Advanced E/M Auditing: The Secrets to Success

Transcription

1 AAPC Workshops Advanced E/M Auditing: The Secrets to Success AAPC 2480 South 3850 West, Suite B Salt Lake City, Utah CODE (2633), Fax

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3 Advanced E/M Auditing Secrets to Success By Angela Jordan, CPC

4 Introduction AAPC Disclaimer This course was current when it was published. Every reasonable effort has been made to assure the accuracy of the information within these pages. Readers are responsible to ensure they are using the codes, and following applicable guidelines, correctly. AAPC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of information is error-free, and will bear no responsibility or liability for the results or consequences of the use of this course. This guide is a general summary that explains guidelines and principles in profitable, efficient health care organizations. US Government Rights This product includes CPT, which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS (b)(2) (November 1995), as applicable, for U.S. Department of Defense procurements and the limited rights restrictions of FAR (June 1987) and/or subject to the restricted rights provision of FAR (June 1987) and FAR (June 1987), as applicable, and any applicable agency FAR Supplements, for non-department of Defense Federal procurements. AMA Disclaimer CPT copyright 2012 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association. The responsibility for the content of any National Correct Coding Policy included in this product is with the Centers for Medicare and Medicaid Services and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, nonuse or interpretation of information contained in this product. About the Author: Angela Jordan, CPC, is a Managing Consultant with Medical Revenue Solutions in Oak Grove, Missouri. Prior to joining MRS Angela worked as a coding and compliance manager for EvolveMD and HCA. She has been involved in consulting engagements associated with EMR implementation with provider and staff support. She provides reviews of CPT, ICD-9-CM, medical record documentation, billing, and compliance issues. Her experience includes; family practice, internal medicine, pediatrics, neurology, OB-gyn, radiology, inpatient, outpatient, and other specialties. Angela is also very active in her support of the AAPC and their members. She is the current AAPCCA Board of Directors chair and is a past-president of the Kansas City Missouri chapter. Notice Regarding Clinical Examples Used in this Book AAPC believes it is important in training and testing to reflect as accurate a coding setting as possible to students and examinees. All examples and case studies used in our study guides and exams are actual, redacted office visit and procedure notes donated by AAPC members. To preserve the real world quality of these notes for educational purposes, we have not rewritten or edited the notes to the stringent grammatical or stylistic standards found in the text of our products. Some minor changes have been made for clarity or to correct spelling errors originally in the notes, but essentially they are as one would find them in a coding setting AAPC 2480 South 3850 West, Suite B, Salt Lake City, Utah CODE (2633), Fax , All rights reserved. CPC, CPC-H, CPC-P, CIRCC, CPCO TM, and CPMA TM are trademarks of AAPC. ii AAPC CODE (2633) CPT copyright 2012 American Medical Association. All rights reserved.

5 Contents Contents Why E/M Auditing? Keys to Success Knowing the Pieces Where Does Your Practice Fit? AAPC Physician Services The 20 Most Common Coding and Documentation Errors The Grey Areas EHR Good or Bad? Tips and Tools for Conducting an Internal Audit Recommended Resources: Glossary: Case Studies CASE STUDY # CASE STUDY # CASE STUDY # CASE STUDY # CASE STUDY # CASE STUDY # Encounter Form Diagnosis List Appendix NGS E/M Tool Novitas Audit Tool Preventive Services Educational Products Quick Reference Charts HCY Screening Guide Instructions and Form Audit Development Letter E/M Audit Checklist Tool Slide Presentation Advanced E/M Auditing Secrets to Success iii

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7 Advanced E/M Auditing: Secrets to Success Why E/M Auditing? Why is auditing so important, especially of Evaluation and Management (E/M) services? It is common knowledge that E/M services have been a favorite auditing target for years. They are frequently the focus of Comprehensive Error Rate Testing (CERT) and recovery audit contractor (RAC) audits, and E/M services always find a place on the annual Office of Inspector General (OIG) Work Plan. However, it was the May 2012 report Coding Trends of Medicare Evaluation and Management Service (OEI ) released by the OIG that grabbed a great deal of attention. Below is the summary from the May 2012 OIG report with findings and recommendations. Why We Did the Study Between 2001 and 2010, Medicare payments for Part B goods and services increased by 43 percent, from $77 billion to $110 billion. During this same time, Medicare payments for evaluation and management (E/M) services increased by 48 percent, from $22.7 billion to $33.5 billion. E/M services have been vulnerable to fraud and abuse. In 2009, two health care entities paid over $10 million to settle allegations that they fraudulently billed Medicare for E/M services. CMS also found that certain types of E/M services had the most improper payments of all Medicare Part B service types in This report is the first in a series of evaluations of E/M services. Subsequent evaluations will determine the appropriateness of Medicare payments for E/M services and the extent of documentation vulnerabilities in E/M services. What We Found From 2001 to 2010, physicians increased their billing of higher level E/M codes in all types of E/M services. Among these physicians, we identified approximately 1,700 who consistently billed higher level E/M codes in Although these physicians differed from others in their billing of E/M codes, they practiced in nearly all States and represented similar specialties. The physicians who consistently billed higher level E/M codes also treated beneficiaries of similar ages and with similar diagnoses as those treated by other physicians. What We Recommend CMS concurred with our recommendations to (1) continue to educate physicians on proper billing for E/M services and (2) encourage its contractor to review physicians billing for E/M services. CMS partially concurred with our third recommendation to review physicians who bill higher level E/M codes for appropriate action asp After reviewing the findings of the OIG s report, it s easy now to see why E/M auditing is necessary. The delivery of health care continues to evolve, and the move to electronic medical records is leading to complex issues for providers when it comes to meeting quality measures and the appropriate documentation for coding and reimbursement. Keys to Success As with anything, the key to success is knowledge. Knowledge is one of many key factors when it comes to auditing. Knowing how to level an E/M service is certainly a requirement, but it s just one small piece of a larger puzzle. You don t need to know everything; however, you do need to know where to look to find the answers. Knowing the Pieces z Carriers interpretations of E/M guidelines z Carriers policies as they apply to CPT, ICD-9-CM, and HCPCS Level II z OIG Work Plan for the year z RAC, CERT, Meaningful Use and any other audits of current focus in your area z Authoritative resources that can be used as credible evidence z Internal office policies pertaining to documentation and coding z Full understanding of the type of documentation used in your office transcription, paper templates, electronic health records (EHRs), etc. z Effective and professional communication with providers and management z Documentation of findings, education, and corrective actions taken Advanced E/M Auditing Secrets to Success 1

8 Advanced E/M Auditing: Secrets to Success Where Does Your Practice Fit? Using the information from a large study can provide groups with a starting point. Much like the OIG study, AAPC Physician Services (AAPCPS) compiled results from 75,000 audits as a tool for comparison. In addition, a case study has been provided from one client to show the effectiveness of an audit that provides reporting, education, and follow-up with re-auditing. Case study for Client A This review was provided on a quarterly basis over a one-year time period. As you can see from the results below, considerable improvement was achieved over the course of the year. The results are reflective of the positive impact of an audit plan that combines audits, education, corrective measures and re-audits. Period Total Supported Compliance Risk (Over coding) Q1 Review 65% 25% 10% Q2 Review 80% 15% 5% Q3 Review 87% 7% 6% Q4 Review 91% 5% 4% Compliance Risk Revenue Opportunity (Under coding) Key Findings: z E/M levels word traps and tricks z E/M provided at the time of a minor office procedure z Medicare Annual Wellness Visit (AWV) at the time of a sick office visit (OV). Trainings: z Individual post audit conference calls specific findings z On site individual and group meetings specific findings and trends z Live webinar styled instruction new concepts (i.e., AWV and other preventive services in the Medicare population) providers had been misinformed and believe things like every time I fill in the blank then that s a level 4! After initial audits and individualized trainings, we saw a steady increase of accuracy each quarter. One year later, Client A s providers are at a 91 percent accuracy rate. The results of this case study are indicative of the effectiveness a comprehensive audit program can have. The education and follow up are just as important as the performance of the audit. The improvement over the course of the year is due to continued education and follow-up audits. In most cases providers who have over-coded services may have been using word choices that are unacceptable to Medicare and other payers for code support purposes. We (AAPC Physician Services) provide the language that Medicare accepts once we ascertain the provider s meaning. Also, we acted in a coding myth-buster function. We found some 2 AAPC CODE (2633) CPT copyright 2012 American Medical Association. All rights reserved.

9 Advanced E/M Auditing: Secrets to Success Let s look at the findings by specialty for all 75,000 chart audits. AAPC Physician Services E/M Audits Results Total Supported Compliance Risk (Over coding) All Specialties 72% 21% 7% PC vs. Specialist Total Supported Compliance Risk (Over coding) Primary Care 74% 19% 7% Specialists 68% 25% 7% Specialists Women s Health 69% 23% 9% Urology 61% 29% 10% Orthopedics 73% 22% 5% Internal Med 7% Pediatrics 72% 22% 6% Family Practice 77% 16% 7% Cardiology 73% 19% 8% Specialties With the Lowest Error Rate Family Practice 77% 16% 7% Internal Medicine 75% 19% 7% Cardiology 73% 19% 8% Specialties With the Highest Error Rate Radiation Oncology 50% 50% 0% Colorectal Surgery 40% 60% 0% Thoracic Surgery 10% 80% 10% Revenue Opportunity (Under coding) Revenue Opportunity (Under coding) The most common over-coded E/M services were and Do you know what your provider s utilization is for these codes? If you don t, AAPC Physician Services has a free utilization tool. This is a valuable resource can provide you with the information needed to see where your providers are, which can assist in determining where to start your audits. E/M Utilization Benchmarking Tool: Advanced E/M Auditing Secrets to Success 3

10 Advanced E/M Auditing: Secrets to Success The 20 Most Common Coding and Documentation Errors z Chief Complaint (CC) Complete lack of CC in hospital documentation. CC in office notes is insufficient most often in follow-up care. Hospitals must give the status of the patient in responding to treatment, detailing how the patient is doing, and how the disease is progressing. z History of Present Illness (HPI) HPI is not completed by the physician or provider of the visit, and was used to level the visit. z Chronic Conditions Simply listing the chronic conditions in the HPI and not providing the actual status, which is the status of the condition per the patient. z Review of Systems (ROS) Lack of or completely absent ROS in note. Pertinent negative and positive findings should contain detail. Statements such as see HPI cannot be counted unless the systems were addressed. z Language Use of unacceptable language such as Non-contributory for PFSH is insufficient for many carriers. z Documentation Lack of documentation of the exam. This could be attributed to the use of check box templates, forgetting to pull in the exam portion in the EHR or the provider s simply not documenting that an exam was performed. z Mixing Mixing of body areas and organ systems when trying to achieve a 95 E&M Coding Guidelines comprehensive exam. The guidelines define Comprehensive a general multi-system examination or complete examination of a single organ system. DG: The medical record for a general multi-system examination should include findings about eight or more of the 12 organ systems. z Check boxes Incorrect use of check boxes or templates. The biggest issue is check boxes or templates that are marked as abnormal without the provider elaborating or providing detail about the abnormality. z Understanding Lack of understanding of the 97 E&M Coding Guidelines specialty exams. Most providers understand the lower level, but the comprehensive exam for each specialty has very specific requirements that must be met to bill the higher level. 4 AAPC CODE (2633) CPT copyright 2012 American Medical Association. All rights reserved.

11 Advanced E/M Auditing: Secrets to Success z Severity and Number Medical Decision Making (MDM) based solely on severity or number of presenting problems is not acceptable. Use all of the MDM components including data in addition to the table of risk. z Time Based Incorrect documentation of time based coding. Be aware of the guidelines for your carriers. Some Medicaid carriers are very specific that time must be actual start and stop time for any service being billed based on time. There are some Medicare carriers that do not allow the use of greater than 50 percent was spent in counseling ; instead they want to see the actual number of minutes listed. z Orders Orders listed without correlation to plan. This typically happens on forms and templates where the Assessment and Plan are separated. The orders need to somehow clearly reflect the need for the order or the specific condition. Orders without a reason are not medically necessary. z Diagnosis Lack of specificity, even with ICD-9-CM, is a major problem that we have allowed to occur. We need to really start working with providers now on this issue; it will make the transition to ICD-10-CM more bearable if they take baby steps now. z Inconsistent Documentation Steer clear of inconsistent documentation in HPI, ROS, and/or assessment and plan. I call this the what the heck note. I m sure you have all seen this at least once. The HPI, Exam, and MDM seem as if they have nothing to do with each other. The patient s HPI is all about a cold with the exam being normal, and the A&P is for a routine breast exam and mammogram. z Abbreviations Avoid use of abbreviations that are not industry standard. If a practice uses non-standard abbreviations, it must maintain a list of what is meant and how the abbreviations are used. That document needs to be submitted with the records anytime an audit is done. z Counting Elements Only two of three elements of history, exam, and medical decision making meet the required elements for E/M categories requiring three key components be met or exceeded. z Office Procedures Insufficient documentation is a big problem. An example is a statement such as biopsy done with nothing more in the record to support billing the service. z Misunderstanding of Preventive Services Misunderstanding of preventive services (Annual Well Visit [AWV], Initial Preventive Physical Examination (IPPE), Medicare Screening Pelvic Exam, Medicaid Early and Periodic Screening, Diagnosis, and Treatment Exam (EPSDT) and annual exams) and required documentation elements. The Centers for Medicare & Medicaid Services (CMS) has great tools and Quick Reference sheets that lay out all of the elements and timing of services. Reference information for the performance and documentation of EPSDT exams can be located on the state Medicaid websites. Medicare-Learning-Network-MLN/MLNProducts/ Downloads/education_products_prevserv.pdf PrevntionGenInfo/Downloads/MPS_ QuickReferenceChart_1.pdf z Lack of Authentication Documentation is not authenticated by the author. z Failure to be Timely Documentation is not completed in a timely manner. The CMS Internet Only Manual (IOM) Publication , Chapter 12,Adobe Portable Document Format Section states that a provider is expected to complete his or her documentation during or as soon as practicable after it is provided in order to maintain an accurate medical record. z Modifier Misuse Incorrect use of modifier 25 and 59 is always a target; errors occur when basic coding guidelines aren t followed. z NCCI and LCD edits Lack of following national correct coding initiative (NCCI) and local coverage determination (LCD) edits raise flags. Following NCCI and LCDs will let indicate when modifiers are needed, certain care criteria must be met, and if there is an issue with timing and frequency. z Diagnosis Coding Diagnosis coding on the claim is more specific than the supporting documentation in the medical record. Not reporting all diagnoses addressed in the assessment and plan can occur when the physician marks his or her choices on an encounter form or superbill. z Chronic Conditions Reporting chronic conditions rather than the specific reason for the visit is a common problem. The reason for the visit and only those conditions that were addressed or had a direct impact on the presenting problem should be reported. Advanced E/M Auditing Secrets to Success 5

12 Advanced E/M Auditing: Secrets to Success The Grey Areas When it comes to the E/M guidelines, there is often more grey than black and white. Over the years there have been many myths about how to use them; recently several Medicare Administrative Contractors (MACs) have provided clarification. Chief Complaint in the HPI Can the CC be pulled from the HPI? According to the E/M 1995 and 1997 DG, The CC, ROS, and PFSH may be listed as separate elements of history or they may be included in the description of the history of present illness. However, best practice is that the CC be documented as a separate statement, which allows the information in the HPI to be used solely to satisfy the elements needed to level the history. Status of Three Chronic Conditions Can the status of three chronic conditions be used to support an extended level of history with the 95 guidelines? The Evaluation and Management Services Guide found on the CMS website, states the following. Note: Either version of the documentation guidelines, not a combination of the two, may be used by the provider for a patient encounter. The definition is Extended HPI: 1995 documentation guidelines Should describe four or more elements of the present HPI or associated comorbidities. Unobtainable History If the history is unobtainable can you automatically bill a comprehensive history? No, and one of the best reference documents can be found on the Wisconsin Physician Services (WPS) Medicare website. There is nothing notated in the 1995 or 1997 DG to indicate any level of history is automatic. The physician should document the reason the patient is unable to provide history and document his/her efforts to obtain history from other sources. This could include family members, other medical personnel, obtaining old medical records (if available) and using information contained therein to document some of the history components (past medical, family, social). j5macpartb/resources/provider_types/2009_0526_ emqahistory.shtml HPI Taken By Nurse If the nurse takes the HPI, can the physician then state, HPI as above by the nurse or Have read and agree with the HPI? Several carriers have released additional clarification that this practice in unacceptable. WPS states No, the physician billing the service must document the HPI. The E/M guidelines are very clear that only the physician/provider can document the HPI. Double Dipping A provider can count a single history item in both the HPI and ROS. This is not a recommended practice and should be discouraged. The fact is that the E/M Guidelines do not clearly state that a single element of history cannot be used more than once. Some carriers have published information regarding double dipping. WPS has published this statement A clearly documented medical record would prevent the need to double-dip for HPI and ROS, but WPS Medicare, in rare circumstances, could accept counting one statement in both areas if necessary. Novitas, for example, allows double dipping HPI and ROS. For more information, consult Know Double Dipping Etiquette in AAPC Cutting Edge, February Single Organ System Exam Is it acceptable to use the 97 Specialty specific exams for the comprehensive exam of a single organ system in 95? The 95 Guidelines never defined the elements of a single organ system exam, which was one of the primary reasons for the development of the 97 Guidelines. Combining the guidelines is not allowed. If a provider wants to do a comprehensive single organ system exam he or she should then use the 97 guidelines or the 97 specialty specific exams. Detailed Exam CMS never defined the requirements of the Detailed Exam for the 95 Guidelines. By definition the guidelines state Detailed An extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s) Most carriers recognize the two to seven organ system/body area exam with a detailed description of the affected organ systems/body areas. Beware that some coders still use the Marshfield System that defines a detailed exam as five to seven body areas/organ systems, but confirm with your carrier to make sure it s acceptable. Hint check to see if your carrier has published their own audit tool. Here is the exam portion of the audit tool from National Government Services. 6 AAPC CODE (2633) CPT copyright 2012 American Medical Association. All rights reserved.

13 Advanced E/M Auditing: Secrets to Success 2 Examination Refer to data section (table below) in order to quantify. After referring to data, identify the type of examination. Circle the type of examination within the appropriate grid in Section 5. Note: Choose 1995 or 1997 rules, but not both. Examination Body areas: Head, including face Chest, including breast and axillae Abdomen Neck Back, including spine Genitalia, groin, buttocks Each extremity Organ systems: Constitutional (e.g., vitals, gen app) Ears, nose. mouth, throat Respiratory GI GU Cardiovascular Musculoskeletal Skin Neuro Psych Hem/lymph/imm Eyes Calculation Choose either 1995 or 1997 rules to calculate result One body area or system 1 5 bullets (1 or more body areas or system) 2 7 areas or systems (Minimal detail for areas and/or systems examined; check list type documentation without any expansion of documentation of findings) areas or systems (Expanded documentation of the areas and/or systems examined; requires more than checklists; needs to have normal/abnormal findings expanded upon) 6 bullets (1 or more body areas or system) 12 bullets in 2 or more body areas/systems or 2 bullets in 6 or more body areas/ systems (except eye and psych exams, which are 9 bullets) 8 or more systems only 2 bullets in 9 or more body areas or systems; or complete single organ system Final Results Problem Focused Expanded Problem Focused Detailed Comprehensive d c1dcef894cf9b8b8c8d5ce/1074_0412_em_ Documentation_Training_Tool.pdf?MOD=AJPERES& usedefaulttext=0&usedefaultdesc=0 This is page 2 of Evaluation & Management Documentation Training Tool. EHR Good or Bad? Page 2 of 6 There are many benefits to EHRs. From a purely practical standpoint there are no more lost charts, no struggling to read a provider s handwriting, and documentation can be accessed in real-time. On a larger scale better quality care and education can be provided based on the ability to easily define patients with chronic conditions. EHRs are evolving to ease transmission of records to wherever a patient is located in a medical emergency. EHRs allow communication, sharing results with patients via patient portals. Systems can transmit prescriptions, orders for lab and ancillary testing, and receive results in such a way that values can be uploaded directly into a patient s chart. This provides the ability to conduct trials and research studies and easily share the information with academic centers across the country. The incentive dollars to adopt EHRs, in conjunction with the promise of lost reimbursement if they don t adopt, have providers and hospital systems on notice to move now. This rapid adoption has led to many concerns as providers select and adopt EHRs without fully understanding the impact systems can have on documentation, coding, and reimbursement. Let s look at some of the most common problems. Copy and Paste Copy forward of History, ROS, PFSH elements that may not be pertinent to the reason for visit is a problem. Most EHRs even allow providers to bring forward a previous exam in addition to assessment and plans. This is why the OIG is taking a close look at EHR notes; copying and pasting lead to cloned notes and to over-billing if the system is choosing the level of the visit. The OIG Work Plan for 2012 addressed this: Evaluation and Management Services: Potentially Inappropriate Payments. We will assess the extent to which CMS made potentially inappropriate payments for E/M services and the consistency of E/M medical review determinations. We will also review multiple E/M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. Medicare requires providers to select the code for the service based upon the content of the service and have documentation to support the level of service reported. (CMS Medicare Claims Pro- Advanced E/M Auditing Secrets to Success 7

14 Advanced E/M Auditing: Secrets to Success cessing Manual, Pub. No , ch. 12, ) (OEI; ; ; expected issue date: FY 2013; work in progress) Over-documentation Over-documented ROS and exam elements solely to meet the requirements of a higher level of service when the nature of the presenting problem suggests a lower level inflates claims. Education at the time of training with providers is essential to curtailing this problem. Templates should be built based on the presenting problem, and when built correctly they will only have the pertinent ROS and exam elements standard for the presenting problem. Missing Documentation All documentation elements for the visit are not provided for audit review. These elements are documented on templates but do not print on the output documents or are found on a separate document. The physician may refer to another document or flow sheet in his note, yet the staff doesn t print it out and submit with the notes for the review. Providers often forget to generate additional notes. Some EHR systems have separate notes for procedures or other services. The provider often forgets to generate and sign off on these notes. Many providers are not thoroughly trained on their EHR systems and are not aware of the extra click required to ensure all documentation elements print on the note. Auto Coding E/M Auto-coding can be inaccurate and often does not follow the local MAC guidelines. It is essential for you, the coder/auditor, to understand your EHR and exactly how it determines the level for E/M codes. After an audit, when you are providing education, the provider is going to ask how or what they need to do to fix the problem. If you fully understand the program you will be able to assist them correct the problem, or at least help the provider understand why it is happening. Your value goes up if you can assist by helping to fix the issue. Favorites Lists There is no way to escape this issue.. This problem has worsened, especially when you have someone in charge of your diagnosis or procedure list who doesn t understand the importance of the wording of a code. In an attempt to alter the descriptions to make it easier for the physician to find the code, he or she may have created confusion. Updates Annual coding updates often don t occur when they are supposed to, which means the office needs to be on top of the changes and their vendor s update schedule. Sometimes a software update contains bugs in the system. Software updates may cause unexpected problems associated with documentation and coding. This is why it s important to go through the release notes and be aware of any known issues any time there is a software update. Who Did It? Authentication of nursing and other nonprovider staff is missing. This is an even more troublesome when you consider there are only certain parts of documentation that the ancillary staff can perform. Not all systems show the authentication of the author within the note. When the note prints, the RN could have documented the entire visit, yet all you see is the provider s electronic signature. On a positive note, systems have audit logs that track who did it in the metadata. Signature Authentication The electronic statement on the document does not meet the requirements or its nonexistent. WPS Medicare has a statement regarding electronic signatures: Electronic Medical Records (EMR) For providers using EMR systems, it is crucial that the electronic signature is affixed to the records when responding to all Medicare requests for documentation. Although CMS has not published formal regulations regarding electronic signatures, we recommend that an electronic signature be accompanied by a statement indicating that the signature was applied electronically. We also recommend including the date and time the record was authenticated. Electronic signature notations can include the following (not all-inclusive): z Electronically signed by z Verified by z Reviewed by z Released by z Signed by z Authenticated by z Authorized z Confirmed by z Finalized by z Electronically approved by Incomplete Notes Authentication of the note before it is completed must be done. Providers may mark a document as Ready or Complete, which drops into a ready to bill type status, when in fact it should have been placed in a Hold, Pending, or In-complete Status. Quite often we see incomplete notes the provider has authenticated. During the course of a busy day, it s very easy to click and sign off 8 AAPC CODE (2633) CPT copyright 2012 American Medical Association. All rights reserved.

15 Advanced E/M Auditing: Secrets to Success on a note that really is not complete. Not all systems have the ability to place encounters on hold. Coding Edits Beware, most out of the box systems containing some type of an edit program that is loosely based on CMS NCCI policy. The problem with several systems is they contain a lot of edits that by some are considered unnecessary. One personal favorite is when a high level code only has one diagnosis, a warning appears indicating the diagnosis selected will not support the level of service. The program isn t looking at the diagnosis code; it only sees that one code is being used. Those using the system may start to ignore the warning messages, which may lead them to ignore something of which they need to be aware. Tips and Tools for Conducting an Internal Audit Now that we have gone through some of the most common issues, it s time to focus on the actual audit. We have established that an internal audit is a very important part of keeping on top of the health of your office s revenue cycle. The last thing any provider wants to do is pay back money to any carrier. Now that we know where carriers are focusing some of their attention, it is important to follow your internal coding compliance program. What if you don t have a coding compliance program? It is time to develop one. You can find a lot of information on the Internet, and you can look to the AAPC for guidance on what your policy should include. An effective coding compliance program will be evaluated and reevaluated continually. It is understood that rules will change, new reimbursement methodologies will be adopted, codes will change, new laws will be enacted, and there will be employee turnover. One method used to assess the effectiveness of the compliance plan is a compliance scorecard. The scorecard can measure specific processes and serve as a motivational tool for employees and managers. Scorecard items should be reviewed and approved by staff and administration. Some scorecard items for a coding compliance department may include the following: z Coding accuracy goal of 95 percent z Reduction in billing/claim errors (measured as a percent of total claims billed) z 100 percent participation in coding and documentation educational programs z Turnaround time to complete audits (measured in days, weeks, months, etc.) z Obtaining continuing education units (CEUs) by all coding staff to maintain coding certification Structure Process Outcome Does the coding compliance department have a code of conduct? Does the coding compliance department regularly report auditing results? Have results been effectively communicated to coding, billing, and clinical departments? Is the necessary education performed to address compliance issues? Have auditing and education improved the results? Have processes changed as a result of audit findings? Include the code of conduct within the coding compliance policy. Staff sign attestation they have reviewed the policy annually. Audits results are presented at quarterly Compliance Advisory Committee meetings. Results are shared with responsible departments promptly. Following reporting of auditing results, training sessions are scheduled. Perform follow-up audits to access the effectiveness of retraining. Coding staff observe the code of conduct. Audit findings are reported and education is initiated. Education is conducted; errors are reduced. Additional training is performed as needed; errors are reduced. Advanced E/M Auditing Secrets to Success 9

16 Advanced E/M Auditing: Secrets to Success Is the coding compliance department properly organized? Do employees have the necessary qualifications to accurately assess coding? Does the coding compliance department have sufficient resources (staff, budget), training, authority, and autonomy to carry out its mission? Does a relationship exist between the corporate compliance program, the coding compliance committee, and the coding compliance department? Coding compliance staff maintains coding certification. Review staff credential maintenance on an annual basis. Budget will contain sufficient resources for accurate coding including resources, training, continuing education opportunities, computer software, auditing, and consultation services. The department will assist with coding services as applicable. Committee structures will be multidisciplinary including coding, business management services, administration, and providers as appropriate. Coding staff receive timely updates on coding and regulatory changes, reducing the potential for coding errors. The coding compliance department will be the health care facility s expert resource for coding advice. Adequate resources reduce the potential for coding errors. Communication among the various departments helps to ensure effective working relationships and follow through on compliance issues. The OIG has recommended that to be effective, both the coding compliance program and the corporate compliance programs be continually assessed and monitored. The effectiveness of a program is the measurement of various outcome indicators and may include billing and coding error rates, identified overpayments and underpayments, and audit results. The focus on examination of the compliance program is a crucial activity that examines the underlying structure, process, and outcomes of the program. Structure measures refer to the capacity of the program to prevent and detect violations of law. Process measures refer to the manner in which the program seeks to prevent and detect violations of the law. Outcomes measures refer to the observable, measurable results related to preventing and detecting violations of law and creating a compliant culture. Focus Know the focus of the audit prior to beginning. Are you looking at all providers specific level of service? Include new, established, consults, IP, OP, etc. z Is this a new hire? The focus will be broad and a repeat review should occur in near future. z Is this a follow-up review of a chronic problem, which has already been addressed with a provider? Be Prepared Prepare your coders and providers for the audit. An audit should not come as a surprise to providers or coders. Inform them of the type of review and what prompted it. Is this the annual review according to compliance plan or is it a focused review because of a higher denial rate, or the provider being identified as an outlier? Let your providers and coders know the expected time frame and if you plan to be on site. In a larger facility, the audit may take place off site. Finally, share the expected timeline of when the audit will begin and the findings are delivered. Auditors Establish a team of specialized auditors for the specialties in your group practice. Utilize coders with a specialty credential such as AAPC s Certified Professional Medical Auditor (CPMA ) or demonstrate advanced knowledge in a specific area, although this may not be an option in smaller settings. Use senior level auditors to perform a quality assessment review where the auditor, as well as the provider and coder are reviewed. z Auditor s Role An auditor s role is to be an advocate to both the coder and provider. Auditors are more successful if they have an attitude of educator and trainer rather than of enforcer. Providers did not go to medical school to be a coder; in fact, many may have never been exposed to coding. Your role is to help the provider understand the constantly changing coding rules. Keep in mind coders speak a different language than the providers. Coders need to adapt to the provider, not the other way around. Sit down with the provider and coding books to explain the coding options available in comparison with the language they may be using. By using phrases like help me to understand what you were thinking instead of your documentation doesn t support what you are doing, I m here to help you, We need to make sure your documentation captures all of the work that you do. 10 AAPC CODE (2633) CPT copyright 2012 American Medical Association. All rights reserved.

17 Advanced E/M Auditing: Secrets to Success A confident and knowledgeable coder can offer reassurance to the provider that he or she is trained and an asset. Standards Develop written audit standards for areas of coding that are grey or ill defined by CMS or your MAC. This will ensure consistency with audits, increases productivity, and assists you to train your coders and providers. z Do you use whichever Guidelines are most advantageous to your provider or is it defined such as 95 for hospital, 97 for office? z What exactly is negative in HEENT? Unless each element is defined, don t use it (head, ears, eyes, nose, throat) z What is included in prescription drug management (PDM)? Is it any prescription given or is it management of medications on an on-going basis? z Has your carrier defined what is or is not included in additional work up in MDM? z Guidelines state 2 of 3 for an established patient. Is the MDM always used as one of the two elements or is the level of service based on history and exam? Documentation Ensure all documentation is pulled and reviewed for the audit. Never assume the referenced documentation truly exists. This can be done in a paper or electronic world. In the electronic world, is there a link to this other information or is it difficult to find? If all the documentation isn t provided, it could be a sign of a larger problem that will require education for the staff responsible for records requests. Carrier Guidelines As with everything in health care, the guidelines are constantly changing and not consistent between payers. You have to be familiar with ALL payer guidelines you submit claims to. Not all payers follow NCCI or CMS guidelines. There are maps on the CMS website that provide the most current information for MAC jurisdictions-notice the date on the A/B MAC map- 3/2012. Gather the additional information needed to complete the audit. Some items you will need to be aware of include: Payers vary on what is acceptable for signature requirements. z Provider signature logs. Signature logs should be updated since handwriting can change with time. Advanced E/M Auditing Secrets to Success 11

18 Advanced E/M Auditing: Secrets to Success 12 AAPC CODE (2633) CPT copyright 2012 American Medical Association. All rights reserved.

19 Advanced E/M Auditing: Secrets to Success z Supervisory physician information for your practice. In highly organized clinics, particularly those which are departmentalized, direct personal physician supervision may be the responsibility of several physicians as opposed to an individual attending physician. In this situation, medical management of all services provided in the clinic is assured. The physician ordering a particular service need not be the physician who is supervising the service. Services performed by auxiliary personnel and other aides are covered even though they are performed in another department of the clinic, as long as the contractor determining the situation allows the supervisor to be present in the clinic, immediately available, and able to provide assistance and direction throughout the service. However, the requirement for direct supervision is not satisfied unless there is a specific physician responsible for the supervision of the billed service. The clinic may meet this requirement, for example, by assigning one supervisor for the day or by assigning individual supervisors for specific services. In the case where a long service requires more than one supervisor, the physician who had the responsibility for the major part of the service should be identified on the claim. z Abbreviation list of office specific abbreviations that are used by your providers that may not be industry standard. Some providers have created unique abbreviations over the course of their careers. These self-created abbreviations can cause problems during an audit. One example found on an exam was no BLB under gastrointestinal. After a quick search on php, none of the options seem to fit. After querying the providers nurse, we found out that it was blood or black. Many large hospital and health systems have a list of acceptable and unacceptable abbreviations that are part of their compliance tools for documentation. z Tools that the providers and coders are using to help with code selection. This could be diagnosis favorites lists, specialty specific procedure code lists or even training material from their specialty society on how to code or document services. that could be addressed in a group setting? However, you will need to be cautious in group training; it can be intimidating if you are sharing one provider s documentation with all of the providers. Make sure to ask permission from each provider before doing so. Another very important piece is following up on questions or getting additional resources. Training Determine the most appropriate method when providing training. Should you provide individualized post audit training to coders and/or providers or group training? Some providers prefer one-on-one training; however, still ask if the coder can be involved so they are both on the same page. Is there a pattern among many of the providers Advanced E/M Auditing Secrets to Success 13

20 Advanced E/M Auditing: Secrets to Success Staff Education Form Education Form Coding and Documentation Review Practice Manager: Provider: Practice: Address: Audit Period: Dates of Review: Type of Audit: Reviewer: Date of Report: Legend: Discussed Not an issue, not found on audit Potential Overcoded HPI Consult/Referral Incident- to Potential Undercoded ROS Preventive Med. PATH/Med Stud Revisions Exam Surgical Coding ABN/LCD/NCD Unbilled MDM Signature Orders Chief Complaint Minor Proc. In Off. Ancillary Signature Prof Int. & Report ICD- 9 Specificity Modifiers Legibility POS ICD- 9 A,I,S,U Medical Necessity Assumption Coding CLIA ICD- 9 Linking CCI Encounter Form Other Issues discussed: Provider/Staff Present: Signature: Signature: Signature: Total Time of Session: Auditor: Signature: Initials Report and Follow Up This is the final piece that provides results and the road map to correcting any issues found. An Executive Summary report should be provided that lays out the findings of the audit. The report should provide a combined result in addition to a break out with each provider s individual results. Grammar and spelling should be watched carefully, as this will reflect upon you, the reviewer. Keep any emotions or feelings you may have out of the report; it should be a factual statement of the findings and recommendations. 14 AAPC CODE (2633) CPT copyright 2012 American Medical Association. All rights reserved.