Corporate Compliance

TIP: Five steps to audit cardiac cath billing

Compliance Monitor, March 17, 2004

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1. Select a sample. For a focused review, use a statistically valid or stratified random sample.

2. Gather documents. The cardiac cath report should include all medical record documentation necessary for the review. If you still have questions after reviewing this report, obtain the flow sheet from the cath lab to validate additional procedures, such as renal angiography.

Also consider reviewing the following documents:

  • Procedure or catheterization report
  • Charge ticket
  • Invoices (1500/UB-92) produced for the service
  • For a retrospective review, examine the Explanation of Benefits received from the insurance carrier

    3. Review chart documentation.

  • Verify that the procedure is documented
  • Review all documentation of the procedure
  • Identify the reason for the procedure to validate medical necessity
  • Verify that the results of the catheterizations are included in the medical record
  • Verify that the ICD-9 coding is accurate
  • Verify that the CPT coding is accurate
  • Verify that the chart follows the Physicians' at Teaching Hospitals (PATH) documentation guidelines
  • Verify that the signature of the physician who performed the service is included

    4. Identify inappropriate bundling. Inappropriate bundling and billing for additional medically necessary procedures are common problems for cardiac cath billing. For example, facilities may bill for renal angiography after meeting certain medical necessity criteria. If the facility does not meet these criteria, the Medicare carrier won't consider the renal angiography medically necessary and the facility would need to obtain an advance beneficiary notice to bill Medicare.

    5. Validate that the appropriate modifiers have been used.

    These tips were offered by Bret Bissey, CHE, CMPE, chief compliance and privacy officer at Deborah Heart and Lung Center in Brown Mills, NJ. and Jennie Campbell, CPC, CCS-P, a consultant with Pershing Yoakley and Associates in Knoxville, TN.



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