Chart Talk: Documenting E&M in Medicare Dispute: Part III

CMS has accused Bryan Merrick, MD of wrongful Medicare billings on 10 patients over a span of 20 months. The town’s mayor has asked for help from Washington.

There are towns in America where time seems to stand still. And that might be the case in the small, rural town of McKenzie, Tenn., population 5,300 – but here, time is an enemy and the stakes are high.

The mayor of McKenzie, Jill Holland, recently wrote to U.S. Sen. Lamar Alexander (R-Tenn.) asking for his help in a tense standoff between the Centers for Medicare & Medicaid Services (CMS) and the town’s most prominent physician, 65-year-old Bryan Merrick, an internist with three decades of experience and the only physician in town who can read an echocardiogram.

Merrick recently had his Medicare billing privileges yanked by Medicare over a billing dispute, and that move by CMS threatens a loss of jobs and closure of a medical center that serves a largely rural and elderly population dependent on its services, as reported here by RACmonitor.

In her letter to Sen. Alexander, chairman of the Senate’s Health, Education, Labor, and Pensions Committee, Holland asked for a subcommittee hearing to consider the reversal of the revocation of Merrick’s billing privileges. She described the action by CMS as being based on “(the) regulation’s vague standard.”

Holland stated that during the 20-month billing period in question, CMS found 30 incorrect billings for 10 patients, representing less than one-tenth of the 1 percent of 30,000 claims submitted on behalf of a number of providers, including Merrick.

For a better understanding of the dilemma facing Merrick, RACmonitor asked Frank Cohen, a senior healthcare analyst with a specialty in physician coding and documentation, to review the data.

“For 2014, there were 93,553 internal medicine physicians listed in the CMS database,” Cohen wrote in an email to RACmonitor, noting that 97.6 percent of the $638,312.65 paid to Dr. Merrick was for medical services, with the remaining 2.4 percent for what CMS calls “drug services.”

In terms of ranking Merrick with regard to payments, he was in the 93rd percentile for the number of services provided per unique beneficiary. According to Cohen, for internal medicine physicians (for 2014), the average was 3.46 services per unique beneficiary.

“Dr. Merrick reported 11 services per beneficiary,” Cohen explained. “That he is in the 93rd percentile means that only 7 percent of internal medicine physicians billed for more services per beneficiary than he did. When you look at where Dr. Merrick ranked with regard to payments, Dr. Merrick ranked in the 67thpercentile, meaning that 33 percent of internal medicine physicians were paid more per beneficiary than he was.”

Cohen said that, as an example, the average internal medicine physician was paid $217.92 per unique beneficiary in 2014, compared to $268.99 for Dr. Merrick. Cohen’s interpretation is that while Merrick may have reported more procedures, on average they were less expensive than those reported by his peer group – and certainly, being in the 67th percentile for payments is not that alarming.

“With regard to evaluation and management (E&M), Dr. Merrick didn’t report any lower-level office visits codes (99201, 99202, 99211, 99212),” Cohen said. “Of the 1,562 established office visits, 94 percent were either 99214 or 99215. The national average for these two codes for IM physicians in 2014 was 51.73 percent, so I do see where this may have created a target on this back.”

Cohen added that just because one codes certain codes at a higher rate doesn’t necessarily mean that one is coding incorrectly. A chart audit, according to Cohen, is always the best way to validate whether a code met documentation or medical necessity criteria.

“But as a proxy, one can look at the average hierarchical condition categories (HCCs) score, which is supposed to measure patient acuity,” Cohen said. “The higher the score, the ‘sicker’ the patient population being treated.”

“For internal medicine docs nationally, the average patient HCC score was 1.77. For Dr. Merrick, his average beneficiary HCC score was 1.396,” Cohen continued. “So if you buy the concept that HCC codes really do equate to the overall acuity of the patient population (and I am not saying that I do), then we would have expected Dr. Merrick’s E&M codes to have been on the lower end of the spectrum, not the higher end.”

Cohen said that he had read that Merrick billed Medicare for services rendered to dead patients, also noting that Merrick defended each of those as clerical errors or some other type of innocent mistake.

“The problem is, when you are a squeaky wheel, pretty much everything you do comes into focus,” Cohen said. “And looking at all of the other issues surrounding this provider, I am inclined to believe that CMS had a lot more to complain about that just those 10 claims. In the end, only a deep dive into this provider’s charts would tell the whole story – however, from a statistician’s perspective, just looking at the data does paint a grim picture, and I am not surprised that he ended up butting heads with CMS.”