Three Forms You Don't Want Used in Your Medical Oncology Audit

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Medicare and other health care auditors across the country are using three forms when performing physician note audits. Simply put, these forms may be appropriate for Primary Care use, however, they have never been approved by the American Medical Association (AMA) for use when auditing the Oncology specialty. To our knowledge, neither the American Society of Clinical Oncology nor the American Society of Hematology has sanctioned their use for auditing purposes. We believe this makes the use of these forms illegal.

These forms score on a "point" system when auditing a physician's note. They assign a point system to the decision-making of diagnosis and tests ordered/reviewed. For example, the audit tool assigns one point whether the patient has a sore throat or a chronic illness diagnosis, such as a stage IV breast cancer. If a medical oncologist orders a Pet CT versus an X-ray, one point is assigned to the score. So, basically auditors down-code a visit based on points that are not part of the 1995/1997 American Medical Association guidelines.

As you may be aware, the auditors should be utilizing the 1995/1997 Guidelines from the AMA Evaluation and Management coding book during the audit process.

Marshfield Clinic Form
One form that is being utilized currently is a Marshfield Clinic form. This was originally created by the Marshfield Clinic, most likely for their internal use. Medical Group Management Association (MGMA) was selling this form on their website until we recently requested they pull this from their store. The form is becoming well accepted across the country and utilized by certified coders in their coding courses. It is also being touted as "the form to use" at some coding seminars and workshops across the country. For a specialty physician, this is a disastrous form.

We are beginning to see a serious pattern by certified coders who are instructing physicians to down-code their medical necessity services even when complex decision-making is evident in the note. The argument is that the physician needs four diagnoses to score a level V decision. We are very concerned that the use of this form may result in recoupment of funds from physicians who care for chronic and other serious illnesses. We recently experienced this in a Medicare audit.

Use of the one-point system (no matter how complex the care is) by internal and external auditors will confuse physicians. Patient care may be compromised since physicians will not be able to recover the cost of caring for their patients.

If you would like to see the other two forms being utilized that we believe to be illegal, visit the
"Tools" section of our website.

Next Steps
1. Neltner Billing uses our own form for internal audits which follows the 1995/1997 AMA Guidelines. We feel this form is more in keeping with the guidelines these auditors should be working with.

2. We recently sent a letter to the AMA and asked them take action to determine which specialties these forms have been approved for and specify that auditors cease and desist in those specialties where they have not been approved.

3. If your practice gets audited and any of these forms are used, we suggest that you question the auditor and take immediate action. Contact the American Society of Clinical Oncology as well as the AMA, and let them know you feel that these forms are being used illegally.

As always, we will keep you posted on our progress and would appreciate knowing if these forms are being used in your audits.

Stay Tuned For More Information in Upcoming Issues of The Billing Brief^TM.