If you treat Medicare patients, this important message is for you. An alarming number of Texas orthopaedists have received a “Comparative Billing Analysis” letter from Trailblazer, a third party administrator for Medicare in Texas. The identical letters claimed that the recipient was billing for E&M services codes 99201-99205 at a statistically different 

rate than other orthopaedists, implying that they were inappropriately over-coding and may be subject to an audit or other action. Our investigation found that the majority of those contacted were sub-specialists who often have “end of the line” practices, where it would be clinically appropriate to have a higher mix of more level 4 and 5 codes. TOA also contacted the TMA, the AAOS, and the other specialties in Texas, and found that none of these other organizations had members reported receiving such a letter.

Concerned that Texas orthopaedists were being targeted for possible audit, we conducted a conference call with the Trailblazer medical director. We expressed our concerns that the letter might be interpreted as threatening, leading our members to react by further restricting access for Medicare beneficiaries. We were reassured that the recipients of the letters were not “targeted”, the purpose was to “educate” us about potential erroneous coding, the letter wasn’t a precursor to an audit, and that Texas orthopaedists were not being singled out. This program is part of a mandate from Center for Medicare and Medicaid Services (CMS) that Medicare contractors such as Trailblazer conduct Certified Error Rate Testing (CERT) to reduce an “unacceptably high percentage of benefit dollars” that allegedly had been paid in error for E&M services nationwide. We have asked Trailblazer to re-examine the tone of their CERT letters, compare their CERT program to those used in other states, and ensure that all specialties were treated similarly.

What we did learn is that Trailblazer has a free Computer-Based Training (CBT) module focused on following Medicare guidelines for proper coding and documentation. Completion of this CBT will grant you an hour of CME credit.  They also offer other modules on consultations, coding, medical records and documentation at their website.  You can log in with your own provider number, or use the “dummy number” LPET if you want to view the material anonymously. To locate the CBT, check the left side under “Explore” and “Part B” then click on Texas, to “Provider Outreach and Education (Educational Issues)” on the left side, and then “Computer Based Training Modules” on the right. I encourage each of you to complete the CME so that you can more accurately code and receive full payment for the services you provide regardless of payer.

Remember that you are not over-coding if you properly document clinically appropriate levels of E&M services. Many of us have practices which would not have a typical bell-shaped distribution of codes centered at level 3, so it’s essential that you are very familiar with the documentation required for each level of E&M. If you do not perform your own coding, you should re-evaluate that practice since ultimately you will be held responsible. I remain chagrined when it seems that the government has made all of us “healthcare fraud” suspects, but remain truly convinced that it is a small minority of physicians who are engaging in such practices. My advice: keep doing the great job you do helping patients with complex problems and demand to be paid fairly for your services.
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An anesthesiologist, Dr. Kyle Janek has served as a state Senator for Senate District 17, which includes parts of Harris, Fort Bend, Brazoria, Galveston, Chambers and Jefferson counties, since November 2002.  After serving for eight years in the House of Representatives, Dr. Janek currently serves as Chairman of the Senate Subcommittee on Emerging Technologies & Economic Development, as Vice Chairman of the Senate Committee on Business & Commerce, and as a member of the Education Committee, the Subcommittee on Higher Education, the Finance Committee, the Subcommittee on Capital Funding for Higher Education, and the Health & Human Services Committee. 

Since the end of the 78th legislative session, he serves as chairman of the Workgroup on Revenue assisting Senate members of the Joint Select Committee on Public School Finance, and as a member of both the Joint Interim Committee on Higher Education and the Legislative Oversight Committee on Higher Education. At the end of 2003, he was appointed by the Lieutenant Governor to the Select Committee on Workers' Compensation.

After the 2003 session, Dr. Janek made the Texas Realtor Honor Roll for his work on issues important to property owners in Texas. In addition, the Texas Association of Business designated him a Fighter For Free Enterprise.  The Texas Hospital Association presented him the Texas Hospital Advocacy Tribute in recognition of outstanding legislative leadership on health care issues, and Preservation Texas honored him for his contributions to historic preservation.

Dr. Janek received his B.S. from Texas A&M University and his PhD from the University of Texas Medical Branch-Galveston.  Currently, Dr. Janek resides in West University Place with his wife Shannon and their three sons, Ryan, Will and Luke.  An active member of St. John the Divine Episcopal Church, he also serves on the Associate Vestry.

Email Senator Janek to thank him for his work!

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Please submit your abstract to the TOA 2007 Program Committee.  The 2007 Annual Meeting will be held at the fabulous Austin Four Seasons Hotel May 11-13. The deadline is Thursday, November 30, 2006.

Special events will be planned for spouses on Saturday and Mother’s Day on Sunday. The Abstract form can be found by clicking here and the Disclosure found can be found here.