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2/18/2014Developing Effective AuditTools & ReportsBy: Kitchi Goodwin, CPC, CPMASenior Auditor, AAPC Client Serviceskitchi.goodwin@aapc.com866.200.4157 ext. 3072Audits are like mountain biking youmust have the right tools to have asuccessful ride!31
2/18/2014Objectives1. Understand benefits of a chart audit2. Gain understanding of types of audits3. Learn of effective tools and data to usefor audits4. Develop meaningful audit reports4What is a chart audit? An audit is *not* an accusation Quality control measure Compares code selection to servicedocumented Identifies error – AKA “opportunity forimprovement” Identifies missed revenue – AKA “moreopportunity for improvement”5Can You Believe That te LawCMSMore than 100Agencies RegulateHealthcare?OIGIRSHealth DeptMore 2
2/18/2014Benefits of Conducting a Chart Audit Proactive self inspection Peace of mind Discover missed revenue opportunity Uncover documentation weaknesses andrisk areas Allows for correction of deficiencies7Where do I find out what the riskareas are? OIG Work plan for the year RAC, CERT, Meaningful Use Statistics Local carrier policies Conferences Denials8Types of Audits Coding and documentation E/M Outlier Modifier utilization (i.e. 25 & 59) Diagnosis Billing Denials ICD-10-CM assessment readiness Clinical documentation93
2/18/2014Coding 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 claimssubmission Proper signature Data entry errors producing wrong DOS Incorrect modifier usage Cloning10Billing Issues to Consider Auditing Incident to 99211 (nurse visit) Services by mid-level providers Teaching physician rules ABN usage Medical necessity Unbundling11Denials Denials may reveal areas of risk What protocols are in place forresolving denied claims? Do billing staff always follow protocol? Consider auditing denial management?124
2/18/2014ICD-10 CM Readiness AssessmentReview documentation to see if current practiceswill sustain ICD-10-CM Coding Some habits may need to be modified in orderto assign an ICD-10 code Delays and/or non payment could result if nocode can be selected With increased specificity in code set, it isexpected that non-specified codes may alsoresult in slow or no payment13How to Conduct A Chart Audit 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 available14Sample Selection Considerations Prospective vs. Retrospective review Sample Selection Decisions Statistically valid sample Snapshot to identify areas forimprovement Code category Focused on higher levels Date range is important Number of cases to include155
2/18/2014Most Common Coding &Documentation Audit Examine the medical recorddocumentation Evaluation & Management level andcategory Other CPT codes HCPCS II ICD-9 CM Documentation elements (i.e.signature, cloning)16AAPC Client Services’ AuditsDemonstrateE/M ver CodedUnder Coded17Some Points to Ponder . . . Before YouBegin Think about what you want to find out Determine if you have internalresources Contemplate expertise of internalresources Consider what work won’t get donewhile staff conducts audit Consider investing in an outside audit186
2/18/2014Effective Tools & Data to Use forAuditsMost important tool .Knowledge“Any Fool can know. The point is to understand.”Albert Einstein19Knowledge Certified Professional Medical Auditor orexperienced auditor Specialty Credentials for type of audit Know your Medicare Administer Contractor& other regulator guidelines Know your state requirements Develop reference guide (i.e. MedicareLearning Network) Know your providers and coders Stay educated20Effective Tools & Data to Use forAudits CPT /ICD-9-CM/HCPCS II books orsoftware Specialty specific coding references CCI/NCCI edits Payer policies All medical record documentation Billing documents Previous audit results217
2/18/2014Effective Tools & Data to Use forAudits Internal Compliance Program standardsand policies Communication skills EMR/Paper templates E/M audit worksheets or software Specialty code lists Provider & staff signature logs22Compliance Program Standards andPolicies 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 To23Compliance Program Standards andPolicies 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 timelines248
2/18/2014Effective CommunicationIt’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 provider25EMR/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 design26EMR/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 canindividualize each note Understand the risks of EMR templates Cloning Inconsistent content Over documentation279
2/18/2014EMR/Paper Templates Templates should include: All elements needed for each level Regulatory requirements Patient Identification Joint Commission Meaningful Use Authentication28EMR/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, planand sign offs Counseling time Train users on appropriate use Update annually293010
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2/18/2014E/M Audit Worksheets Use worksheet or software Include your defined standards Benefits: Ensures audit quality Provides visual support Enhances training34Sample E/M Worksheet353612
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2/18/2014Specialty 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 methods40EMR Diagnosis List41Encounter Form/Cheat sheetDiagnosis List4214
2/18/2014Provider and Staff Signature Log Gather prior to audits Send with payer reviews Improves quality of audits Differentiates between auxiliary staff andproviders Demonstrates services were accuratelydocumented Prevents auditor follow-up Payer and state requirements may differ43Sample Signature Log44Perform the Review Assign codes supported by medical recorddocumentation 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 notbilled Include accuracy of ICD-9 CM assignment Measure accuracy4515
2/18/2014Results/Reports An audit without a report of findings isuseless Method of reporting varies by audience Verbal Written Individual vs. Group46Reporting 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 actions47Writing a Report – data Scope chart pulls for DOS September 1st –15th Sample 10 DOS per provider Focus baseline audit - establish benchmark Accuracy over/under levelscorrect/incorrect/additional codes Causes of error lack of documentation, EMRmisuse, lack of specificity Solution training Action follow up audit, monetary action4816
2/18/2014Graph Sample – E/M Accuracy49A Practice Sample 10Dr. 54903Dr. 44710Dr. 3# UC49# OCAccurate025Dr. 225150Dr. 1350510152025303540455050Graph Example – E/M Accuracy5117
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2/18/20145556Results are in Now what? Refund any overpayments Option to rebill a corrected claim in the case ofunder-coding Need to consider cost vs. additional funds Provide information and instruction forimproved coding/documentation as needed Training and education Start all over5719
2/18/2014It’s not a one time event58In Summary, Performing Chart Auditsis Good business using effective tools and reportsprovides: 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 intentto do right59AAPC Client Services can assist youwith: Coding and documentation audits ICD-10-CM assessment readiness audits Compliance risk assessments Compliance program implementation Training and educationVisit us at www.aapcps.com or call 866-200-41576020
2/18/2014Questions?61OIGCMS and Its Contractors HaveAdopted Few Program IntegrityPractices To AddressVulnerabilities in .asp6221
Graph Sample - E/M Accuracy 49 A Practice Sample 50 0 5 10 15 20 25 30 35 40 45 50 Dr. 1 Dr. 2 Dr. 3 Dr. 4 Dr. 5 35 25 49 # OC 47 49 0 25 0 3 0 15 0 1 0 1 # UC Accurate Graph Example - E/M Accuracy 51
