1/17/2014. Objectives. What is a chart audit? Audits are like mountain biking you must have the right tools to have a successful ride!

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1 Audits are like mountain biking you must have the right tools to have a successful ride! 1 Objectives 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 2 What is a chart audit? 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 3 1

2 Can You Believe That Medicaid Medicare DEA State Law CMS FDA Private Accreditation HIPAA More than 100 Agencies Regulate Healthcare? OIG More IRS Health Dept 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 5 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 6 2

3 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 7 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 8 Billing Issues to Consider Auditing Incident to (nurse visit) Services by mid-level providers Teaching physician rules ABN usage Medical necessity Unbundling 9 3

4 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? 10 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 11 How 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 available 12 4

5 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 13 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) 14 AAPC Client Services Audits Demonstrate 15 5

6 Some Points to Ponder... Before You Begin 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 16 Effective Tools & Data to Use for Audits Most important tool..knowledge Any Fool can know. The point is to understand. Albert Einstein 17 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 18 6

7 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 19 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 20 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 21 7

8 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 22 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 23 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 24 8

9 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 25 EMR/Paper Templates Templates should include: All elements needed for each level Regulatory requirements Patient Identification Joint Commission Meaningful Use Authentication 26 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 27 9

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11 31 Quick Reference for AWV Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/AWV_Chart_ICN pdf 32 E/M Audit Worksheets Use worksheet or software Include your defined standards Benefits: Ensures audit quality Provides visual support Enhances training 33 11

12 Sample E/M Worksheet

13 37 38 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 39 13

14 EMR Diagnosis List 40 Encounter Form/Cheat sheet Diagnosis List

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16 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 46 Sample Signature Log 47 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 48 16

17 Results/Reports An audit without a report of findings is useless Method of reporting varies by audience Verbal Written Individual vs. Group 49 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 50 Writing a Report data Scope = chart pulls for DOS September 1 st 15 th 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 51 17

18 Graph Sample E/M Accuracy 52 A Practice Sample 53 Graph Example E/M Accuracy 54 18

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20 58 59 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 60 20

21 It s not a one time event 61 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 62 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 or call

22 Questions? 64 Senior Auditor AAPC Client Services 65 22