COVID-19 and CMS Audit Ramp-up Information

Audit Landscape

Regardless of where COVID-19 is on August 3rd, 2020, CMS’ audit programs are going live! CMS halted audits in March, 2020 for RACs, SMRC, TPE and most other pre and post-payment audits at the beginning of the Pandemic. However, beginning August 3rd CMS is resuming TPE, SMRC and RAC audits regardless of whether or not the U.S. is still battling COVID! CMS has made it crystal clear these audits are critical to their Integrity Programs and there will be no extending the enforcement discretion period.

Sean’s Recommendations for Medical Practices and Health Systems

  1. It is important to keep in mind these auditing groups must comply with any of the Waivers put in place during the crisis and billed within that time frame.

  2. If a hardship exists It is critical you communicate this to CMS as soon as possible.

  3. Prepare by preemptively auditing claims, put in place any corrective actions and/or make voluntary refunds to avoid aggressive actions by auditors.

  4. Make sure your audit review process is up to date and staff is aware CMS audits are ramping up to ensure any communications received from CMS get to you.

  5. Audit targets will most likely be in the following areas:

    1. COVID-19 screenings – This is based on the number of OIG Investigations and Settlement Actions during the past few months.

    2. Application of COVID-19 Dx and documentation to support the use of the codes – remember there are several COVID-19 Dx and ranking and sequencing is important as are the secondary and tertiary Dx used

    3. Telehealth Services – We have audited a lot of these services for clients during the crisis and the lack of documentation is troubling. Do not just rely on the time documented or the Medical Decision-Making (MDM) to support these services. “Medical Necessity” is still the driving force for the level you select! Additionally, there still must be some form of history and exam to be able to bill for a 99201 – 99215. The problem we have seen is that a lot of the exams documented are highly improbable so be careful and do not over-document or falsify what it is that you have actually performed.

    4. In-person encounters with minor procedures (modifier 25) during the same visit. Again, you must have a significantly, separately identifiable E/M above and beyond the pre-service work-up that would normally be included in a minor procedure. I believe Dermatology, Primary Care, Urgent Care, ENT, Podiatry and Orthopedics are at the highest risk.

    5. Surgical procedures – I believe there will be a focus on major surgery codes prior to the stay in place issued in many states and the resumption of surgeries once the stay in place was lifted. I believe Orthopedics is at the highest risk here.

    6.    Sean M. Weiss, CHC, CEMA, CMCO, CPMA, CPC-P, CMPE, CPC
         Partner, Vice President and Chief Compliance Officer
         DoctorsManagement, LLC
         O: 800.635.4040
         C: 770.402.0855


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