, there is a proud legacy of excellence in ASCs that is only occasionally marred by problems of the sort we've described here.

Mr. Corcoran is president of Corcoran Consulting Group, which specializes in reimbursement issues in ophthalmology. You may reach him at [email protected].