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Developing Effective Audit Tools & Reports

By: Stephani Scott, CPC, RHIT

Managing Director, AAPC Client Services

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. Effective tools and data to use for

audits 4. Developing meaningful audit reports

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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…

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)

•Billing

•Denials

•ICD-10-CM assessment readiness

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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 modify 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 • 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

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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

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 Medical Professional 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

•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 44

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

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25

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49

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?