Physician E/M Audit Problems and Effective Solutions

Transcription

1 Physician E/M Audit Problems and Effective Solutions Lamon Willis Director of Business Development Healthicity CPCO, CPC-I, COC, CPC Agenda 1. Setting Up Your Audits 2. Audit Resources 3. Auditing Methodology 4. Auditing Education and Reporting 5. Case Studies and Challenges of Medical Auditing 6. Common Areas of Risk 2 1

2 Setting Up Your Audits 3 Good Leadership The Audit Director has an active role within the organization's compliance committee, coding leadership, billing leadership and other revenue cycle related leaders in the organization's decision making structure and process. The Audit Director participates in established meetings of the organization's compliance program. The Audit Director directs: The implementation of an effective program to measure and monitor the quality of the auditors and auditing activities being performed. The Audit Director approves audit related policies, standards and guidelines for the organization before they are implemented. 4 2

3 Utilizing Audit Guidelines Do you have written internal practice guidelines for your audits? Consistency Accuracy Increased productivity Fortifies your audits Identifying / understanding unintended consequences of your guidelines. For example, requiring MDM can lower provider scores. Does this impact RVU bonus or other things? 5 Utilizing Audit Guidelines Type of E/M guideline (1995 or 1997 guidelines) to use If using the 1995 E/M guidelines, define what equals a detailed exam If the chief complaint can be inferred Define what prescription drug management includes Define what additional work up includes Is MDM required for 2 of the 3 key components Provider and staff signature logs Define acceptable abbreviations and/or acronyms Define timely authentication time line List approved coding tools and resources 6 3

4 Utilizing Audit Guidelines Educate coders and providers on your audit guidelines Incorporate into your coding and documentation training for new staff as well as for your annual trainings Include your audit guidelines in your audit worksheet, reports, etc. Review your MAC carrier and commercial payer website and/or s for changes, and attend local payer workshops to ensure you aware of any changes and incorporate into your guidelines 7 Audit Resources 8 4

5 Common Resourcing Issues Not allocating the necessary resources to conduct audit and post audit education activities. Audits being conducted by qualified and competent staff. Failure to monitor quality. 9 Invest in Compliance Access to current coding books and reference materials. Auditors are appropriately trained and proficient in the use of any audit tools and software programs. Appropriate staffing ratios. The recommended auditor to provider ratio should not exceed 100 providers per auditor. This ratio may vary depending on the scope and frequency outlined within the organizations audit / compliance program requirements 10 5

6 Working with Limited Resources Outsource audits and keep education internal Staggering audit projects Don t compromise compliance standards Leverage technology to improve efficiency 11 Working with Limited Resources 12 6

7 Auditor Qualifications Audit staff have demonstrated their competency by obtaining applicable certifications. Auditors are subject to a skills tests to evaluate their auditing skill levels before being allowed to perform audits. Audits are assigned to auditors matching the experience and expertise to the medical specialty being reviewed. Auditors are checked against all required State and Federal regulatory exclusion databases annually. 13 Resources to Monitor Quality Quality Audit Committee or appointed designee(s) Developed audit quality standards, guidelines and corrective actions which are clearly outlined Oversees corrective actions of audit staff Quality performance reviews are conducted regularly Conduct periodic external review to audit your auditors Quality reviews include meaningful elements 14 7

8 Quality Metrics E/M coding accuracy CPT coding accuracy Modifier coding accuracy Diagnosis coding accuracy HCPCS coding accuracy Data entry accuracy Key findings accuracy Recommendations accuracy Reference citation accuracy 15 Auditing Methodology 16 8

9 Written Policies Key objectives or focus of the audit Sampling parameters Type of audit (e.g. prepayment vs. retrospective) Frequency requirements for audits to be performed Minimum scope (e.g. CPT, E/M, HCPCS, Documentation elements) Establish minimum audit pass rate requirements Establish audit scoring and accuracy rate calculation methodologies 17 Written Policies Approved reference materials (e.g. CPT Assistant, Coding Clinic, etc.) Define post-audit training or education requirements Define remedial training or auditing requirements for individuals who do not meet the minimum audit pass rate requirements Establish appropriate guidelines for incentives or punitive actions associated with audit results or performance Auditing standards are maintained by the organization, reviewed regularly, acted on, and updated as needed 18 9

10 Selecting Your Sample Size Federal Register / Vol. 65, No. 194 Optimally, a randomly selected number of medical records could be reviewed to ensure that the coding was performed accurately. Although there is no set formula to how many medical records should be reviewed, a basic guide is five or more medical records per Federal payor (i.e., Medicare, Medicaid), or five to ten medical records per physician Selecting Your Sample Size Vs Is your sampling methodology outdated? What are payers and the OIG using to evaluate you? Risk scoring and predictive modeling Cross payer analytics Special Investigation Units Detection Analytics Provider profiling Multi-variant modeling 20 10

11 Example of Utilization Review 21 Example of Utilization Review (Lesion Destruction 2-15 Lesions) Per Patient California Dermatology Providers

12 Scoring Audit Results/Pass Rates Equal weight - total errors / total possible Under-coded not counted as an error Weighted averages Fee schedule overpayment Type of scoring should be based on the type of audit performed OIG uses 95% of dollars from the claim as an acceptable passing rate.set your passing threshold to match 23 Auditing & Monitoring Frequency Baseline Ongoing monitoring Focused 24 12

13 Auditing Education and Reporting 25 Post-Audit Education Perform the audit, provide feedback, monitor, and then reaudit. Requirements for providing results Structure in place to monitor feedback and training of providers Ensure trainers are giving correct and accurate feedback Feedback is shared with compliance / administration 26 13

14 Documenting Your Results What type of reports should you use? What type of information should be included on an audit report? How long should you keep your reports? Signature page When is attorney client privilege appropriate? 27 What To Include In Reports Patient identification, DOS Comparison of audited and reported codes Key documentation or coding issues Observation of findings for each encounter reviewed Recommendations for improvement and to correct problems Results are reported in an organized format that allows the viewer to easily draw conclusions Audit results are maintained by the organization and easily accessible 28 14

15 What To Include In Reports 29 What To Include In Reports 30 15

16 What To Include In Reports 31 Providing Feedback Best Practice An audit is not an accusation. An auditor s role is to be an advocate to the coder and/or provider. Providing the feedback can be done several different ways; one/one training, group training, shadowing, or written report. Best practice is to use the method of education based on the audit results and your provider s needs

17 Dealing with Difficult Providers What do you do if the provider does not like the result and requests a change? Listen Try understand from a clinical perspective Educate using approved reference Agree to resolution revise or leave as is 33 Proactive Versus Reactive Training The organization has appointed a designated individual(s) responsible for monitoring and managing coding and billing updates. Auditors receive training and are aware of applicable coding and billing updates and amendments. Providers receive training and are aware of applicable coding and billing updates and amendments. Coders receive training and are aware of applicable coding and billing updates and amendments

18 Proactive Versus Reactive Training The organization has appointed a designated individual(s) responsible for monitoring and managing coding and billing updates. Auditors receive training and are aware of applicable coding and billing updates and amendments. Providers receive training and are aware of applicable coding and billing updates and amendments. Coders receive training and are aware of applicable coding and billing updates and amendments. 35 Case Studies and Challenges of Medical Auditing 36 18

19 Complexity of Coding E/M coding results CPT coded correct CPT coding results CPT coded incorrect CPT codes added Medical Specialty Correct Overcoded Undercoded "Anesthesiology" 84% 12% 5% 89.5% 6.1% 4.3% "Cardiology" 74% 19% 7% 72.1% 25.3% 2.6% "Critical Care" 87% 7% 7% 60.0% 40.0% 0.0% "Dermatology" 79% 13% 8% 83.5% 11.4% 5.1% "Emergency Medicine" 74% 21% 5% 86.7% 5.6% 7.7% "Family Medicine" 77% 17% 5% 70.2% 25.0% 4.8% "Otorhinolaryngology (ENT)" 77% 19% 5% 61.8% 30.3% 7.8% "Gastroenterology" 63% 32% 5% 91.1% 5.7% 3.3% "Internal Medicine" 78% 15% 6% 67.9% 26.6% 5.5% "Obstetrics and Gynecology" 77% 17% 5% 68.7% 26.0% 5.3% "Orthopedic" 76% 20% 4% 79.9% 16.6% 3.5% "Pediatrics" 79% 17% 4% 68.4% 24.8% 6.8% "Surgery, General" 69% 25% 7% 76.9% 17.7% 5.3% Averages 73% 21% 6% 79% 16% 5% 37 Complexity of Coding Financial Impact To A Practice: Primary Care Average Number of Patient Visits / Year = 4,000 RVU weighted conversion factor / RVU = $35.82 Average RVU variance for undercoding =.80 Average RVU variance for overcoding = ,000 x 21% = 840 claims x $37.00 (overcoded value) = $31,000 / year 4,000 x 6% = 240 claims x $29.00 (undercoded value) = $7,000 / year 38 19

20 Case Study Audit Results Correct Over Coding (Compliance Risk) Under coded (Revenue Loss) Baseline Review 65% 25% 10% Impact Baseline Compliance Risk $26M Missed Revenue $5.8M 39 Client Challenges Understaffing key resources Failure to leverage technology Poorly structured audit reports Failure to provide feedback and close the loop Battle between Revenue Cycle vs. Compliance Utilizing auditors with the wrong skill set 40 20

21 Case Study Period Correct Over Coding Under coded Baseline Review 65% 25% 10% Q2 Review 80% 15% 5% Q3 Review 87% 7% 6% Q4 Review 91% 5% 4% Impact Baseline Q4 Compliance Risk $26M $3.7M Missed Revenue $5.8M $2.3M 41 How They Made Improvements Interim step outsourced audits Worked to re-build improve internal audit abilities Revised their audit reports Instituted remedial training program and re-audit standards based on defined accuracy rates Required all providers receive audit results 42 21

22 Common Risk Areas 43 EMR Impacts Over documentation for follow up visits or based on the nature of the presenting problem. Missing documentation of procedures. This is caused by providers not reviewing the final note prior to authentication. Misuse of templates

23 Common E/M Errors Documenting non-contributory for family history. Documenting see HPI for review of systems when there are no associated signs / symptoms or a ROS documented in the HPI. Not documenting the chief complaint for subsequent hospital visits. Coding MDM based on the point system alone rather than the nature of the presenting problem and the medical necessity of the service. 45 Common E/M Errors Documenting non-contributory for family history. Documenting see HPI for review of systems when there are no associated signs / symptoms or a ROS documented in the HPI. Not documenting the chief complaint for subsequent hospital visits. Coding MDM based on the point system alone rather than the nature of the presenting problem and the medical necessity of the service

24 Questions? 47 Contact Info Lamon Willis , Ext