[email protected] 866.200.4157 ext. 307
TRANSCRIPT
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Developing Effective Audit Tools & Reports
By: Kitchi Goodwin, CPC, CPMA
Senior Auditor, AAPC Client Services
[email protected] 866.200.4157 ext. 307
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Audits are like mountain biking… you must have the right tools to have a
successful ride!
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Objectives
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1. Understand benefits of a chart audit 2. Gain understanding of types of audits 3. Learn of effective tools and data to use
for audits 4. Develop meaningful audit reports
What is a chart audit?
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• An audit is *not* an accusation • Quality control measure • Compares code selection to service
documented • Identifies error – AKA “opportunity for
improvement” • Identifies missed revenue – AKA “more
opportunity for improvement”
Can You Believe That…
More than 100 Agencies Regulate
Healthcare?
Medicare CMS
IRS
Private Accreditation
OIG
Medicaid
State Law
FDA
Health Dept
HIPAA
DEA
More…
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Benefits of Conducting a Chart Audit
•Proactive self inspection
•Peace of mind
•Discover missed revenue opportunity
•Uncover documentation weaknesses and risk areas
•Allows for correction of deficiencies
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Where do I find out what the risk areas are?
•OIG Work plan for the year
•RAC, CERT, Meaningful Use Statistics
•Local carrier policies
•Conferences
•Denials
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Types of Audits
•Coding and documentation •E/M Outlier •Modifier utilization (i.e. 25 & 59) •Diagnosis
•Billing •Denials •ICD-10-CM assessment readiness •Clinical documentation 9
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Coding and Documentation Audit
•Compares code selection to documented services
•Reveals areas of potential risk (over-coding)
•Reveals potentially missed revenue (under-coding)
•Reveals other issues relevant to correct claims submission •Proper signature •Data entry errors producing wrong DOS • Incorrect modifier usage •Cloning
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Billing Issues to Consider Auditing
•Incident to •99211 (nurse visit) •Services by mid-level providers
•Teaching physician rules
•ABN usage
•Medical necessity
•Unbundling
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Denials
•Denials may reveal areas of risk •What protocols are in place for resolving denied claims? •Do billing staff always follow protocol? •Consider auditing denial management?
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ICD-10 CM Readiness Assessment
Review documentation to see if current practices will sustain ICD-10-CM Coding •Some habits may need to be modified in order
to assign an ICD-10 code • Delays and/or non payment could result if no
code can be selected • With increased specificity in code set, it is
expected that non-specified codes may also result in slow or no payment
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How to Conduct A Chart Audit
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• Identify the key objective or focus
• Identify sample parameters
• Consider prospective vs. retrospective
• Consider billing questions
• Consider time to perform
• Consider objectivity
• Identify resources needed
• Develop and make tools available
Sample Selection Considerations
•Prospective vs. Retrospective review
•Sample Selection Decisions •Statistically valid sample •Snapshot to identify areas for improvement • Code category • Focused on higher levels • Date range is important • Number of cases to include
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Most Common Coding & Documentation Audit
•Examine the medical record documentation •Evaluation & Management level and category •Other CPT® codes •HCPCS II •ICD-9 CM •Documentation elements (i.e. signature, cloning)
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AAPC Client Services’ Audits Demonstrate
[PERCENTAGE]
[PERCENTAGE]
[PERCENTAGE]
E/M Coding
Correct
Over Coded
Under Coded
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Some Points to Ponder . . . Before You Begin
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• Think about what you want to find out
• Determine if you have internal resources
• Contemplate expertise of internal resources
• Consider what work won’t get done while staff conducts audit
• Consider investing in an outside audit
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Effective Tools & Data to Use for Audits
Most important tool…..Knowledge
“Any Fool can know. The point is to understand.”
Albert Einstein
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Knowledge
•Certified Professional Medical Auditor or experienced auditor •Specialty Credentials for type of audit •Know your Medicare Administer Contractor & other regulator guidelines •Know your state requirements •Develop reference guide (i.e. Medicare Learning Network) •Know your providers and coders •Stay educated
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Effective Tools & Data to Use for Audits
•CPT®/ICD-9-CM/HCPCS II books or software •Specialty specific coding references •CCI/NCCI edits •Payer policies •All medical record documentation •Billing documents •Previous audit results
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Effective Tools & Data to Use for Audits
•Internal Compliance Program standards and policies
•Communication skills
•EMR/Paper templates
•E/M audit worksheets or software
•Specialty code lists
•Provider & staff signature logs
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Compliance Program Standards and Policies
•Audit guidelines – define the “grey” areas •95 or 97 guidelines •95 detailed exam •HEENT: negative •Prescription drug management •Additional work up •Medical Decision Making required •CMS rules for all patients •Who documents HPI •Consultations
•Mid-level providers – Incident To
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Compliance Program Standards and Policies
•Define acceptable abbreviations/acronyms
•Set coding accuracy threshold
•Staff certification and education
•Define post audit follow up actions •Training/education •Follow up audits •Monetary incentive
•Establish timelines
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Effective Communication
It’s all in the approach! •An audit is *not* an accusation •Auditor’s role •Advocate to the coder and provider •Educator •Trainer
•Attitude •Communication among various departments •Written communication •Do not overwhelm the provider
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EMR/Paper Templates
•Templates can be a powerful & effective tool •Poorly designed templates can: •Put your practice at risk •Lead to inefficiencies •Lead to lost revenue
•Educate your team on template design •Third-party consultants (EMR templates) •Train the trainer •Books, webinars, etc. • Involve coders in the design
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EMR/Paper Templates
•Avoid designing templates that “look good”
•Too much content leads to clutter •Follow 80/20 rule •Allow for free text fields so users can individualize each note •Understand the risks of EMR templates •Cloning • Inconsistent content •Over documentation
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EMR/Paper Templates
•Templates should include: •All elements needed for each level •Regulatory requirements •Patient Identification •Joint Commission •Meaningful Use •Authentication
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EMR/Paper Templates
•Medical decision making elements such as: •Personal review of tracings/images •Request for records •Conversations with other providers •Both mid-level and physician exam, plan and sign offs
•Counseling time
•Train users on appropriate use
•Update annually
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E/M Audit Worksheets
•Use worksheet or software
•Include your defined standards
•Benefits: •Ensures audit quality •Provides visual support •Enhances training
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Sample E/M Worksheet
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Specialty Code Lists
•Use of specialty code lists improve: •Efficiencies •Code specificity and accuracy •Audit scores
•EMR lists and paper cheat sheets
•Update annually
•Allow other look up methods
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EMR Diagnosis List
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Encounter Form/Cheat sheet Diagnosis List
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Provider and Staff Signature Log
•Gather prior to audits
•Send with payer reviews
• Improves quality of audits
•Differentiates between auxiliary staff and providers
•Demonstrates services were accurately documented
•Prevents auditor follow-up
•Payer and state requirements may differ
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Sample Signature Log
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Perform the Review
•Assign codes supported by medical record documentation
•Compare to billed codes noting any variance • Include modifiers used/omitted •Review POS/DOS/Rendering provider •Review authentication •CPT® or HCPCS II codes reported incorrectly •CPT® or HCPCS II services documented and not
billed • Include accuracy of ICD-9 CM assignment
•Measure accuracy 45
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Results/Reports
•An audit without a report of findings is useless
•Method of reporting varies by audience •Verbal •Written •Individual vs. Group
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Reporting Concepts
•What was the scope •How did you choose sample •Why are you looking at this •Degree of accuracy •Causes of inaccuracy •Solutions for improved accuracy •Recommended actions
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Writing a Report – data
•Scope = chart pulls for DOS September 1st – 15th •Sample = 10 DOS per provider •Focus = baseline audit - establish benchmark •Accuracy = over/under levels correct/incorrect/additional codes •Causes of error = lack of documentation, EMR misuse, lack of specificity •Solution = training •Action = follow up audit, monetary action
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Graph Sample – E/M Accuracy
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A Practice Sample…
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0 5 10 15 20 25 30 35 40 45 50
Dr. 1
Dr. 2
Dr. 3
Dr. 4
Dr. 5
35
25
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0
25
0
3
0
15
0
1
0
1
# UC
# OC
Accurate
Graph Example – E/M Accuracy
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Results are in…Now what?
•Refund any overpayments
•Option to rebill a corrected claim in the case of under-coding •Need to consider cost vs. additional funds
•Provide information and instruction for improved coding/documentation as needed
•Training and education
•Start all over
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It’s not a one time event
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In Summary, Performing Chart Audits is…
•Good business…using effective tools and reports provides: • Knowledge •Are we doing what we think we are doing? •Where are our risk areas?
• Control •Quality Control •Remediation if needed
• In the event of investigation - demonstrates intent to do right
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AAPC Client Services can assist you with:
•Coding and documentation audits
• ICD-10-CM assessment readiness audits
•Compliance risk assessments
•Compliance program implementation
•Training and education
Visit us at www.aapcps.com or call 866-200-4157
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Questions?
OIG
CMS and Its Contractors Have Adopted Few Program Integrity
Practices To Address Vulnerabilities in EHRs
http://oig.hhs.gov/oei/reports/oei-01-11-00571.asp
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