WHAT DO YOUR PROVIDERS DO?

Presented by Angela Brown, CHCA, CHC, CCS-P, PCS Deputy HSC Compliance Officer Director of Compliance Education Interim Audit Manager University of Louisville Health Sciences Center 1 Learning Points Why audit What should we audit How many audits should be done How should we audit What references do we need to audit How to build an AUDIT REFERENCE BINDER 2 1

Why Audit OIG Guidances Compliance Program Guidance for Third Party Billing Companies ~ Federal Register December 18, 1998 Final Compliance Program Guidance for Individual & Small Group Physician Practices ~ Federal Register October 5, 2000 More intensive scrutiny from the government and third party payers Being aware of where your practice stands before someone else come to audit 3 Why Audit Losing revenue from documented but unbilled services Lack of documented medical necessity Code over/under utilization Unbundling, upcoding, and miscoding Correct documentation Correct up-to-date procedural and diagnosis coding Correct reimbursement Decreases denials and recoupments 4 2

Why Audit Become the SUBJECT MATTER EXPERT Do not be the COMPLIANCE POLICE Educate your providers to the why and how of auditing Gain a champion by teaching and not preaching Show them the impact of correct compliant documentation & coding 5 What to Audit There is only one question to answer when deciding WHAT TO AUDIT. That question is... WHAT DO YOUR PROVIDERS DO? 6 3

What to Audit You must become the expert in what your providers do everyday. If you do not know WHAT they do you cannot effectively audit. If you do not know how to drive a car you CANNOT drive a car. SIMPLY PUT Youhave to be the Subject Matter Expert in your practice. 7 Develop an audit plan of the services that your practice provides Evaluation & Management Services Related procedures done in the office Related labs and diagnostic testing done in the office Start small Look at one thing in the beginning Documentation & levels of E/Ms coded 8 4

Determine the number of audits that you will do and then times that by the number of providers you have Remember if you are the only one auditing and you also have other responsibilities DO NOT CHOOSE A LARGE NUMBER Maybe start with 10 audits per provider 9 Once you have made a decision on what you will audit do a BASE-LINE audit This will be a fixed number of audits that you will do for a chosen population An example: 5 E/M services for 1 month for each provider 10 5

Get familiar with the documentation styles of your providers Handwriting Dictation EMRs If you use templatedforms ask yourself Is it complete and up-to-date? Is the provider being directed to specific codes based on the form and the information required on the form? 11 Know the terminology indicative of your practice type Learn the terminology unique to your specific practice Regional Ethnic Abbreviations If you don t know a term LOOK IT UP or ASK and then write it down 12 6

Pick your audit tool Handwritten Electronic Computerized Along with your audit tool chose guidelines that you will audit by CMS Other payer State Guidelines/Law Remember that if a state law is more stringent than the federal law you must adhere to the state law 13 Example of a state law and it s effect on an audit: 1. KRS states that a Physician Assistant must have a supervising Physician s cosignature before billing the service. 2. The Kentucky statute that governs radiology equipment states that either a Physician (MD or DO) or someone with a radiology certification can shoot the film. A ARNP or PA cannot shoot the film. 14 7

What References Do You Need to Audit Current ICD-9-CM, CPT, and HCPCS coding manuals Current governmental or payer guidelines Anatomy and Physiology Book Lab Book Reference Books such as a CDR, PDR or Abbreviation Book Documentation Guidelines Specialty Specific Guidelines or Publications Current Medical Dictionary Merck Manual Reference Binder with Web-based printouts of articles Quick list of website for references, articles and resources Quick list of list-servs Daily TO-DO list of websites to scan for updated information 15 What WEBSITES Provide Good References AHIMA AAPC HCCA TRAILBLAZERS MEDICARE NATIONAL GOVERNMENT SERVICES MEDICARE AMA OIG 16 8

Important References OIG Guidances Third Party Billing Companies http://oig.hhs.gov/fraud/docs/complianceguidance/thirdparty.pdf Individual & Small Group Physician Practices http://oig.hhs.gov/authorities/docs/physician.pdf Documentation Guidelines 1995 https://www.cms.gov/mlnproducts/downloads/1995dg.pdf 1997 https://www.cms.gov/mlnproducts/downloads/master1.pdf Evaluation & Management Services Guide https://www.cms.gov/mlnproducts/downloads/eval_mgmt_serv_guide.pdf 17 Important References Guided Pathways of Resources for Fee-For-Service Providers https://www.cms.gov/mlnedwebguide/downloads/guided_pathways_basic_booklet.pdf MLN Resources for Billing & Coding Professionals https://www.cms.gov/mlnproducts/downloads/billers_and_coders_suite_of_products_listings.pdf ICD-9-CM Coding Guidelines effective 10/01/2010 http://www.cdc.gov/nchs/data/icd9/icdguide10.pdf Trailblazers Medicare References Modifiers http://www.trailblazerhealth.com/publications/training%20manual/modifiers.pdf Non-Physician Practitioners http://www.trailblazerhealth.com/publications/training%20manual/nonphysicianpractitioners.pdf Partners in Compliance http://www.trailblazerhealth.com/publications/training%20manual/partnersincompliance.pdf 18 9

Important References Trailblazers Medicare References continued CMS 1500 Instruction Manual http://www.trailblazerhealth.com/publications/training%20manual/claim%20form%20instructions.pdf Advanced Beneficiary Notice of Noncoverage Manual http://www.trailblazerhealth.com/publications/training%20manual/abn.pdf Incident-to Services Manual http://www.trailblazerhealth.com/publications/training%20manual/incident_to.pdf Appeals Manual http://www.trailblazerhealth.com/publications/training%20manual/appeals.pdf Office of the Inspector General (OIG) 2011 Workplan http://oig.hhs.gov/publications/workplan/2011/fy11_workplan-all.pdf 19 Questions and Contact Info Angela Brown, CHC, CHCA, CCS-P, PCS Deputy HSC Compliance Officer University of Louisville Health Sciences Center Louisville, KY angela.brown@louisville.edu 502-852-8680 (phone) 502-852-8013 (fax) 20 10