Audit Tools. Audits are like a marathon you must have the right tools to have a successful run!

Transcription

1 Audit Tools Paul Chandler, BS-HRM, AA-C, CPC, CPC-I, COC, CPC-P, CPMA, CPCO, CPPM, CPB, CANPC, CASCC, CCC, CCVTC, CEDC, CEMC, CENTC, CFPC, CGSC, CGIC, CHONC, CIMC, COBGC, COSC, CPCD, CPEDC, CPRC, CRHC, CSFAC, CUC President & CEO Audits are like a marathon you must have the right tools to have a successful run! 1

2 Objectives 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 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 2

3 Can You Believe That More than 100 agencies regulate healthcare? 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 3

4 Types of Audits Coding and documentation E/M Outlier Modifier utilization (i.e. 25 & 59) Billing Denials ICD-10-CM assessment 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 4

5 Billing Issues to Consider Auditing Incident to (nurse visit) Services by mid-level providers Teaching physician rules ABN usage Medical necessity Unbundling 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? 5

6 ICD-10 CM Assessment Review documentation to see if current practices are sustaining 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 nonspecified codes may also result in slow or no payment 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 6

7 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 Most Common Coding & Documentation Audit Examine the medical record documentation Evaluation & Management level and category Other CPT codes HCPCS II ICD-10-CM 7

8 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 Effective Tools & Data to Use for Audits KNOWLEDGE! 8

9 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 Effective Tools & Data to Use for Audits CPT /ICD-10-CM/HCPCS II books or software Specialty specific coding references CCI/NCCI edits Payer policies All medical record documentation Billing documents Previous audit results 9

10 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 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 10

11 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 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 11

12 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 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 12

13 Templates Templates should include: All elements needed for each level Regulatory requirements Patient Identification Joint Commission Meaningful Use Authentication 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 13

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15 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 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-10-CM assignment Measure accuracy 15

16 Results and Reports An audit without a report of findings is useless Method of reporting varies by audience Verbal Written Individual vs. Group 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 16

17 Writing a Report 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 Sample Graph: E/M Accuracy 17

18 Sample Graph: E/M Accuracy Practice Sample 18

19 Staff Education Form Detailed Summary and Report of Findings 19

20 Report Results are in.what is next? 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 20

21 Repeat Audit Educate Monitor Educate Audit Educate Monitor Educate Summary 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 21

22 Questions? THANK YOU! 22