a division of Managed Resources

Mastering the Audit Process

Presented byLynn Handy CCS-P CPC CPC-I COC LPN

Vice President of Coding amp Audit ServicesCodingAID a division of Managed Resources Inc

Agenda

Why do we perform Audits Types of Audits

o Internal Auditso External AuditsoAuditor Quality Audits (QA)

Defining the Audit Scope Sample Selection Methodology Scoring Methodology Coding Guidelines

Auditor Quality Reviews amp Productivity Standards Audit Reports

oProvider Audit Reportso Executive Summary Reports

Presenting the Audit Results Post Audit EducationHandling Audit Disputes Self Disclosures Refunds and

Corrected Billing

Why do we Perform Audits

To determine outliers before large payers find them in their claims software and request an internal audit be done

To protect against fraudulent claims and billing activity

To reveal whether there is variation from national averages due to inappropriate coding insufficient documentation or lost revenue

To help identify and correct problem areas before insurance or government payers challenge inappropriate coding

To help prevent governmental investigational auditors like recovery audit contractors (RACs) or zone program integrity contractors (ZPICs) from knocking at your door

To remedy undercoding bad unbundling habits and code overuse and to bill appropriately for documented procedures

To identify reimbursement deficiencies and opportunities for appropriate reimbursement

To stop the use of outdated or incorrect codes for procedures

To verify ICD-10-CM and electronic health record (EHR) meaningful use readiness and Risk Adjustment (HCC) reporting

Developing an Internal Audit amp Education Program

Office Inspector General Guidanceo OIG has developed a series of voluntary compliance program guidance documents

directed at various segments of the health care industry such as hospitals nursing homes third-party billers and durable medical equipment suppliers to encourage the development and use of internal controls to monitor adherence to applicable statutes regulations and program requirements

Components of an Effective Compliance Programndash bull Conducting internal monitoring and auditing ndash bull Implementing compliance and practice standards ndash bull Designating a compliance officer or contact ndash bull Conducting appropriate training and education ndash bull Responding appropriately to detected offenses and developing corrective action ndash bull Developing open lines of communication and ndash bull Enforcing disciplinary standards through well-publicized guidelines

Program Development Questions

Who will be auditedHow often will they be auditedWhat is the sample size to be auditedWhat is the sample selection methodologyWhat is the scoring methodologyWhat is the passing scoreWhat is the follow up when the providers fall below the passing

scoreWhat is the process for education and re-audit

What does the OIG recommend

Provider education A baseline audit 3 months after training Audit each provider annually Sample size of at least 5-10 records per provider (industry standard is

at least 10) Include all Federal payers in your sample selection If problems are identified perform follow up focused reviews Educate Educate Educate

OIG Potential Risk Areas

Coding and Billing Reasonable and necessary services Documentation Improper inducements kickbacks and self-referrals

These are not all inclusive but should be a starting point when developing your Compliance Program

Types of Audits

Types of Audits

Internal AuditsoPros

ndash Continuityndash Familiar with internal coding

guidelinesndash Familiar with the providersndash No outside cost

oConsndash Limited resourcesndash Limited expertise in specialty areasndash Employees may not be receptive to a

peer finding their errors

External AuditsoPros

ndash Qualityndash Expertise in specialty areasndash Outside perspectivendash Error findings may be received easier

from an outsider than a peerndash Objective

oConsndash Costndash Quality

Defining the Audit Objective

What is the objective of the auditoCompliance (baseline) audito Financial Audito Investigative Audit (High Risk or Known Issues)oWork Flow Audit

ndash Did the codes get transferred correctly to the claim formndash Staffing analysis (Productivity)

oRevenue Cycle Audit (Billing Audit)o Educational AuditoCoder Quality Audits (QA)

Defining the Audit Scope

Prospective (prebill)o Pros

ndash Errors are fixed before billedndash No refunds to the payersndash Education can be more immediate on

current serviceso Cons

ndash Requires extra effort and focus to completing the audits timely to prevent a negative impact on revenue

ndash May hold up the billing process because claims will be on hold

ndash Limited selection to what the provider is currently billing

ndash Potential to miss timely filing deadlines

Retrospective (postbill)o Pros

ndash Allows more breathing room for completion and workflow

ndash More comprehensive sample selection of all services by each provider

ndash Allows for retrospective review for a focused audit for a specific time period

o Consndash Errors need to be correctndash Corrected claims and possible refunds

will be requiredndash Education is on previous services (but

not always a negative thing)ndash Timely filing contraints when re-billing

for higher reimbursement

Defining the Audit Scope Date Range

o Most audits will look at either current services (prospective) or a recent look back of 3-4 months (retrospective)

Scheduleo Frequency of the audits Annually Quarterlyo Will all providers be audits at onceo Will their be a rolling schedule of audits over a period of timeo How will re-audits be done

Types of Services to includeo E amp M Services onlyo E amp M with office procedureso Will the audit include diagnostic serviceso Surgery onlyo Will ICD-10-CM be included

Sample Sizeo How many encounters per provider

ndash 10-20 is average for a baseline or annual reviewo Types of services provided by each provider can affect sample sizeo Budget can affect sample sizeo Resources can affect sample size

Sample Selection Methodology

Sample Selection Methodologies

Define your sample selection methodologyoRandom Selection

ndash Totally RandomoRandomly Selective Selection

ndash Random within a set of parameterso Focused Selection

ndash Specific to certain services or codesoRATSTATS

ndash Only when a statistically valid sample selection is required

Sample Selection Methodology

Data AnalysisoBell Curve Analysis

ndash Use Medicare Utilization DataoPrior audit results

ndash Make sure your capturing the previous issuesoHigh Risk Areas

ndash Specialtyndash Groupndash Previously Identified issues

oOIG Work PlanoRAC or ZPIC audit findings

Sample Selection Methodology

Sample selection reportsoUtilization reports

ndash Specified Date Range of Servicesndash Providerndash Patient IDndash DOSndash CPT ICD-10 and Modifiers

Sample selection can be done with only CPT but all the codes gives you a better picture ndash Include the payer if you want your sample to be specific to certain payersndash Include the site of service if you want the audit results to identify each site

o You will want this in excel so you can do lots of filtering and sorting

Sample Selection Methodology Turn your filters on Sort by

o Provider (unless you run a separate report for each provider)o CPT code

ndash If you did not do an bell curve analysis prior you can review the volume of each E amp M level here

ndash Determine what types of services (outpatient inpatient EM Surgery etc)ndash How many of each level of service (depends on the providers EM utilization patterns)

o Resort by Patientndash This will allow you to see all services performed for each DOSndash Helps to capture encounters that have both EM amp Procedures Preventive with EM etc

o Pay attention to the Modifiersndash Do you want to include resident documentation Look for GC or GEndash Do you want to include EM with procedure Look for 25

ndash ReportsSample Selectionxlsx

Scoring Methodology

Scoring Methodology

Establish an Accuracy Rateo The OIG recommends that physicians maintain an accuracy rate of 95

ndash Net Error Rate

o Is it realistic to establish a 95 accuracy rate for the providers

Scoring Examples (automated)

Total Visits Accurately Coded Under CodedBilled Over CodedBilled(+) Wrong Category (WC) Gross Financial Error ()

62 20 3226 4 645 13 2097 29 4677 4203

$123000 $14694 $37000 Provider RVUs User RVUs Points

0 129 5772 6200 (931)

EM Coding Total Sample Size 4 codes EM Detailed Review Total Sample Size 4 codes

Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

CPTreg HCPCS II Coding Total Sample Size 0 codes

Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0

Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0

ICD-CM Coding Total Sample Size 5 codes RVU Comparison

Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20

wRVU Comp Original Audited Change Total wRVU Value 523 429 -18

Dollar Comparison Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 -

EM Coding Total Sample Size 4 codes		EM Detailed Review Total Sample Size 4 codes
CPTreg HCPCS II Coding Total Sample Size 0 codes ICD-CM Coding Total Sample Size 5 codes RVU Comparison Dollar Comparison Scoring Methodology Evaluation amp Management 7 points if correct5 points if off by one level 0 points if wrong category or if off by 2 or more levels or if not coded Procedure(s) 7 points if correct4 points if units incorrect0 points if not correct CPT HCPCS 7 points if correct4 points if units incorrect0 points if not correct ICD-10-CM 3 points if correct2 points if the primary is correct but not the others1 point if the secondary is correct but not the primary Modifier(s) -1 if not correct or if missing Your scoring methodology is an essential component of your audit reports The scoring methodology should be defined in the Executive Summary Report In-Patient DRG Scoring Example Ttl DRG 10 Ttl Assign 12 DRG Accuracy Ttl Chg 3 I-10 Px Accuracy Ttl Chg 1 Accu 70 Ttl Code 13 Accu 92 Ttl Assign 159 Total Cht 10Coding AccuracyTtl Chng 16Disposition Acc Ttl Chg 0 Ttl Code 175 Accu 100 Accu 91 Ttl Assign 137 Total Cht 137Dx Accuracy Ttl Chg 12POA Accuracy Ttl Chg 0 Ttl Code 149 Accu 100 Accu 92 Coding Guidelines Coding Guidelines Standardized Coding Guidelines is criticaloCPT Guidelineso ICD-10 GuidelinesoCMS Guidelines ndash Follow your Medicare Carriers GuidelinesoCCI GuidelinesEditsoMedicaidMedi-Cal Guidelineso Internal Guidelines that define ndash Gray areas of codingndash Payer specific guidelines Coding Guidelines E amp M Guidelineso95 or 97oDefine the 95 detailed examo Is ldquonon contributoryrdquo allowedo2 out of 3 key components (Is MDM required) Coding Guidelines Other Risk AreasoMedical Necessityo Teaching Physician Guidelineso Incident To o SplitSharedoCopy amp PasteCloned noteso Scribeso SignatureAuthenticationsoOrders for diagnostic servicesoDate of ServiceoNew versus Established CodesoConsultations Audit Reports Goals of the Audit Report The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a recommendation Prioritize High Risk Findings Who will be reading the Audit Report What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team) Audit Report Format Tips Provide perspective for the readero Positive and Negative findings Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined Benefits of Automating your Audit Reports Results o Consistent Resultso Better Datao Increases Efficiency Trackingo Allows audit results to be tracked by provider and by specialty QAo Allows for an automated approach to your internal quality reviews Trendingo Allows for data analysis at a detailed level that can be tracked Productivityo Increases auditor productivityo Decreases re-work ProviderCoder Audit Reports Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date Detailed results for each encounteroMeaningful comments Key Findingso From all encounters Recommendations and Resources Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description 1 001 Patient A 02-19-16 Blue Cross 99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported 1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture 1 S92355D2 W109XXD 1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed 2 002 Patient B 02-05-16 Blue Cross 99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported Detailed Findings 135 822012 New Consultations - Office Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged Chart Level Comments Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM oReportsAudit Manager Macros 061218 (version 1)xlsx Recommendations and ReferencesCategory Short Description Long Description EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM ConsultationReview the consultation guidelines located in the CPT book EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a- preventive-service-with-a-sick-visit EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation) EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf EMEM Time billing suggestion Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EMConsultation Documentation Suggestion Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 - wRVU Comp Original Audited Change Total wRVU Value 523 429 -18 Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20 Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0 Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0 Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

Mastering the Audit Process

Presented byLynn Handy CCS-P CPC CPC-I COC LPN

Vice President of Coding amp Audit ServicesCodingAID a division of Managed Resources Inc

Agenda

Why do we perform Audits Types of Audits

o Internal Auditso External AuditsoAuditor Quality Audits (QA)

Defining the Audit Scope Sample Selection Methodology Scoring Methodology Coding Guidelines

Auditor Quality Reviews amp Productivity Standards Audit Reports

oProvider Audit Reportso Executive Summary Reports

Presenting the Audit Results Post Audit EducationHandling Audit Disputes Self Disclosures Refunds and

Corrected Billing

Why do we Perform Audits

To determine outliers before large payers find them in their claims software and request an internal audit be done

To protect against fraudulent claims and billing activity

To reveal whether there is variation from national averages due to inappropriate coding insufficient documentation or lost revenue

To help identify and correct problem areas before insurance or government payers challenge inappropriate coding

To help prevent governmental investigational auditors like recovery audit contractors (RACs) or zone program integrity contractors (ZPICs) from knocking at your door

To remedy undercoding bad unbundling habits and code overuse and to bill appropriately for documented procedures

To identify reimbursement deficiencies and opportunities for appropriate reimbursement

To stop the use of outdated or incorrect codes for procedures

To verify ICD-10-CM and electronic health record (EHR) meaningful use readiness and Risk Adjustment (HCC) reporting

Developing an Internal Audit amp Education Program

Office Inspector General Guidanceo OIG has developed a series of voluntary compliance program guidance documents

directed at various segments of the health care industry such as hospitals nursing homes third-party billers and durable medical equipment suppliers to encourage the development and use of internal controls to monitor adherence to applicable statutes regulations and program requirements

Components of an Effective Compliance Programndash bull Conducting internal monitoring and auditing ndash bull Implementing compliance and practice standards ndash bull Designating a compliance officer or contact ndash bull Conducting appropriate training and education ndash bull Responding appropriately to detected offenses and developing corrective action ndash bull Developing open lines of communication and ndash bull Enforcing disciplinary standards through well-publicized guidelines

Program Development Questions

Who will be auditedHow often will they be auditedWhat is the sample size to be auditedWhat is the sample selection methodologyWhat is the scoring methodologyWhat is the passing scoreWhat is the follow up when the providers fall below the passing

scoreWhat is the process for education and re-audit

What does the OIG recommend

Provider education A baseline audit 3 months after training Audit each provider annually Sample size of at least 5-10 records per provider (industry standard is

at least 10) Include all Federal payers in your sample selection If problems are identified perform follow up focused reviews Educate Educate Educate

OIG Potential Risk Areas

Coding and Billing Reasonable and necessary services Documentation Improper inducements kickbacks and self-referrals

These are not all inclusive but should be a starting point when developing your Compliance Program

Types of Audits

Types of Audits

Internal AuditsoPros

ndash Continuityndash Familiar with internal coding

guidelinesndash Familiar with the providersndash No outside cost

oConsndash Limited resourcesndash Limited expertise in specialty areasndash Employees may not be receptive to a

peer finding their errors

External AuditsoPros

ndash Qualityndash Expertise in specialty areasndash Outside perspectivendash Error findings may be received easier

from an outsider than a peerndash Objective

oConsndash Costndash Quality

Defining the Audit Objective

What is the objective of the auditoCompliance (baseline) audito Financial Audito Investigative Audit (High Risk or Known Issues)oWork Flow Audit

ndash Did the codes get transferred correctly to the claim formndash Staffing analysis (Productivity)

oRevenue Cycle Audit (Billing Audit)o Educational AuditoCoder Quality Audits (QA)

Defining the Audit Scope

Prospective (prebill)o Pros

ndash Errors are fixed before billedndash No refunds to the payersndash Education can be more immediate on

current serviceso Cons

ndash Requires extra effort and focus to completing the audits timely to prevent a negative impact on revenue

ndash May hold up the billing process because claims will be on hold

ndash Limited selection to what the provider is currently billing

ndash Potential to miss timely filing deadlines

Retrospective (postbill)o Pros

ndash Allows more breathing room for completion and workflow

ndash More comprehensive sample selection of all services by each provider

ndash Allows for retrospective review for a focused audit for a specific time period

o Consndash Errors need to be correctndash Corrected claims and possible refunds

will be requiredndash Education is on previous services (but

not always a negative thing)ndash Timely filing contraints when re-billing

for higher reimbursement

Defining the Audit Scope Date Range

o Most audits will look at either current services (prospective) or a recent look back of 3-4 months (retrospective)

Scheduleo Frequency of the audits Annually Quarterlyo Will all providers be audits at onceo Will their be a rolling schedule of audits over a period of timeo How will re-audits be done

Types of Services to includeo E amp M Services onlyo E amp M with office procedureso Will the audit include diagnostic serviceso Surgery onlyo Will ICD-10-CM be included

Sample Sizeo How many encounters per provider

ndash 10-20 is average for a baseline or annual reviewo Types of services provided by each provider can affect sample sizeo Budget can affect sample sizeo Resources can affect sample size

Sample Selection Methodology

Sample Selection Methodologies

Define your sample selection methodologyoRandom Selection

ndash Totally RandomoRandomly Selective Selection

ndash Random within a set of parameterso Focused Selection

ndash Specific to certain services or codesoRATSTATS

ndash Only when a statistically valid sample selection is required

Sample Selection Methodology

Data AnalysisoBell Curve Analysis

ndash Use Medicare Utilization DataoPrior audit results

ndash Make sure your capturing the previous issuesoHigh Risk Areas

ndash Specialtyndash Groupndash Previously Identified issues

oOIG Work PlanoRAC or ZPIC audit findings

Sample Selection Methodology

Sample selection reportsoUtilization reports

ndash Specified Date Range of Servicesndash Providerndash Patient IDndash DOSndash CPT ICD-10 and Modifiers

Sample selection can be done with only CPT but all the codes gives you a better picture ndash Include the payer if you want your sample to be specific to certain payersndash Include the site of service if you want the audit results to identify each site

o You will want this in excel so you can do lots of filtering and sorting

Sample Selection Methodology Turn your filters on Sort by

o Provider (unless you run a separate report for each provider)o CPT code

ndash If you did not do an bell curve analysis prior you can review the volume of each E amp M level here

ndash Determine what types of services (outpatient inpatient EM Surgery etc)ndash How many of each level of service (depends on the providers EM utilization patterns)

o Resort by Patientndash This will allow you to see all services performed for each DOSndash Helps to capture encounters that have both EM amp Procedures Preventive with EM etc

o Pay attention to the Modifiersndash Do you want to include resident documentation Look for GC or GEndash Do you want to include EM with procedure Look for 25

ndash ReportsSample Selectionxlsx

Scoring Methodology

Scoring Methodology

Establish an Accuracy Rateo The OIG recommends that physicians maintain an accuracy rate of 95

ndash Net Error Rate

o Is it realistic to establish a 95 accuracy rate for the providers

Scoring Examples (automated)

Total Visits Accurately Coded Under CodedBilled Over CodedBilled(+) Wrong Category (WC) Gross Financial Error ()

62 20 3226 4 645 13 2097 29 4677 4203

$123000 $14694 $37000 Provider RVUs User RVUs Points

0 129 5772 6200 (931)

EM Coding Total Sample Size 4 codes EM Detailed Review Total Sample Size 4 codes

Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

CPTreg HCPCS II Coding Total Sample Size 0 codes

Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0

Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0

ICD-CM Coding Total Sample Size 5 codes RVU Comparison

Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20

wRVU Comp Original Audited Change Total wRVU Value 523 429 -18

Dollar Comparison Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 -

EM Coding Total Sample Size 4 codes		EM Detailed Review Total Sample Size 4 codes
CPTreg HCPCS II Coding Total Sample Size 0 codes ICD-CM Coding Total Sample Size 5 codes RVU Comparison Dollar Comparison Scoring Methodology Evaluation amp Management 7 points if correct5 points if off by one level 0 points if wrong category or if off by 2 or more levels or if not coded Procedure(s) 7 points if correct4 points if units incorrect0 points if not correct CPT HCPCS 7 points if correct4 points if units incorrect0 points if not correct ICD-10-CM 3 points if correct2 points if the primary is correct but not the others1 point if the secondary is correct but not the primary Modifier(s) -1 if not correct or if missing Your scoring methodology is an essential component of your audit reports The scoring methodology should be defined in the Executive Summary Report In-Patient DRG Scoring Example Ttl DRG 10 Ttl Assign 12 DRG Accuracy Ttl Chg 3 I-10 Px Accuracy Ttl Chg 1 Accu 70 Ttl Code 13 Accu 92 Ttl Assign 159 Total Cht 10Coding AccuracyTtl Chng 16Disposition Acc Ttl Chg 0 Ttl Code 175 Accu 100 Accu 91 Ttl Assign 137 Total Cht 137Dx Accuracy Ttl Chg 12POA Accuracy Ttl Chg 0 Ttl Code 149 Accu 100 Accu 92 Coding Guidelines Coding Guidelines Standardized Coding Guidelines is criticaloCPT Guidelineso ICD-10 GuidelinesoCMS Guidelines ndash Follow your Medicare Carriers GuidelinesoCCI GuidelinesEditsoMedicaidMedi-Cal Guidelineso Internal Guidelines that define ndash Gray areas of codingndash Payer specific guidelines Coding Guidelines E amp M Guidelineso95 or 97oDefine the 95 detailed examo Is ldquonon contributoryrdquo allowedo2 out of 3 key components (Is MDM required) Coding Guidelines Other Risk AreasoMedical Necessityo Teaching Physician Guidelineso Incident To o SplitSharedoCopy amp PasteCloned noteso Scribeso SignatureAuthenticationsoOrders for diagnostic servicesoDate of ServiceoNew versus Established CodesoConsultations Audit Reports Goals of the Audit Report The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a recommendation Prioritize High Risk Findings Who will be reading the Audit Report What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team) Audit Report Format Tips Provide perspective for the readero Positive and Negative findings Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined Benefits of Automating your Audit Reports Results o Consistent Resultso Better Datao Increases Efficiency Trackingo Allows audit results to be tracked by provider and by specialty QAo Allows for an automated approach to your internal quality reviews Trendingo Allows for data analysis at a detailed level that can be tracked Productivityo Increases auditor productivityo Decreases re-work ProviderCoder Audit Reports Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date Detailed results for each encounteroMeaningful comments Key Findingso From all encounters Recommendations and Resources Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description 1 001 Patient A 02-19-16 Blue Cross 99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported 1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture 1 S92355D2 W109XXD 1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed 2 002 Patient B 02-05-16 Blue Cross 99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported Detailed Findings 135 822012 New Consultations - Office Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged Chart Level Comments Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM oReportsAudit Manager Macros 061218 (version 1)xlsx Recommendations and ReferencesCategory Short Description Long Description EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM ConsultationReview the consultation guidelines located in the CPT book EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a- preventive-service-with-a-sick-visit EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation) EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf EMEM Time billing suggestion Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EMConsultation Documentation Suggestion Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 - wRVU Comp Original Audited Change Total wRVU Value 523 429 -18 Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20 Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0 Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0 Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

Agenda

Why do we perform Audits Types of Audits

o Internal Auditso External AuditsoAuditor Quality Audits (QA)

Defining the Audit Scope Sample Selection Methodology Scoring Methodology Coding Guidelines

Auditor Quality Reviews amp Productivity Standards Audit Reports

oProvider Audit Reportso Executive Summary Reports

Presenting the Audit Results Post Audit EducationHandling Audit Disputes Self Disclosures Refunds and

Corrected Billing

Why do we Perform Audits

To determine outliers before large payers find them in their claims software and request an internal audit be done

To protect against fraudulent claims and billing activity

To reveal whether there is variation from national averages due to inappropriate coding insufficient documentation or lost revenue

To help identify and correct problem areas before insurance or government payers challenge inappropriate coding

To help prevent governmental investigational auditors like recovery audit contractors (RACs) or zone program integrity contractors (ZPICs) from knocking at your door

To remedy undercoding bad unbundling habits and code overuse and to bill appropriately for documented procedures

To identify reimbursement deficiencies and opportunities for appropriate reimbursement

To stop the use of outdated or incorrect codes for procedures

To verify ICD-10-CM and electronic health record (EHR) meaningful use readiness and Risk Adjustment (HCC) reporting

Developing an Internal Audit amp Education Program

Office Inspector General Guidanceo OIG has developed a series of voluntary compliance program guidance documents

directed at various segments of the health care industry such as hospitals nursing homes third-party billers and durable medical equipment suppliers to encourage the development and use of internal controls to monitor adherence to applicable statutes regulations and program requirements

Components of an Effective Compliance Programndash bull Conducting internal monitoring and auditing ndash bull Implementing compliance and practice standards ndash bull Designating a compliance officer or contact ndash bull Conducting appropriate training and education ndash bull Responding appropriately to detected offenses and developing corrective action ndash bull Developing open lines of communication and ndash bull Enforcing disciplinary standards through well-publicized guidelines

Program Development Questions

Who will be auditedHow often will they be auditedWhat is the sample size to be auditedWhat is the sample selection methodologyWhat is the scoring methodologyWhat is the passing scoreWhat is the follow up when the providers fall below the passing

scoreWhat is the process for education and re-audit

What does the OIG recommend

Provider education A baseline audit 3 months after training Audit each provider annually Sample size of at least 5-10 records per provider (industry standard is

at least 10) Include all Federal payers in your sample selection If problems are identified perform follow up focused reviews Educate Educate Educate

OIG Potential Risk Areas

Coding and Billing Reasonable and necessary services Documentation Improper inducements kickbacks and self-referrals

These are not all inclusive but should be a starting point when developing your Compliance Program

Types of Audits

Types of Audits

Internal AuditsoPros

ndash Continuityndash Familiar with internal coding

guidelinesndash Familiar with the providersndash No outside cost

oConsndash Limited resourcesndash Limited expertise in specialty areasndash Employees may not be receptive to a

peer finding their errors

External AuditsoPros

ndash Qualityndash Expertise in specialty areasndash Outside perspectivendash Error findings may be received easier

from an outsider than a peerndash Objective

oConsndash Costndash Quality

Defining the Audit Objective

What is the objective of the auditoCompliance (baseline) audito Financial Audito Investigative Audit (High Risk or Known Issues)oWork Flow Audit

ndash Did the codes get transferred correctly to the claim formndash Staffing analysis (Productivity)

oRevenue Cycle Audit (Billing Audit)o Educational AuditoCoder Quality Audits (QA)

Defining the Audit Scope

Prospective (prebill)o Pros

ndash Errors are fixed before billedndash No refunds to the payersndash Education can be more immediate on

current serviceso Cons

ndash Requires extra effort and focus to completing the audits timely to prevent a negative impact on revenue

ndash May hold up the billing process because claims will be on hold

ndash Limited selection to what the provider is currently billing

ndash Potential to miss timely filing deadlines

Retrospective (postbill)o Pros

ndash Allows more breathing room for completion and workflow

ndash More comprehensive sample selection of all services by each provider

ndash Allows for retrospective review for a focused audit for a specific time period

o Consndash Errors need to be correctndash Corrected claims and possible refunds

will be requiredndash Education is on previous services (but

not always a negative thing)ndash Timely filing contraints when re-billing

for higher reimbursement

Defining the Audit Scope Date Range

o Most audits will look at either current services (prospective) or a recent look back of 3-4 months (retrospective)

Scheduleo Frequency of the audits Annually Quarterlyo Will all providers be audits at onceo Will their be a rolling schedule of audits over a period of timeo How will re-audits be done

Types of Services to includeo E amp M Services onlyo E amp M with office procedureso Will the audit include diagnostic serviceso Surgery onlyo Will ICD-10-CM be included

Sample Sizeo How many encounters per provider

ndash 10-20 is average for a baseline or annual reviewo Types of services provided by each provider can affect sample sizeo Budget can affect sample sizeo Resources can affect sample size

Sample Selection Methodology

Sample Selection Methodologies

Define your sample selection methodologyoRandom Selection

ndash Totally RandomoRandomly Selective Selection

ndash Random within a set of parameterso Focused Selection

ndash Specific to certain services or codesoRATSTATS

ndash Only when a statistically valid sample selection is required

Sample Selection Methodology

Data AnalysisoBell Curve Analysis

ndash Use Medicare Utilization DataoPrior audit results

ndash Make sure your capturing the previous issuesoHigh Risk Areas

ndash Specialtyndash Groupndash Previously Identified issues

oOIG Work PlanoRAC or ZPIC audit findings

Sample Selection Methodology

Sample selection reportsoUtilization reports

ndash Specified Date Range of Servicesndash Providerndash Patient IDndash DOSndash CPT ICD-10 and Modifiers

Sample selection can be done with only CPT but all the codes gives you a better picture ndash Include the payer if you want your sample to be specific to certain payersndash Include the site of service if you want the audit results to identify each site

o You will want this in excel so you can do lots of filtering and sorting

Sample Selection Methodology Turn your filters on Sort by

o Provider (unless you run a separate report for each provider)o CPT code

ndash If you did not do an bell curve analysis prior you can review the volume of each E amp M level here

ndash Determine what types of services (outpatient inpatient EM Surgery etc)ndash How many of each level of service (depends on the providers EM utilization patterns)

o Resort by Patientndash This will allow you to see all services performed for each DOSndash Helps to capture encounters that have both EM amp Procedures Preventive with EM etc

o Pay attention to the Modifiersndash Do you want to include resident documentation Look for GC or GEndash Do you want to include EM with procedure Look for 25

ndash ReportsSample Selectionxlsx

Scoring Methodology

Scoring Methodology

Establish an Accuracy Rateo The OIG recommends that physicians maintain an accuracy rate of 95

ndash Net Error Rate

o Is it realistic to establish a 95 accuracy rate for the providers

Scoring Examples (automated)

Total Visits Accurately Coded Under CodedBilled Over CodedBilled(+) Wrong Category (WC) Gross Financial Error ()

62 20 3226 4 645 13 2097 29 4677 4203

$123000 $14694 $37000 Provider RVUs User RVUs Points

0 129 5772 6200 (931)

EM Coding Total Sample Size 4 codes EM Detailed Review Total Sample Size 4 codes

Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

CPTreg HCPCS II Coding Total Sample Size 0 codes

Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0

Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0

ICD-CM Coding Total Sample Size 5 codes RVU Comparison

Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20

wRVU Comp Original Audited Change Total wRVU Value 523 429 -18

Dollar Comparison Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 -

EM Coding Total Sample Size 4 codes		EM Detailed Review Total Sample Size 4 codes
CPTreg HCPCS II Coding Total Sample Size 0 codes ICD-CM Coding Total Sample Size 5 codes RVU Comparison Dollar Comparison Scoring Methodology Evaluation amp Management 7 points if correct5 points if off by one level 0 points if wrong category or if off by 2 or more levels or if not coded Procedure(s) 7 points if correct4 points if units incorrect0 points if not correct CPT HCPCS 7 points if correct4 points if units incorrect0 points if not correct ICD-10-CM 3 points if correct2 points if the primary is correct but not the others1 point if the secondary is correct but not the primary Modifier(s) -1 if not correct or if missing Your scoring methodology is an essential component of your audit reports The scoring methodology should be defined in the Executive Summary Report In-Patient DRG Scoring Example Ttl DRG 10 Ttl Assign 12 DRG Accuracy Ttl Chg 3 I-10 Px Accuracy Ttl Chg 1 Accu 70 Ttl Code 13 Accu 92 Ttl Assign 159 Total Cht 10Coding AccuracyTtl Chng 16Disposition Acc Ttl Chg 0 Ttl Code 175 Accu 100 Accu 91 Ttl Assign 137 Total Cht 137Dx Accuracy Ttl Chg 12POA Accuracy Ttl Chg 0 Ttl Code 149 Accu 100 Accu 92 Coding Guidelines Coding Guidelines Standardized Coding Guidelines is criticaloCPT Guidelineso ICD-10 GuidelinesoCMS Guidelines ndash Follow your Medicare Carriers GuidelinesoCCI GuidelinesEditsoMedicaidMedi-Cal Guidelineso Internal Guidelines that define ndash Gray areas of codingndash Payer specific guidelines Coding Guidelines E amp M Guidelineso95 or 97oDefine the 95 detailed examo Is ldquonon contributoryrdquo allowedo2 out of 3 key components (Is MDM required) Coding Guidelines Other Risk AreasoMedical Necessityo Teaching Physician Guidelineso Incident To o SplitSharedoCopy amp PasteCloned noteso Scribeso SignatureAuthenticationsoOrders for diagnostic servicesoDate of ServiceoNew versus Established CodesoConsultations Audit Reports Goals of the Audit Report The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a recommendation Prioritize High Risk Findings Who will be reading the Audit Report What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team) Audit Report Format Tips Provide perspective for the readero Positive and Negative findings Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined Benefits of Automating your Audit Reports Results o Consistent Resultso Better Datao Increases Efficiency Trackingo Allows audit results to be tracked by provider and by specialty QAo Allows for an automated approach to your internal quality reviews Trendingo Allows for data analysis at a detailed level that can be tracked Productivityo Increases auditor productivityo Decreases re-work ProviderCoder Audit Reports Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date Detailed results for each encounteroMeaningful comments Key Findingso From all encounters Recommendations and Resources Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description 1 001 Patient A 02-19-16 Blue Cross 99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported 1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture 1 S92355D2 W109XXD 1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed 2 002 Patient B 02-05-16 Blue Cross 99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported Detailed Findings 135 822012 New Consultations - Office Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged Chart Level Comments Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM oReportsAudit Manager Macros 061218 (version 1)xlsx Recommendations and ReferencesCategory Short Description Long Description EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM ConsultationReview the consultation guidelines located in the CPT book EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a- preventive-service-with-a-sick-visit EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation) EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf EMEM Time billing suggestion Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EMConsultation Documentation Suggestion Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 - wRVU Comp Original Audited Change Total wRVU Value 523 429 -18 Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20 Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0 Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0 Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

Why do we Perform Audits

To determine outliers before large payers find them in their claims software and request an internal audit be done

To protect against fraudulent claims and billing activity

To reveal whether there is variation from national averages due to inappropriate coding insufficient documentation or lost revenue

To help identify and correct problem areas before insurance or government payers challenge inappropriate coding

To help prevent governmental investigational auditors like recovery audit contractors (RACs) or zone program integrity contractors (ZPICs) from knocking at your door

To remedy undercoding bad unbundling habits and code overuse and to bill appropriately for documented procedures

To identify reimbursement deficiencies and opportunities for appropriate reimbursement

To stop the use of outdated or incorrect codes for procedures

To verify ICD-10-CM and electronic health record (EHR) meaningful use readiness and Risk Adjustment (HCC) reporting

Developing an Internal Audit amp Education Program

Office Inspector General Guidanceo OIG has developed a series of voluntary compliance program guidance documents

directed at various segments of the health care industry such as hospitals nursing homes third-party billers and durable medical equipment suppliers to encourage the development and use of internal controls to monitor adherence to applicable statutes regulations and program requirements

Components of an Effective Compliance Programndash bull Conducting internal monitoring and auditing ndash bull Implementing compliance and practice standards ndash bull Designating a compliance officer or contact ndash bull Conducting appropriate training and education ndash bull Responding appropriately to detected offenses and developing corrective action ndash bull Developing open lines of communication and ndash bull Enforcing disciplinary standards through well-publicized guidelines

Program Development Questions

Who will be auditedHow often will they be auditedWhat is the sample size to be auditedWhat is the sample selection methodologyWhat is the scoring methodologyWhat is the passing scoreWhat is the follow up when the providers fall below the passing

scoreWhat is the process for education and re-audit

What does the OIG recommend

Provider education A baseline audit 3 months after training Audit each provider annually Sample size of at least 5-10 records per provider (industry standard is

at least 10) Include all Federal payers in your sample selection If problems are identified perform follow up focused reviews Educate Educate Educate

OIG Potential Risk Areas

Coding and Billing Reasonable and necessary services Documentation Improper inducements kickbacks and self-referrals

These are not all inclusive but should be a starting point when developing your Compliance Program

Types of Audits

Types of Audits

Internal AuditsoPros

ndash Continuityndash Familiar with internal coding

guidelinesndash Familiar with the providersndash No outside cost

oConsndash Limited resourcesndash Limited expertise in specialty areasndash Employees may not be receptive to a

peer finding their errors

External AuditsoPros

ndash Qualityndash Expertise in specialty areasndash Outside perspectivendash Error findings may be received easier

from an outsider than a peerndash Objective

oConsndash Costndash Quality

Defining the Audit Objective

What is the objective of the auditoCompliance (baseline) audito Financial Audito Investigative Audit (High Risk or Known Issues)oWork Flow Audit

ndash Did the codes get transferred correctly to the claim formndash Staffing analysis (Productivity)

oRevenue Cycle Audit (Billing Audit)o Educational AuditoCoder Quality Audits (QA)

Defining the Audit Scope

Prospective (prebill)o Pros

ndash Errors are fixed before billedndash No refunds to the payersndash Education can be more immediate on

current serviceso Cons

ndash Requires extra effort and focus to completing the audits timely to prevent a negative impact on revenue

ndash May hold up the billing process because claims will be on hold

ndash Limited selection to what the provider is currently billing

ndash Potential to miss timely filing deadlines

Retrospective (postbill)o Pros

ndash Allows more breathing room for completion and workflow

ndash More comprehensive sample selection of all services by each provider

ndash Allows for retrospective review for a focused audit for a specific time period

o Consndash Errors need to be correctndash Corrected claims and possible refunds

will be requiredndash Education is on previous services (but

not always a negative thing)ndash Timely filing contraints when re-billing

for higher reimbursement

Defining the Audit Scope Date Range

o Most audits will look at either current services (prospective) or a recent look back of 3-4 months (retrospective)

Scheduleo Frequency of the audits Annually Quarterlyo Will all providers be audits at onceo Will their be a rolling schedule of audits over a period of timeo How will re-audits be done

Types of Services to includeo E amp M Services onlyo E amp M with office procedureso Will the audit include diagnostic serviceso Surgery onlyo Will ICD-10-CM be included

Sample Sizeo How many encounters per provider

ndash 10-20 is average for a baseline or annual reviewo Types of services provided by each provider can affect sample sizeo Budget can affect sample sizeo Resources can affect sample size

Sample Selection Methodology

Sample Selection Methodologies

Define your sample selection methodologyoRandom Selection

ndash Totally RandomoRandomly Selective Selection

ndash Random within a set of parameterso Focused Selection

ndash Specific to certain services or codesoRATSTATS

ndash Only when a statistically valid sample selection is required

Sample Selection Methodology

Data AnalysisoBell Curve Analysis

ndash Use Medicare Utilization DataoPrior audit results

ndash Make sure your capturing the previous issuesoHigh Risk Areas

ndash Specialtyndash Groupndash Previously Identified issues

oOIG Work PlanoRAC or ZPIC audit findings

Sample Selection Methodology

Sample selection reportsoUtilization reports

ndash Specified Date Range of Servicesndash Providerndash Patient IDndash DOSndash CPT ICD-10 and Modifiers

Sample selection can be done with only CPT but all the codes gives you a better picture ndash Include the payer if you want your sample to be specific to certain payersndash Include the site of service if you want the audit results to identify each site

o You will want this in excel so you can do lots of filtering and sorting

Sample Selection Methodology Turn your filters on Sort by

o Provider (unless you run a separate report for each provider)o CPT code

ndash If you did not do an bell curve analysis prior you can review the volume of each E amp M level here

ndash Determine what types of services (outpatient inpatient EM Surgery etc)ndash How many of each level of service (depends on the providers EM utilization patterns)

o Resort by Patientndash This will allow you to see all services performed for each DOSndash Helps to capture encounters that have both EM amp Procedures Preventive with EM etc

o Pay attention to the Modifiersndash Do you want to include resident documentation Look for GC or GEndash Do you want to include EM with procedure Look for 25

ndash ReportsSample Selectionxlsx

Scoring Methodology

Scoring Methodology

Establish an Accuracy Rateo The OIG recommends that physicians maintain an accuracy rate of 95

ndash Net Error Rate

o Is it realistic to establish a 95 accuracy rate for the providers

Scoring Examples (automated)

Total Visits Accurately Coded Under CodedBilled Over CodedBilled(+) Wrong Category (WC) Gross Financial Error ()

62 20 3226 4 645 13 2097 29 4677 4203

$123000 $14694 $37000 Provider RVUs User RVUs Points

0 129 5772 6200 (931)

EM Coding Total Sample Size 4 codes EM Detailed Review Total Sample Size 4 codes

Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

CPTreg HCPCS II Coding Total Sample Size 0 codes

Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0

Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0

ICD-CM Coding Total Sample Size 5 codes RVU Comparison

Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20

wRVU Comp Original Audited Change Total wRVU Value 523 429 -18

Dollar Comparison Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 -

EM Coding Total Sample Size 4 codes		EM Detailed Review Total Sample Size 4 codes
CPTreg HCPCS II Coding Total Sample Size 0 codes ICD-CM Coding Total Sample Size 5 codes RVU Comparison Dollar Comparison Scoring Methodology Evaluation amp Management 7 points if correct5 points if off by one level 0 points if wrong category or if off by 2 or more levels or if not coded Procedure(s) 7 points if correct4 points if units incorrect0 points if not correct CPT HCPCS 7 points if correct4 points if units incorrect0 points if not correct ICD-10-CM 3 points if correct2 points if the primary is correct but not the others1 point if the secondary is correct but not the primary Modifier(s) -1 if not correct or if missing Your scoring methodology is an essential component of your audit reports The scoring methodology should be defined in the Executive Summary Report In-Patient DRG Scoring Example Ttl DRG 10 Ttl Assign 12 DRG Accuracy Ttl Chg 3 I-10 Px Accuracy Ttl Chg 1 Accu 70 Ttl Code 13 Accu 92 Ttl Assign 159 Total Cht 10Coding AccuracyTtl Chng 16Disposition Acc Ttl Chg 0 Ttl Code 175 Accu 100 Accu 91 Ttl Assign 137 Total Cht 137Dx Accuracy Ttl Chg 12POA Accuracy Ttl Chg 0 Ttl Code 149 Accu 100 Accu 92 Coding Guidelines Coding Guidelines Standardized Coding Guidelines is criticaloCPT Guidelineso ICD-10 GuidelinesoCMS Guidelines ndash Follow your Medicare Carriers GuidelinesoCCI GuidelinesEditsoMedicaidMedi-Cal Guidelineso Internal Guidelines that define ndash Gray areas of codingndash Payer specific guidelines Coding Guidelines E amp M Guidelineso95 or 97oDefine the 95 detailed examo Is ldquonon contributoryrdquo allowedo2 out of 3 key components (Is MDM required) Coding Guidelines Other Risk AreasoMedical Necessityo Teaching Physician Guidelineso Incident To o SplitSharedoCopy amp PasteCloned noteso Scribeso SignatureAuthenticationsoOrders for diagnostic servicesoDate of ServiceoNew versus Established CodesoConsultations Audit Reports Goals of the Audit Report The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a recommendation Prioritize High Risk Findings Who will be reading the Audit Report What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team) Audit Report Format Tips Provide perspective for the readero Positive and Negative findings Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined Benefits of Automating your Audit Reports Results o Consistent Resultso Better Datao Increases Efficiency Trackingo Allows audit results to be tracked by provider and by specialty QAo Allows for an automated approach to your internal quality reviews Trendingo Allows for data analysis at a detailed level that can be tracked Productivityo Increases auditor productivityo Decreases re-work ProviderCoder Audit Reports Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date Detailed results for each encounteroMeaningful comments Key Findingso From all encounters Recommendations and Resources Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description 1 001 Patient A 02-19-16 Blue Cross 99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported 1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture 1 S92355D2 W109XXD 1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed 2 002 Patient B 02-05-16 Blue Cross 99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported Detailed Findings 135 822012 New Consultations - Office Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged Chart Level Comments Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM oReportsAudit Manager Macros 061218 (version 1)xlsx Recommendations and ReferencesCategory Short Description Long Description EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM ConsultationReview the consultation guidelines located in the CPT book EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a- preventive-service-with-a-sick-visit EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation) EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf EMEM Time billing suggestion Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EMConsultation Documentation Suggestion Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 - wRVU Comp Original Audited Change Total wRVU Value 523 429 -18 Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20 Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0 Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0 Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

Developing an Internal Audit amp Education Program

Office Inspector General Guidanceo OIG has developed a series of voluntary compliance program guidance documents

directed at various segments of the health care industry such as hospitals nursing homes third-party billers and durable medical equipment suppliers to encourage the development and use of internal controls to monitor adherence to applicable statutes regulations and program requirements

Components of an Effective Compliance Programndash bull Conducting internal monitoring and auditing ndash bull Implementing compliance and practice standards ndash bull Designating a compliance officer or contact ndash bull Conducting appropriate training and education ndash bull Responding appropriately to detected offenses and developing corrective action ndash bull Developing open lines of communication and ndash bull Enforcing disciplinary standards through well-publicized guidelines

Program Development Questions

Who will be auditedHow often will they be auditedWhat is the sample size to be auditedWhat is the sample selection methodologyWhat is the scoring methodologyWhat is the passing scoreWhat is the follow up when the providers fall below the passing

scoreWhat is the process for education and re-audit

What does the OIG recommend

Provider education A baseline audit 3 months after training Audit each provider annually Sample size of at least 5-10 records per provider (industry standard is

at least 10) Include all Federal payers in your sample selection If problems are identified perform follow up focused reviews Educate Educate Educate

OIG Potential Risk Areas

Coding and Billing Reasonable and necessary services Documentation Improper inducements kickbacks and self-referrals

These are not all inclusive but should be a starting point when developing your Compliance Program

Types of Audits

Types of Audits

Internal AuditsoPros

ndash Continuityndash Familiar with internal coding

guidelinesndash Familiar with the providersndash No outside cost

oConsndash Limited resourcesndash Limited expertise in specialty areasndash Employees may not be receptive to a

peer finding their errors

External AuditsoPros

ndash Qualityndash Expertise in specialty areasndash Outside perspectivendash Error findings may be received easier

from an outsider than a peerndash Objective

oConsndash Costndash Quality

Defining the Audit Objective

What is the objective of the auditoCompliance (baseline) audito Financial Audito Investigative Audit (High Risk or Known Issues)oWork Flow Audit

ndash Did the codes get transferred correctly to the claim formndash Staffing analysis (Productivity)

oRevenue Cycle Audit (Billing Audit)o Educational AuditoCoder Quality Audits (QA)

Defining the Audit Scope

Prospective (prebill)o Pros

ndash Errors are fixed before billedndash No refunds to the payersndash Education can be more immediate on

current serviceso Cons

ndash Requires extra effort and focus to completing the audits timely to prevent a negative impact on revenue

ndash May hold up the billing process because claims will be on hold

ndash Limited selection to what the provider is currently billing

ndash Potential to miss timely filing deadlines

Retrospective (postbill)o Pros

ndash Allows more breathing room for completion and workflow

ndash More comprehensive sample selection of all services by each provider

ndash Allows for retrospective review for a focused audit for a specific time period

o Consndash Errors need to be correctndash Corrected claims and possible refunds

will be requiredndash Education is on previous services (but

not always a negative thing)ndash Timely filing contraints when re-billing

for higher reimbursement

Defining the Audit Scope Date Range

o Most audits will look at either current services (prospective) or a recent look back of 3-4 months (retrospective)

Scheduleo Frequency of the audits Annually Quarterlyo Will all providers be audits at onceo Will their be a rolling schedule of audits over a period of timeo How will re-audits be done

Types of Services to includeo E amp M Services onlyo E amp M with office procedureso Will the audit include diagnostic serviceso Surgery onlyo Will ICD-10-CM be included

Sample Sizeo How many encounters per provider

ndash 10-20 is average for a baseline or annual reviewo Types of services provided by each provider can affect sample sizeo Budget can affect sample sizeo Resources can affect sample size

Sample Selection Methodology

Sample Selection Methodologies

Define your sample selection methodologyoRandom Selection

ndash Totally RandomoRandomly Selective Selection

ndash Random within a set of parameterso Focused Selection

ndash Specific to certain services or codesoRATSTATS

ndash Only when a statistically valid sample selection is required

Sample Selection Methodology

Data AnalysisoBell Curve Analysis

ndash Use Medicare Utilization DataoPrior audit results

ndash Make sure your capturing the previous issuesoHigh Risk Areas

ndash Specialtyndash Groupndash Previously Identified issues

oOIG Work PlanoRAC or ZPIC audit findings

Sample Selection Methodology

Sample selection reportsoUtilization reports

ndash Specified Date Range of Servicesndash Providerndash Patient IDndash DOSndash CPT ICD-10 and Modifiers

Sample selection can be done with only CPT but all the codes gives you a better picture ndash Include the payer if you want your sample to be specific to certain payersndash Include the site of service if you want the audit results to identify each site

o You will want this in excel so you can do lots of filtering and sorting

Sample Selection Methodology Turn your filters on Sort by

o Provider (unless you run a separate report for each provider)o CPT code

ndash If you did not do an bell curve analysis prior you can review the volume of each E amp M level here

ndash Determine what types of services (outpatient inpatient EM Surgery etc)ndash How many of each level of service (depends on the providers EM utilization patterns)

o Resort by Patientndash This will allow you to see all services performed for each DOSndash Helps to capture encounters that have both EM amp Procedures Preventive with EM etc

o Pay attention to the Modifiersndash Do you want to include resident documentation Look for GC or GEndash Do you want to include EM with procedure Look for 25

ndash ReportsSample Selectionxlsx

Scoring Methodology

Scoring Methodology

Establish an Accuracy Rateo The OIG recommends that physicians maintain an accuracy rate of 95

ndash Net Error Rate

o Is it realistic to establish a 95 accuracy rate for the providers

Scoring Examples (automated)

Total Visits Accurately Coded Under CodedBilled Over CodedBilled(+) Wrong Category (WC) Gross Financial Error ()

62 20 3226 4 645 13 2097 29 4677 4203

$123000 $14694 $37000 Provider RVUs User RVUs Points

0 129 5772 6200 (931)

EM Coding Total Sample Size 4 codes EM Detailed Review Total Sample Size 4 codes

Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

CPTreg HCPCS II Coding Total Sample Size 0 codes

Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0

Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0

ICD-CM Coding Total Sample Size 5 codes RVU Comparison

Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20

wRVU Comp Original Audited Change Total wRVU Value 523 429 -18

Dollar Comparison Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 -

EM Coding Total Sample Size 4 codes		EM Detailed Review Total Sample Size 4 codes
CPTreg HCPCS II Coding Total Sample Size 0 codes ICD-CM Coding Total Sample Size 5 codes RVU Comparison Dollar Comparison Scoring Methodology Evaluation amp Management 7 points if correct5 points if off by one level 0 points if wrong category or if off by 2 or more levels or if not coded Procedure(s) 7 points if correct4 points if units incorrect0 points if not correct CPT HCPCS 7 points if correct4 points if units incorrect0 points if not correct ICD-10-CM 3 points if correct2 points if the primary is correct but not the others1 point if the secondary is correct but not the primary Modifier(s) -1 if not correct or if missing Your scoring methodology is an essential component of your audit reports The scoring methodology should be defined in the Executive Summary Report In-Patient DRG Scoring Example Ttl DRG 10 Ttl Assign 12 DRG Accuracy Ttl Chg 3 I-10 Px Accuracy Ttl Chg 1 Accu 70 Ttl Code 13 Accu 92 Ttl Assign 159 Total Cht 10Coding AccuracyTtl Chng 16Disposition Acc Ttl Chg 0 Ttl Code 175 Accu 100 Accu 91 Ttl Assign 137 Total Cht 137Dx Accuracy Ttl Chg 12POA Accuracy Ttl Chg 0 Ttl Code 149 Accu 100 Accu 92 Coding Guidelines Coding Guidelines Standardized Coding Guidelines is criticaloCPT Guidelineso ICD-10 GuidelinesoCMS Guidelines ndash Follow your Medicare Carriers GuidelinesoCCI GuidelinesEditsoMedicaidMedi-Cal Guidelineso Internal Guidelines that define ndash Gray areas of codingndash Payer specific guidelines Coding Guidelines E amp M Guidelineso95 or 97oDefine the 95 detailed examo Is ldquonon contributoryrdquo allowedo2 out of 3 key components (Is MDM required) Coding Guidelines Other Risk AreasoMedical Necessityo Teaching Physician Guidelineso Incident To o SplitSharedoCopy amp PasteCloned noteso Scribeso SignatureAuthenticationsoOrders for diagnostic servicesoDate of ServiceoNew versus Established CodesoConsultations Audit Reports Goals of the Audit Report The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a recommendation Prioritize High Risk Findings Who will be reading the Audit Report What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team) Audit Report Format Tips Provide perspective for the readero Positive and Negative findings Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined Benefits of Automating your Audit Reports Results o Consistent Resultso Better Datao Increases Efficiency Trackingo Allows audit results to be tracked by provider and by specialty QAo Allows for an automated approach to your internal quality reviews Trendingo Allows for data analysis at a detailed level that can be tracked Productivityo Increases auditor productivityo Decreases re-work ProviderCoder Audit Reports Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date Detailed results for each encounteroMeaningful comments Key Findingso From all encounters Recommendations and Resources Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description 1 001 Patient A 02-19-16 Blue Cross 99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported 1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture 1 S92355D2 W109XXD 1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed 2 002 Patient B 02-05-16 Blue Cross 99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported Detailed Findings 135 822012 New Consultations - Office Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged Chart Level Comments Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM oReportsAudit Manager Macros 061218 (version 1)xlsx Recommendations and ReferencesCategory Short Description Long Description EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM ConsultationReview the consultation guidelines located in the CPT book EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a- preventive-service-with-a-sick-visit EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation) EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf EMEM Time billing suggestion Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EMConsultation Documentation Suggestion Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 - wRVU Comp Original Audited Change Total wRVU Value 523 429 -18 Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20 Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0 Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0 Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

Program Development Questions

Who will be auditedHow often will they be auditedWhat is the sample size to be auditedWhat is the sample selection methodologyWhat is the scoring methodologyWhat is the passing scoreWhat is the follow up when the providers fall below the passing

scoreWhat is the process for education and re-audit

What does the OIG recommend

Provider education A baseline audit 3 months after training Audit each provider annually Sample size of at least 5-10 records per provider (industry standard is

at least 10) Include all Federal payers in your sample selection If problems are identified perform follow up focused reviews Educate Educate Educate

OIG Potential Risk Areas

Coding and Billing Reasonable and necessary services Documentation Improper inducements kickbacks and self-referrals

These are not all inclusive but should be a starting point when developing your Compliance Program

Types of Audits

Types of Audits

Internal AuditsoPros

ndash Continuityndash Familiar with internal coding

guidelinesndash Familiar with the providersndash No outside cost

oConsndash Limited resourcesndash Limited expertise in specialty areasndash Employees may not be receptive to a

peer finding their errors

External AuditsoPros

ndash Qualityndash Expertise in specialty areasndash Outside perspectivendash Error findings may be received easier

from an outsider than a peerndash Objective

oConsndash Costndash Quality

Defining the Audit Objective

What is the objective of the auditoCompliance (baseline) audito Financial Audito Investigative Audit (High Risk or Known Issues)oWork Flow Audit

ndash Did the codes get transferred correctly to the claim formndash Staffing analysis (Productivity)

oRevenue Cycle Audit (Billing Audit)o Educational AuditoCoder Quality Audits (QA)

Defining the Audit Scope

Prospective (prebill)o Pros

ndash Errors are fixed before billedndash No refunds to the payersndash Education can be more immediate on

current serviceso Cons

ndash Requires extra effort and focus to completing the audits timely to prevent a negative impact on revenue

ndash May hold up the billing process because claims will be on hold

ndash Limited selection to what the provider is currently billing

ndash Potential to miss timely filing deadlines

Retrospective (postbill)o Pros

ndash Allows more breathing room for completion and workflow

ndash More comprehensive sample selection of all services by each provider

ndash Allows for retrospective review for a focused audit for a specific time period

o Consndash Errors need to be correctndash Corrected claims and possible refunds

will be requiredndash Education is on previous services (but

not always a negative thing)ndash Timely filing contraints when re-billing

for higher reimbursement

Defining the Audit Scope Date Range

o Most audits will look at either current services (prospective) or a recent look back of 3-4 months (retrospective)

Scheduleo Frequency of the audits Annually Quarterlyo Will all providers be audits at onceo Will their be a rolling schedule of audits over a period of timeo How will re-audits be done

Types of Services to includeo E amp M Services onlyo E amp M with office procedureso Will the audit include diagnostic serviceso Surgery onlyo Will ICD-10-CM be included

Sample Sizeo How many encounters per provider

ndash 10-20 is average for a baseline or annual reviewo Types of services provided by each provider can affect sample sizeo Budget can affect sample sizeo Resources can affect sample size

Sample Selection Methodology

Sample Selection Methodologies

Define your sample selection methodologyoRandom Selection

ndash Totally RandomoRandomly Selective Selection

ndash Random within a set of parameterso Focused Selection

ndash Specific to certain services or codesoRATSTATS

ndash Only when a statistically valid sample selection is required

Sample Selection Methodology

Data AnalysisoBell Curve Analysis

ndash Use Medicare Utilization DataoPrior audit results

ndash Make sure your capturing the previous issuesoHigh Risk Areas

ndash Specialtyndash Groupndash Previously Identified issues

oOIG Work PlanoRAC or ZPIC audit findings

Sample Selection Methodology

Sample selection reportsoUtilization reports

ndash Specified Date Range of Servicesndash Providerndash Patient IDndash DOSndash CPT ICD-10 and Modifiers

Sample selection can be done with only CPT but all the codes gives you a better picture ndash Include the payer if you want your sample to be specific to certain payersndash Include the site of service if you want the audit results to identify each site

o You will want this in excel so you can do lots of filtering and sorting

Sample Selection Methodology Turn your filters on Sort by

o Provider (unless you run a separate report for each provider)o CPT code

ndash If you did not do an bell curve analysis prior you can review the volume of each E amp M level here

ndash Determine what types of services (outpatient inpatient EM Surgery etc)ndash How many of each level of service (depends on the providers EM utilization patterns)

o Resort by Patientndash This will allow you to see all services performed for each DOSndash Helps to capture encounters that have both EM amp Procedures Preventive with EM etc

o Pay attention to the Modifiersndash Do you want to include resident documentation Look for GC or GEndash Do you want to include EM with procedure Look for 25

ndash ReportsSample Selectionxlsx

Scoring Methodology

Scoring Methodology

Establish an Accuracy Rateo The OIG recommends that physicians maintain an accuracy rate of 95

ndash Net Error Rate

o Is it realistic to establish a 95 accuracy rate for the providers

Scoring Examples (automated)

Total Visits Accurately Coded Under CodedBilled Over CodedBilled(+) Wrong Category (WC) Gross Financial Error ()

62 20 3226 4 645 13 2097 29 4677 4203

$123000 $14694 $37000 Provider RVUs User RVUs Points

0 129 5772 6200 (931)

EM Coding Total Sample Size 4 codes EM Detailed Review Total Sample Size 4 codes

Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

CPTreg HCPCS II Coding Total Sample Size 0 codes

Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0

Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0

ICD-CM Coding Total Sample Size 5 codes RVU Comparison

Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20

wRVU Comp Original Audited Change Total wRVU Value 523 429 -18

Dollar Comparison Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 -

EM Coding Total Sample Size 4 codes		EM Detailed Review Total Sample Size 4 codes
CPTreg HCPCS II Coding Total Sample Size 0 codes ICD-CM Coding Total Sample Size 5 codes RVU Comparison Dollar Comparison Scoring Methodology Evaluation amp Management 7 points if correct5 points if off by one level 0 points if wrong category or if off by 2 or more levels or if not coded Procedure(s) 7 points if correct4 points if units incorrect0 points if not correct CPT HCPCS 7 points if correct4 points if units incorrect0 points if not correct ICD-10-CM 3 points if correct2 points if the primary is correct but not the others1 point if the secondary is correct but not the primary Modifier(s) -1 if not correct or if missing Your scoring methodology is an essential component of your audit reports The scoring methodology should be defined in the Executive Summary Report In-Patient DRG Scoring Example Ttl DRG 10 Ttl Assign 12 DRG Accuracy Ttl Chg 3 I-10 Px Accuracy Ttl Chg 1 Accu 70 Ttl Code 13 Accu 92 Ttl Assign 159 Total Cht 10Coding AccuracyTtl Chng 16Disposition Acc Ttl Chg 0 Ttl Code 175 Accu 100 Accu 91 Ttl Assign 137 Total Cht 137Dx Accuracy Ttl Chg 12POA Accuracy Ttl Chg 0 Ttl Code 149 Accu 100 Accu 92 Coding Guidelines Coding Guidelines Standardized Coding Guidelines is criticaloCPT Guidelineso ICD-10 GuidelinesoCMS Guidelines ndash Follow your Medicare Carriers GuidelinesoCCI GuidelinesEditsoMedicaidMedi-Cal Guidelineso Internal Guidelines that define ndash Gray areas of codingndash Payer specific guidelines Coding Guidelines E amp M Guidelineso95 or 97oDefine the 95 detailed examo Is ldquonon contributoryrdquo allowedo2 out of 3 key components (Is MDM required) Coding Guidelines Other Risk AreasoMedical Necessityo Teaching Physician Guidelineso Incident To o SplitSharedoCopy amp PasteCloned noteso Scribeso SignatureAuthenticationsoOrders for diagnostic servicesoDate of ServiceoNew versus Established CodesoConsultations Audit Reports Goals of the Audit Report The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a recommendation Prioritize High Risk Findings Who will be reading the Audit Report What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team) Audit Report Format Tips Provide perspective for the readero Positive and Negative findings Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined Benefits of Automating your Audit Reports Results o Consistent Resultso Better Datao Increases Efficiency Trackingo Allows audit results to be tracked by provider and by specialty QAo Allows for an automated approach to your internal quality reviews Trendingo Allows for data analysis at a detailed level that can be tracked Productivityo Increases auditor productivityo Decreases re-work ProviderCoder Audit Reports Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date Detailed results for each encounteroMeaningful comments Key Findingso From all encounters Recommendations and Resources Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description 1 001 Patient A 02-19-16 Blue Cross 99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported 1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture 1 S92355D2 W109XXD 1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed 2 002 Patient B 02-05-16 Blue Cross 99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported Detailed Findings 135 822012 New Consultations - Office Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged Chart Level Comments Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM oReportsAudit Manager Macros 061218 (version 1)xlsx Recommendations and ReferencesCategory Short Description Long Description EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM ConsultationReview the consultation guidelines located in the CPT book EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a- preventive-service-with-a-sick-visit EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation) EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf EMEM Time billing suggestion Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EMConsultation Documentation Suggestion Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 - wRVU Comp Original Audited Change Total wRVU Value 523 429 -18 Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20 Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0 Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0 Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

What does the OIG recommend

Provider education A baseline audit 3 months after training Audit each provider annually Sample size of at least 5-10 records per provider (industry standard is

at least 10) Include all Federal payers in your sample selection If problems are identified perform follow up focused reviews Educate Educate Educate

OIG Potential Risk Areas

Coding and Billing Reasonable and necessary services Documentation Improper inducements kickbacks and self-referrals

These are not all inclusive but should be a starting point when developing your Compliance Program

Types of Audits

Types of Audits

Internal AuditsoPros

ndash Continuityndash Familiar with internal coding

guidelinesndash Familiar with the providersndash No outside cost

oConsndash Limited resourcesndash Limited expertise in specialty areasndash Employees may not be receptive to a

peer finding their errors

External AuditsoPros

ndash Qualityndash Expertise in specialty areasndash Outside perspectivendash Error findings may be received easier

from an outsider than a peerndash Objective

oConsndash Costndash Quality

Defining the Audit Objective

What is the objective of the auditoCompliance (baseline) audito Financial Audito Investigative Audit (High Risk or Known Issues)oWork Flow Audit

ndash Did the codes get transferred correctly to the claim formndash Staffing analysis (Productivity)

oRevenue Cycle Audit (Billing Audit)o Educational AuditoCoder Quality Audits (QA)

Defining the Audit Scope

Prospective (prebill)o Pros

ndash Errors are fixed before billedndash No refunds to the payersndash Education can be more immediate on

current serviceso Cons

ndash Requires extra effort and focus to completing the audits timely to prevent a negative impact on revenue

ndash May hold up the billing process because claims will be on hold

ndash Limited selection to what the provider is currently billing

ndash Potential to miss timely filing deadlines

Retrospective (postbill)o Pros

ndash Allows more breathing room for completion and workflow

ndash More comprehensive sample selection of all services by each provider

ndash Allows for retrospective review for a focused audit for a specific time period

o Consndash Errors need to be correctndash Corrected claims and possible refunds

will be requiredndash Education is on previous services (but

not always a negative thing)ndash Timely filing contraints when re-billing

for higher reimbursement

Defining the Audit Scope Date Range

o Most audits will look at either current services (prospective) or a recent look back of 3-4 months (retrospective)

Scheduleo Frequency of the audits Annually Quarterlyo Will all providers be audits at onceo Will their be a rolling schedule of audits over a period of timeo How will re-audits be done

Types of Services to includeo E amp M Services onlyo E amp M with office procedureso Will the audit include diagnostic serviceso Surgery onlyo Will ICD-10-CM be included

Sample Sizeo How many encounters per provider

ndash 10-20 is average for a baseline or annual reviewo Types of services provided by each provider can affect sample sizeo Budget can affect sample sizeo Resources can affect sample size

Sample Selection Methodology

Sample Selection Methodologies

Define your sample selection methodologyoRandom Selection

ndash Totally RandomoRandomly Selective Selection

ndash Random within a set of parameterso Focused Selection

ndash Specific to certain services or codesoRATSTATS

ndash Only when a statistically valid sample selection is required

Sample Selection Methodology

Data AnalysisoBell Curve Analysis

ndash Use Medicare Utilization DataoPrior audit results

ndash Make sure your capturing the previous issuesoHigh Risk Areas

ndash Specialtyndash Groupndash Previously Identified issues

oOIG Work PlanoRAC or ZPIC audit findings

Sample Selection Methodology

Sample selection reportsoUtilization reports

ndash Specified Date Range of Servicesndash Providerndash Patient IDndash DOSndash CPT ICD-10 and Modifiers

Sample selection can be done with only CPT but all the codes gives you a better picture ndash Include the payer if you want your sample to be specific to certain payersndash Include the site of service if you want the audit results to identify each site

o You will want this in excel so you can do lots of filtering and sorting

Sample Selection Methodology Turn your filters on Sort by

o Provider (unless you run a separate report for each provider)o CPT code

ndash If you did not do an bell curve analysis prior you can review the volume of each E amp M level here

ndash Determine what types of services (outpatient inpatient EM Surgery etc)ndash How many of each level of service (depends on the providers EM utilization patterns)

o Resort by Patientndash This will allow you to see all services performed for each DOSndash Helps to capture encounters that have both EM amp Procedures Preventive with EM etc

o Pay attention to the Modifiersndash Do you want to include resident documentation Look for GC or GEndash Do you want to include EM with procedure Look for 25

ndash ReportsSample Selectionxlsx

Scoring Methodology

Scoring Methodology

Establish an Accuracy Rateo The OIG recommends that physicians maintain an accuracy rate of 95

ndash Net Error Rate

o Is it realistic to establish a 95 accuracy rate for the providers

Scoring Examples (automated)

Total Visits Accurately Coded Under CodedBilled Over CodedBilled(+) Wrong Category (WC) Gross Financial Error ()

62 20 3226 4 645 13 2097 29 4677 4203

$123000 $14694 $37000 Provider RVUs User RVUs Points

0 129 5772 6200 (931)

EM Coding Total Sample Size 4 codes EM Detailed Review Total Sample Size 4 codes

Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

CPTreg HCPCS II Coding Total Sample Size 0 codes

Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0

Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0

ICD-CM Coding Total Sample Size 5 codes RVU Comparison

Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20

wRVU Comp Original Audited Change Total wRVU Value 523 429 -18

Dollar Comparison Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 -

EM Coding Total Sample Size 4 codes		EM Detailed Review Total Sample Size 4 codes
CPTreg HCPCS II Coding Total Sample Size 0 codes ICD-CM Coding Total Sample Size 5 codes RVU Comparison Dollar Comparison Scoring Methodology Evaluation amp Management 7 points if correct5 points if off by one level 0 points if wrong category or if off by 2 or more levels or if not coded Procedure(s) 7 points if correct4 points if units incorrect0 points if not correct CPT HCPCS 7 points if correct4 points if units incorrect0 points if not correct ICD-10-CM 3 points if correct2 points if the primary is correct but not the others1 point if the secondary is correct but not the primary Modifier(s) -1 if not correct or if missing Your scoring methodology is an essential component of your audit reports The scoring methodology should be defined in the Executive Summary Report In-Patient DRG Scoring Example Ttl DRG 10 Ttl Assign 12 DRG Accuracy Ttl Chg 3 I-10 Px Accuracy Ttl Chg 1 Accu 70 Ttl Code 13 Accu 92 Ttl Assign 159 Total Cht 10Coding AccuracyTtl Chng 16Disposition Acc Ttl Chg 0 Ttl Code 175 Accu 100 Accu 91 Ttl Assign 137 Total Cht 137Dx Accuracy Ttl Chg 12POA Accuracy Ttl Chg 0 Ttl Code 149 Accu 100 Accu 92 Coding Guidelines Coding Guidelines Standardized Coding Guidelines is criticaloCPT Guidelineso ICD-10 GuidelinesoCMS Guidelines ndash Follow your Medicare Carriers GuidelinesoCCI GuidelinesEditsoMedicaidMedi-Cal Guidelineso Internal Guidelines that define ndash Gray areas of codingndash Payer specific guidelines Coding Guidelines E amp M Guidelineso95 or 97oDefine the 95 detailed examo Is ldquonon contributoryrdquo allowedo2 out of 3 key components (Is MDM required) Coding Guidelines Other Risk AreasoMedical Necessityo Teaching Physician Guidelineso Incident To o SplitSharedoCopy amp PasteCloned noteso Scribeso SignatureAuthenticationsoOrders for diagnostic servicesoDate of ServiceoNew versus Established CodesoConsultations Audit Reports Goals of the Audit Report The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a recommendation Prioritize High Risk Findings Who will be reading the Audit Report What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team) Audit Report Format Tips Provide perspective for the readero Positive and Negative findings Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined Benefits of Automating your Audit Reports Results o Consistent Resultso Better Datao Increases Efficiency Trackingo Allows audit results to be tracked by provider and by specialty QAo Allows for an automated approach to your internal quality reviews Trendingo Allows for data analysis at a detailed level that can be tracked Productivityo Increases auditor productivityo Decreases re-work ProviderCoder Audit Reports Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date Detailed results for each encounteroMeaningful comments Key Findingso From all encounters Recommendations and Resources Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description 1 001 Patient A 02-19-16 Blue Cross 99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported 1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture 1 S92355D2 W109XXD 1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed 2 002 Patient B 02-05-16 Blue Cross 99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported Detailed Findings 135 822012 New Consultations - Office Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged Chart Level Comments Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM oReportsAudit Manager Macros 061218 (version 1)xlsx Recommendations and ReferencesCategory Short Description Long Description EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM ConsultationReview the consultation guidelines located in the CPT book EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a- preventive-service-with-a-sick-visit EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation) EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf EMEM Time billing suggestion Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EMConsultation Documentation Suggestion Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 - wRVU Comp Original Audited Change Total wRVU Value 523 429 -18 Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20 Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0 Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0 Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

OIG Potential Risk Areas

Coding and Billing Reasonable and necessary services Documentation Improper inducements kickbacks and self-referrals

These are not all inclusive but should be a starting point when developing your Compliance Program

Types of Audits

Types of Audits

Internal AuditsoPros

ndash Continuityndash Familiar with internal coding

guidelinesndash Familiar with the providersndash No outside cost

oConsndash Limited resourcesndash Limited expertise in specialty areasndash Employees may not be receptive to a

peer finding their errors

External AuditsoPros

ndash Qualityndash Expertise in specialty areasndash Outside perspectivendash Error findings may be received easier

from an outsider than a peerndash Objective

oConsndash Costndash Quality

Defining the Audit Objective

What is the objective of the auditoCompliance (baseline) audito Financial Audito Investigative Audit (High Risk or Known Issues)oWork Flow Audit

ndash Did the codes get transferred correctly to the claim formndash Staffing analysis (Productivity)

oRevenue Cycle Audit (Billing Audit)o Educational AuditoCoder Quality Audits (QA)

Defining the Audit Scope

Prospective (prebill)o Pros

ndash Errors are fixed before billedndash No refunds to the payersndash Education can be more immediate on

current serviceso Cons

ndash Requires extra effort and focus to completing the audits timely to prevent a negative impact on revenue

ndash May hold up the billing process because claims will be on hold

ndash Limited selection to what the provider is currently billing

ndash Potential to miss timely filing deadlines

Retrospective (postbill)o Pros

ndash Allows more breathing room for completion and workflow

ndash More comprehensive sample selection of all services by each provider

ndash Allows for retrospective review for a focused audit for a specific time period

o Consndash Errors need to be correctndash Corrected claims and possible refunds

will be requiredndash Education is on previous services (but

not always a negative thing)ndash Timely filing contraints when re-billing

for higher reimbursement

Defining the Audit Scope Date Range

o Most audits will look at either current services (prospective) or a recent look back of 3-4 months (retrospective)

Scheduleo Frequency of the audits Annually Quarterlyo Will all providers be audits at onceo Will their be a rolling schedule of audits over a period of timeo How will re-audits be done

Types of Services to includeo E amp M Services onlyo E amp M with office procedureso Will the audit include diagnostic serviceso Surgery onlyo Will ICD-10-CM be included

Sample Sizeo How many encounters per provider

ndash 10-20 is average for a baseline or annual reviewo Types of services provided by each provider can affect sample sizeo Budget can affect sample sizeo Resources can affect sample size

Sample Selection Methodology

Sample Selection Methodologies

Define your sample selection methodologyoRandom Selection

ndash Totally RandomoRandomly Selective Selection

ndash Random within a set of parameterso Focused Selection

ndash Specific to certain services or codesoRATSTATS

ndash Only when a statistically valid sample selection is required

Sample Selection Methodology

Data AnalysisoBell Curve Analysis

ndash Use Medicare Utilization DataoPrior audit results

ndash Make sure your capturing the previous issuesoHigh Risk Areas

ndash Specialtyndash Groupndash Previously Identified issues

oOIG Work PlanoRAC or ZPIC audit findings

Sample Selection Methodology

Sample selection reportsoUtilization reports

ndash Specified Date Range of Servicesndash Providerndash Patient IDndash DOSndash CPT ICD-10 and Modifiers

Sample selection can be done with only CPT but all the codes gives you a better picture ndash Include the payer if you want your sample to be specific to certain payersndash Include the site of service if you want the audit results to identify each site

o You will want this in excel so you can do lots of filtering and sorting

Sample Selection Methodology Turn your filters on Sort by

o Provider (unless you run a separate report for each provider)o CPT code

ndash If you did not do an bell curve analysis prior you can review the volume of each E amp M level here

ndash Determine what types of services (outpatient inpatient EM Surgery etc)ndash How many of each level of service (depends on the providers EM utilization patterns)

o Resort by Patientndash This will allow you to see all services performed for each DOSndash Helps to capture encounters that have both EM amp Procedures Preventive with EM etc

o Pay attention to the Modifiersndash Do you want to include resident documentation Look for GC or GEndash Do you want to include EM with procedure Look for 25

ndash ReportsSample Selectionxlsx

Scoring Methodology

Scoring Methodology

Establish an Accuracy Rateo The OIG recommends that physicians maintain an accuracy rate of 95

ndash Net Error Rate

o Is it realistic to establish a 95 accuracy rate for the providers

Scoring Examples (automated)

Total Visits Accurately Coded Under CodedBilled Over CodedBilled(+) Wrong Category (WC) Gross Financial Error ()

62 20 3226 4 645 13 2097 29 4677 4203

$123000 $14694 $37000 Provider RVUs User RVUs Points

0 129 5772 6200 (931)

EM Coding Total Sample Size 4 codes EM Detailed Review Total Sample Size 4 codes

Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

CPTreg HCPCS II Coding Total Sample Size 0 codes

Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0

Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0

ICD-CM Coding Total Sample Size 5 codes RVU Comparison

Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20

wRVU Comp Original Audited Change Total wRVU Value 523 429 -18

Dollar Comparison Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 -

EM Coding Total Sample Size 4 codes		EM Detailed Review Total Sample Size 4 codes
CPTreg HCPCS II Coding Total Sample Size 0 codes ICD-CM Coding Total Sample Size 5 codes RVU Comparison Dollar Comparison Scoring Methodology Evaluation amp Management 7 points if correct5 points if off by one level 0 points if wrong category or if off by 2 or more levels or if not coded Procedure(s) 7 points if correct4 points if units incorrect0 points if not correct CPT HCPCS 7 points if correct4 points if units incorrect0 points if not correct ICD-10-CM 3 points if correct2 points if the primary is correct but not the others1 point if the secondary is correct but not the primary Modifier(s) -1 if not correct or if missing Your scoring methodology is an essential component of your audit reports The scoring methodology should be defined in the Executive Summary Report In-Patient DRG Scoring Example Ttl DRG 10 Ttl Assign 12 DRG Accuracy Ttl Chg 3 I-10 Px Accuracy Ttl Chg 1 Accu 70 Ttl Code 13 Accu 92 Ttl Assign 159 Total Cht 10Coding AccuracyTtl Chng 16Disposition Acc Ttl Chg 0 Ttl Code 175 Accu 100 Accu 91 Ttl Assign 137 Total Cht 137Dx Accuracy Ttl Chg 12POA Accuracy Ttl Chg 0 Ttl Code 149 Accu 100 Accu 92 Coding Guidelines Coding Guidelines Standardized Coding Guidelines is criticaloCPT Guidelineso ICD-10 GuidelinesoCMS Guidelines ndash Follow your Medicare Carriers GuidelinesoCCI GuidelinesEditsoMedicaidMedi-Cal Guidelineso Internal Guidelines that define ndash Gray areas of codingndash Payer specific guidelines Coding Guidelines E amp M Guidelineso95 or 97oDefine the 95 detailed examo Is ldquonon contributoryrdquo allowedo2 out of 3 key components (Is MDM required) Coding Guidelines Other Risk AreasoMedical Necessityo Teaching Physician Guidelineso Incident To o SplitSharedoCopy amp PasteCloned noteso Scribeso SignatureAuthenticationsoOrders for diagnostic servicesoDate of ServiceoNew versus Established CodesoConsultations Audit Reports Goals of the Audit Report The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a recommendation Prioritize High Risk Findings Who will be reading the Audit Report What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team) Audit Report Format Tips Provide perspective for the readero Positive and Negative findings Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined Benefits of Automating your Audit Reports Results o Consistent Resultso Better Datao Increases Efficiency Trackingo Allows audit results to be tracked by provider and by specialty QAo Allows for an automated approach to your internal quality reviews Trendingo Allows for data analysis at a detailed level that can be tracked Productivityo Increases auditor productivityo Decreases re-work ProviderCoder Audit Reports Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date Detailed results for each encounteroMeaningful comments Key Findingso From all encounters Recommendations and Resources Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description 1 001 Patient A 02-19-16 Blue Cross 99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported 1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture 1 S92355D2 W109XXD 1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed 2 002 Patient B 02-05-16 Blue Cross 99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported Detailed Findings 135 822012 New Consultations - Office Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged Chart Level Comments Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM oReportsAudit Manager Macros 061218 (version 1)xlsx Recommendations and ReferencesCategory Short Description Long Description EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM ConsultationReview the consultation guidelines located in the CPT book EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a- preventive-service-with-a-sick-visit EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation) EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf EMEM Time billing suggestion Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EMConsultation Documentation Suggestion Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 - wRVU Comp Original Audited Change Total wRVU Value 523 429 -18 Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20 Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0 Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0 Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

Types of Audits

Types of Audits

Internal AuditsoPros

ndash Continuityndash Familiar with internal coding

guidelinesndash Familiar with the providersndash No outside cost

oConsndash Limited resourcesndash Limited expertise in specialty areasndash Employees may not be receptive to a

peer finding their errors

External AuditsoPros

ndash Qualityndash Expertise in specialty areasndash Outside perspectivendash Error findings may be received easier

from an outsider than a peerndash Objective

oConsndash Costndash Quality

Defining the Audit Objective

What is the objective of the auditoCompliance (baseline) audito Financial Audito Investigative Audit (High Risk or Known Issues)oWork Flow Audit

ndash Did the codes get transferred correctly to the claim formndash Staffing analysis (Productivity)

oRevenue Cycle Audit (Billing Audit)o Educational AuditoCoder Quality Audits (QA)

Defining the Audit Scope

Prospective (prebill)o Pros

ndash Errors are fixed before billedndash No refunds to the payersndash Education can be more immediate on

current serviceso Cons

ndash Requires extra effort and focus to completing the audits timely to prevent a negative impact on revenue

ndash May hold up the billing process because claims will be on hold

ndash Limited selection to what the provider is currently billing

ndash Potential to miss timely filing deadlines

Retrospective (postbill)o Pros

ndash Allows more breathing room for completion and workflow

ndash More comprehensive sample selection of all services by each provider

ndash Allows for retrospective review for a focused audit for a specific time period

o Consndash Errors need to be correctndash Corrected claims and possible refunds

will be requiredndash Education is on previous services (but

not always a negative thing)ndash Timely filing contraints when re-billing

for higher reimbursement

Defining the Audit Scope Date Range

o Most audits will look at either current services (prospective) or a recent look back of 3-4 months (retrospective)

Scheduleo Frequency of the audits Annually Quarterlyo Will all providers be audits at onceo Will their be a rolling schedule of audits over a period of timeo How will re-audits be done

Types of Services to includeo E amp M Services onlyo E amp M with office procedureso Will the audit include diagnostic serviceso Surgery onlyo Will ICD-10-CM be included

Sample Sizeo How many encounters per provider

ndash 10-20 is average for a baseline or annual reviewo Types of services provided by each provider can affect sample sizeo Budget can affect sample sizeo Resources can affect sample size

Sample Selection Methodology

Sample Selection Methodologies

Define your sample selection methodologyoRandom Selection

ndash Totally RandomoRandomly Selective Selection

ndash Random within a set of parameterso Focused Selection

ndash Specific to certain services or codesoRATSTATS

ndash Only when a statistically valid sample selection is required

Sample Selection Methodology

Data AnalysisoBell Curve Analysis

ndash Use Medicare Utilization DataoPrior audit results

ndash Make sure your capturing the previous issuesoHigh Risk Areas

ndash Specialtyndash Groupndash Previously Identified issues

oOIG Work PlanoRAC or ZPIC audit findings

Sample Selection Methodology

Sample selection reportsoUtilization reports

ndash Specified Date Range of Servicesndash Providerndash Patient IDndash DOSndash CPT ICD-10 and Modifiers

Sample selection can be done with only CPT but all the codes gives you a better picture ndash Include the payer if you want your sample to be specific to certain payersndash Include the site of service if you want the audit results to identify each site

o You will want this in excel so you can do lots of filtering and sorting

Sample Selection Methodology Turn your filters on Sort by

o Provider (unless you run a separate report for each provider)o CPT code

ndash If you did not do an bell curve analysis prior you can review the volume of each E amp M level here

ndash Determine what types of services (outpatient inpatient EM Surgery etc)ndash How many of each level of service (depends on the providers EM utilization patterns)

o Resort by Patientndash This will allow you to see all services performed for each DOSndash Helps to capture encounters that have both EM amp Procedures Preventive with EM etc

o Pay attention to the Modifiersndash Do you want to include resident documentation Look for GC or GEndash Do you want to include EM with procedure Look for 25

ndash ReportsSample Selectionxlsx

Scoring Methodology

Scoring Methodology

Establish an Accuracy Rateo The OIG recommends that physicians maintain an accuracy rate of 95

ndash Net Error Rate

o Is it realistic to establish a 95 accuracy rate for the providers

Scoring Examples (automated)

Total Visits Accurately Coded Under CodedBilled Over CodedBilled(+) Wrong Category (WC) Gross Financial Error ()

62 20 3226 4 645 13 2097 29 4677 4203

$123000 $14694 $37000 Provider RVUs User RVUs Points

0 129 5772 6200 (931)

EM Coding Total Sample Size 4 codes EM Detailed Review Total Sample Size 4 codes

Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

CPTreg HCPCS II Coding Total Sample Size 0 codes

Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0

Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0

ICD-CM Coding Total Sample Size 5 codes RVU Comparison

Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20

wRVU Comp Original Audited Change Total wRVU Value 523 429 -18

Dollar Comparison Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 -

EM Coding Total Sample Size 4 codes		EM Detailed Review Total Sample Size 4 codes
CPTreg HCPCS II Coding Total Sample Size 0 codes ICD-CM Coding Total Sample Size 5 codes RVU Comparison Dollar Comparison Scoring Methodology Evaluation amp Management 7 points if correct5 points if off by one level 0 points if wrong category or if off by 2 or more levels or if not coded Procedure(s) 7 points if correct4 points if units incorrect0 points if not correct CPT HCPCS 7 points if correct4 points if units incorrect0 points if not correct ICD-10-CM 3 points if correct2 points if the primary is correct but not the others1 point if the secondary is correct but not the primary Modifier(s) -1 if not correct or if missing Your scoring methodology is an essential component of your audit reports The scoring methodology should be defined in the Executive Summary Report In-Patient DRG Scoring Example Ttl DRG 10 Ttl Assign 12 DRG Accuracy Ttl Chg 3 I-10 Px Accuracy Ttl Chg 1 Accu 70 Ttl Code 13 Accu 92 Ttl Assign 159 Total Cht 10Coding AccuracyTtl Chng 16Disposition Acc Ttl Chg 0 Ttl Code 175 Accu 100 Accu 91 Ttl Assign 137 Total Cht 137Dx Accuracy Ttl Chg 12POA Accuracy Ttl Chg 0 Ttl Code 149 Accu 100 Accu 92 Coding Guidelines Coding Guidelines Standardized Coding Guidelines is criticaloCPT Guidelineso ICD-10 GuidelinesoCMS Guidelines ndash Follow your Medicare Carriers GuidelinesoCCI GuidelinesEditsoMedicaidMedi-Cal Guidelineso Internal Guidelines that define ndash Gray areas of codingndash Payer specific guidelines Coding Guidelines E amp M Guidelineso95 or 97oDefine the 95 detailed examo Is ldquonon contributoryrdquo allowedo2 out of 3 key components (Is MDM required) Coding Guidelines Other Risk AreasoMedical Necessityo Teaching Physician Guidelineso Incident To o SplitSharedoCopy amp PasteCloned noteso Scribeso SignatureAuthenticationsoOrders for diagnostic servicesoDate of ServiceoNew versus Established CodesoConsultations Audit Reports Goals of the Audit Report The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a recommendation Prioritize High Risk Findings Who will be reading the Audit Report What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team) Audit Report Format Tips Provide perspective for the readero Positive and Negative findings Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined Benefits of Automating your Audit Reports Results o Consistent Resultso Better Datao Increases Efficiency Trackingo Allows audit results to be tracked by provider and by specialty QAo Allows for an automated approach to your internal quality reviews Trendingo Allows for data analysis at a detailed level that can be tracked Productivityo Increases auditor productivityo Decreases re-work ProviderCoder Audit Reports Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date Detailed results for each encounteroMeaningful comments Key Findingso From all encounters Recommendations and Resources Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description 1 001 Patient A 02-19-16 Blue Cross 99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported 1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture 1 S92355D2 W109XXD 1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed 2 002 Patient B 02-05-16 Blue Cross 99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported Detailed Findings 135 822012 New Consultations - Office Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged Chart Level Comments Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM oReportsAudit Manager Macros 061218 (version 1)xlsx Recommendations and ReferencesCategory Short Description Long Description EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM ConsultationReview the consultation guidelines located in the CPT book EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a- preventive-service-with-a-sick-visit EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation) EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf EMEM Time billing suggestion Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EMConsultation Documentation Suggestion Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 - wRVU Comp Original Audited Change Total wRVU Value 523 429 -18 Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20 Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0 Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0 Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

Types of Audits

Internal AuditsoPros

ndash Continuityndash Familiar with internal coding

guidelinesndash Familiar with the providersndash No outside cost

oConsndash Limited resourcesndash Limited expertise in specialty areasndash Employees may not be receptive to a

peer finding their errors

External AuditsoPros

ndash Qualityndash Expertise in specialty areasndash Outside perspectivendash Error findings may be received easier

from an outsider than a peerndash Objective

oConsndash Costndash Quality

Defining the Audit Objective

What is the objective of the auditoCompliance (baseline) audito Financial Audito Investigative Audit (High Risk or Known Issues)oWork Flow Audit

ndash Did the codes get transferred correctly to the claim formndash Staffing analysis (Productivity)

oRevenue Cycle Audit (Billing Audit)o Educational AuditoCoder Quality Audits (QA)

Defining the Audit Scope

Prospective (prebill)o Pros

ndash Errors are fixed before billedndash No refunds to the payersndash Education can be more immediate on

current serviceso Cons

ndash Requires extra effort and focus to completing the audits timely to prevent a negative impact on revenue

ndash May hold up the billing process because claims will be on hold

ndash Limited selection to what the provider is currently billing

ndash Potential to miss timely filing deadlines

Retrospective (postbill)o Pros

ndash Allows more breathing room for completion and workflow

ndash More comprehensive sample selection of all services by each provider

ndash Allows for retrospective review for a focused audit for a specific time period

o Consndash Errors need to be correctndash Corrected claims and possible refunds

will be requiredndash Education is on previous services (but

not always a negative thing)ndash Timely filing contraints when re-billing

for higher reimbursement

Defining the Audit Scope Date Range

o Most audits will look at either current services (prospective) or a recent look back of 3-4 months (retrospective)

Scheduleo Frequency of the audits Annually Quarterlyo Will all providers be audits at onceo Will their be a rolling schedule of audits over a period of timeo How will re-audits be done

Types of Services to includeo E amp M Services onlyo E amp M with office procedureso Will the audit include diagnostic serviceso Surgery onlyo Will ICD-10-CM be included

Sample Sizeo How many encounters per provider

ndash 10-20 is average for a baseline or annual reviewo Types of services provided by each provider can affect sample sizeo Budget can affect sample sizeo Resources can affect sample size

Sample Selection Methodology

Sample Selection Methodologies

Define your sample selection methodologyoRandom Selection

ndash Totally RandomoRandomly Selective Selection

ndash Random within a set of parameterso Focused Selection

ndash Specific to certain services or codesoRATSTATS

ndash Only when a statistically valid sample selection is required

Sample Selection Methodology

Data AnalysisoBell Curve Analysis

ndash Use Medicare Utilization DataoPrior audit results

ndash Make sure your capturing the previous issuesoHigh Risk Areas

ndash Specialtyndash Groupndash Previously Identified issues

oOIG Work PlanoRAC or ZPIC audit findings

Sample Selection Methodology

Sample selection reportsoUtilization reports

ndash Specified Date Range of Servicesndash Providerndash Patient IDndash DOSndash CPT ICD-10 and Modifiers

Sample selection can be done with only CPT but all the codes gives you a better picture ndash Include the payer if you want your sample to be specific to certain payersndash Include the site of service if you want the audit results to identify each site

o You will want this in excel so you can do lots of filtering and sorting

Sample Selection Methodology Turn your filters on Sort by

o Provider (unless you run a separate report for each provider)o CPT code

ndash If you did not do an bell curve analysis prior you can review the volume of each E amp M level here

ndash Determine what types of services (outpatient inpatient EM Surgery etc)ndash How many of each level of service (depends on the providers EM utilization patterns)

o Resort by Patientndash This will allow you to see all services performed for each DOSndash Helps to capture encounters that have both EM amp Procedures Preventive with EM etc

o Pay attention to the Modifiersndash Do you want to include resident documentation Look for GC or GEndash Do you want to include EM with procedure Look for 25

ndash ReportsSample Selectionxlsx

Scoring Methodology

Scoring Methodology

Establish an Accuracy Rateo The OIG recommends that physicians maintain an accuracy rate of 95

ndash Net Error Rate

o Is it realistic to establish a 95 accuracy rate for the providers

Scoring Examples (automated)

Total Visits Accurately Coded Under CodedBilled Over CodedBilled(+) Wrong Category (WC) Gross Financial Error ()

62 20 3226 4 645 13 2097 29 4677 4203

$123000 $14694 $37000 Provider RVUs User RVUs Points

0 129 5772 6200 (931)

EM Coding Total Sample Size 4 codes EM Detailed Review Total Sample Size 4 codes

Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

CPTreg HCPCS II Coding Total Sample Size 0 codes

Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0

Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0

ICD-CM Coding Total Sample Size 5 codes RVU Comparison

Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20

wRVU Comp Original Audited Change Total wRVU Value 523 429 -18

Dollar Comparison Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 -

EM Coding Total Sample Size 4 codes		EM Detailed Review Total Sample Size 4 codes
CPTreg HCPCS II Coding Total Sample Size 0 codes ICD-CM Coding Total Sample Size 5 codes RVU Comparison Dollar Comparison Scoring Methodology Evaluation amp Management 7 points if correct5 points if off by one level 0 points if wrong category or if off by 2 or more levels or if not coded Procedure(s) 7 points if correct4 points if units incorrect0 points if not correct CPT HCPCS 7 points if correct4 points if units incorrect0 points if not correct ICD-10-CM 3 points if correct2 points if the primary is correct but not the others1 point if the secondary is correct but not the primary Modifier(s) -1 if not correct or if missing Your scoring methodology is an essential component of your audit reports The scoring methodology should be defined in the Executive Summary Report In-Patient DRG Scoring Example Ttl DRG 10 Ttl Assign 12 DRG Accuracy Ttl Chg 3 I-10 Px Accuracy Ttl Chg 1 Accu 70 Ttl Code 13 Accu 92 Ttl Assign 159 Total Cht 10Coding AccuracyTtl Chng 16Disposition Acc Ttl Chg 0 Ttl Code 175 Accu 100 Accu 91 Ttl Assign 137 Total Cht 137Dx Accuracy Ttl Chg 12POA Accuracy Ttl Chg 0 Ttl Code 149 Accu 100 Accu 92 Coding Guidelines Coding Guidelines Standardized Coding Guidelines is criticaloCPT Guidelineso ICD-10 GuidelinesoCMS Guidelines ndash Follow your Medicare Carriers GuidelinesoCCI GuidelinesEditsoMedicaidMedi-Cal Guidelineso Internal Guidelines that define ndash Gray areas of codingndash Payer specific guidelines Coding Guidelines E amp M Guidelineso95 or 97oDefine the 95 detailed examo Is ldquonon contributoryrdquo allowedo2 out of 3 key components (Is MDM required) Coding Guidelines Other Risk AreasoMedical Necessityo Teaching Physician Guidelineso Incident To o SplitSharedoCopy amp PasteCloned noteso Scribeso SignatureAuthenticationsoOrders for diagnostic servicesoDate of ServiceoNew versus Established CodesoConsultations Audit Reports Goals of the Audit Report The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a recommendation Prioritize High Risk Findings Who will be reading the Audit Report What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team) Audit Report Format Tips Provide perspective for the readero Positive and Negative findings Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined Benefits of Automating your Audit Reports Results o Consistent Resultso Better Datao Increases Efficiency Trackingo Allows audit results to be tracked by provider and by specialty QAo Allows for an automated approach to your internal quality reviews Trendingo Allows for data analysis at a detailed level that can be tracked Productivityo Increases auditor productivityo Decreases re-work ProviderCoder Audit Reports Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date Detailed results for each encounteroMeaningful comments Key Findingso From all encounters Recommendations and Resources Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description 1 001 Patient A 02-19-16 Blue Cross 99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported 1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture 1 S92355D2 W109XXD 1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed 2 002 Patient B 02-05-16 Blue Cross 99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported Detailed Findings 135 822012 New Consultations - Office Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged Chart Level Comments Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM oReportsAudit Manager Macros 061218 (version 1)xlsx Recommendations and ReferencesCategory Short Description Long Description EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM ConsultationReview the consultation guidelines located in the CPT book EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a- preventive-service-with-a-sick-visit EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation) EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf EMEM Time billing suggestion Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EMConsultation Documentation Suggestion Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 - wRVU Comp Original Audited Change Total wRVU Value 523 429 -18 Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20 Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0 Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0 Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

Defining the Audit Objective

What is the objective of the auditoCompliance (baseline) audito Financial Audito Investigative Audit (High Risk or Known Issues)oWork Flow Audit

ndash Did the codes get transferred correctly to the claim formndash Staffing analysis (Productivity)

oRevenue Cycle Audit (Billing Audit)o Educational AuditoCoder Quality Audits (QA)

Defining the Audit Scope

Prospective (prebill)o Pros

ndash Errors are fixed before billedndash No refunds to the payersndash Education can be more immediate on

current serviceso Cons

ndash Requires extra effort and focus to completing the audits timely to prevent a negative impact on revenue

ndash May hold up the billing process because claims will be on hold

ndash Limited selection to what the provider is currently billing

ndash Potential to miss timely filing deadlines

Retrospective (postbill)o Pros

ndash Allows more breathing room for completion and workflow

ndash More comprehensive sample selection of all services by each provider

ndash Allows for retrospective review for a focused audit for a specific time period

o Consndash Errors need to be correctndash Corrected claims and possible refunds

will be requiredndash Education is on previous services (but

not always a negative thing)ndash Timely filing contraints when re-billing

for higher reimbursement

Defining the Audit Scope Date Range

o Most audits will look at either current services (prospective) or a recent look back of 3-4 months (retrospective)

Scheduleo Frequency of the audits Annually Quarterlyo Will all providers be audits at onceo Will their be a rolling schedule of audits over a period of timeo How will re-audits be done

Types of Services to includeo E amp M Services onlyo E amp M with office procedureso Will the audit include diagnostic serviceso Surgery onlyo Will ICD-10-CM be included

Sample Sizeo How many encounters per provider

ndash 10-20 is average for a baseline or annual reviewo Types of services provided by each provider can affect sample sizeo Budget can affect sample sizeo Resources can affect sample size

Sample Selection Methodology

Sample Selection Methodologies

Define your sample selection methodologyoRandom Selection

ndash Totally RandomoRandomly Selective Selection

ndash Random within a set of parameterso Focused Selection

ndash Specific to certain services or codesoRATSTATS

ndash Only when a statistically valid sample selection is required

Sample Selection Methodology

Data AnalysisoBell Curve Analysis

ndash Use Medicare Utilization DataoPrior audit results

ndash Make sure your capturing the previous issuesoHigh Risk Areas

ndash Specialtyndash Groupndash Previously Identified issues

oOIG Work PlanoRAC or ZPIC audit findings

Sample Selection Methodology

Sample selection reportsoUtilization reports

ndash Specified Date Range of Servicesndash Providerndash Patient IDndash DOSndash CPT ICD-10 and Modifiers

Sample selection can be done with only CPT but all the codes gives you a better picture ndash Include the payer if you want your sample to be specific to certain payersndash Include the site of service if you want the audit results to identify each site

o You will want this in excel so you can do lots of filtering and sorting

Sample Selection Methodology Turn your filters on Sort by

o Provider (unless you run a separate report for each provider)o CPT code

ndash If you did not do an bell curve analysis prior you can review the volume of each E amp M level here

ndash Determine what types of services (outpatient inpatient EM Surgery etc)ndash How many of each level of service (depends on the providers EM utilization patterns)

o Resort by Patientndash This will allow you to see all services performed for each DOSndash Helps to capture encounters that have both EM amp Procedures Preventive with EM etc

o Pay attention to the Modifiersndash Do you want to include resident documentation Look for GC or GEndash Do you want to include EM with procedure Look for 25

ndash ReportsSample Selectionxlsx

Scoring Methodology

Scoring Methodology

Establish an Accuracy Rateo The OIG recommends that physicians maintain an accuracy rate of 95

ndash Net Error Rate

o Is it realistic to establish a 95 accuracy rate for the providers

Scoring Examples (automated)

Total Visits Accurately Coded Under CodedBilled Over CodedBilled(+) Wrong Category (WC) Gross Financial Error ()

62 20 3226 4 645 13 2097 29 4677 4203

$123000 $14694 $37000 Provider RVUs User RVUs Points

0 129 5772 6200 (931)

EM Coding Total Sample Size 4 codes EM Detailed Review Total Sample Size 4 codes

Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

CPTreg HCPCS II Coding Total Sample Size 0 codes

Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0

Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0

ICD-CM Coding Total Sample Size 5 codes RVU Comparison

Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20

wRVU Comp Original Audited Change Total wRVU Value 523 429 -18

Dollar Comparison Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 -

EM Coding Total Sample Size 4 codes		EM Detailed Review Total Sample Size 4 codes
CPTreg HCPCS II Coding Total Sample Size 0 codes ICD-CM Coding Total Sample Size 5 codes RVU Comparison Dollar Comparison Scoring Methodology Evaluation amp Management 7 points if correct5 points if off by one level 0 points if wrong category or if off by 2 or more levels or if not coded Procedure(s) 7 points if correct4 points if units incorrect0 points if not correct CPT HCPCS 7 points if correct4 points if units incorrect0 points if not correct ICD-10-CM 3 points if correct2 points if the primary is correct but not the others1 point if the secondary is correct but not the primary Modifier(s) -1 if not correct or if missing Your scoring methodology is an essential component of your audit reports The scoring methodology should be defined in the Executive Summary Report In-Patient DRG Scoring Example Ttl DRG 10 Ttl Assign 12 DRG Accuracy Ttl Chg 3 I-10 Px Accuracy Ttl Chg 1 Accu 70 Ttl Code 13 Accu 92 Ttl Assign 159 Total Cht 10Coding AccuracyTtl Chng 16Disposition Acc Ttl Chg 0 Ttl Code 175 Accu 100 Accu 91 Ttl Assign 137 Total Cht 137Dx Accuracy Ttl Chg 12POA Accuracy Ttl Chg 0 Ttl Code 149 Accu 100 Accu 92 Coding Guidelines Coding Guidelines Standardized Coding Guidelines is criticaloCPT Guidelineso ICD-10 GuidelinesoCMS Guidelines ndash Follow your Medicare Carriers GuidelinesoCCI GuidelinesEditsoMedicaidMedi-Cal Guidelineso Internal Guidelines that define ndash Gray areas of codingndash Payer specific guidelines Coding Guidelines E amp M Guidelineso95 or 97oDefine the 95 detailed examo Is ldquonon contributoryrdquo allowedo2 out of 3 key components (Is MDM required) Coding Guidelines Other Risk AreasoMedical Necessityo Teaching Physician Guidelineso Incident To o SplitSharedoCopy amp PasteCloned noteso Scribeso SignatureAuthenticationsoOrders for diagnostic servicesoDate of ServiceoNew versus Established CodesoConsultations Audit Reports Goals of the Audit Report The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a recommendation Prioritize High Risk Findings Who will be reading the Audit Report What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team) Audit Report Format Tips Provide perspective for the readero Positive and Negative findings Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined Benefits of Automating your Audit Reports Results o Consistent Resultso Better Datao Increases Efficiency Trackingo Allows audit results to be tracked by provider and by specialty QAo Allows for an automated approach to your internal quality reviews Trendingo Allows for data analysis at a detailed level that can be tracked Productivityo Increases auditor productivityo Decreases re-work ProviderCoder Audit Reports Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date Detailed results for each encounteroMeaningful comments Key Findingso From all encounters Recommendations and Resources Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description 1 001 Patient A 02-19-16 Blue Cross 99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported 1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture 1 S92355D2 W109XXD 1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed 2 002 Patient B 02-05-16 Blue Cross 99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported Detailed Findings 135 822012 New Consultations - Office Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged Chart Level Comments Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM oReportsAudit Manager Macros 061218 (version 1)xlsx Recommendations and ReferencesCategory Short Description Long Description EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM ConsultationReview the consultation guidelines located in the CPT book EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a- preventive-service-with-a-sick-visit EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation) EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf EMEM Time billing suggestion Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EMConsultation Documentation Suggestion Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 - wRVU Comp Original Audited Change Total wRVU Value 523 429 -18 Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20 Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0 Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0 Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

Defining the Audit Scope

Prospective (prebill)o Pros

ndash Errors are fixed before billedndash No refunds to the payersndash Education can be more immediate on

current serviceso Cons

ndash Requires extra effort and focus to completing the audits timely to prevent a negative impact on revenue

ndash May hold up the billing process because claims will be on hold

ndash Limited selection to what the provider is currently billing

ndash Potential to miss timely filing deadlines

Retrospective (postbill)o Pros

ndash Allows more breathing room for completion and workflow

ndash More comprehensive sample selection of all services by each provider

ndash Allows for retrospective review for a focused audit for a specific time period

o Consndash Errors need to be correctndash Corrected claims and possible refunds

will be requiredndash Education is on previous services (but

not always a negative thing)ndash Timely filing contraints when re-billing

for higher reimbursement

Defining the Audit Scope Date Range

o Most audits will look at either current services (prospective) or a recent look back of 3-4 months (retrospective)

Scheduleo Frequency of the audits Annually Quarterlyo Will all providers be audits at onceo Will their be a rolling schedule of audits over a period of timeo How will re-audits be done

Types of Services to includeo E amp M Services onlyo E amp M with office procedureso Will the audit include diagnostic serviceso Surgery onlyo Will ICD-10-CM be included

Sample Sizeo How many encounters per provider

ndash 10-20 is average for a baseline or annual reviewo Types of services provided by each provider can affect sample sizeo Budget can affect sample sizeo Resources can affect sample size

Sample Selection Methodology

Sample Selection Methodologies

Define your sample selection methodologyoRandom Selection

ndash Totally RandomoRandomly Selective Selection

ndash Random within a set of parameterso Focused Selection

ndash Specific to certain services or codesoRATSTATS

ndash Only when a statistically valid sample selection is required

Sample Selection Methodology

Data AnalysisoBell Curve Analysis

ndash Use Medicare Utilization DataoPrior audit results

ndash Make sure your capturing the previous issuesoHigh Risk Areas

ndash Specialtyndash Groupndash Previously Identified issues

oOIG Work PlanoRAC or ZPIC audit findings

Sample Selection Methodology

Sample selection reportsoUtilization reports

ndash Specified Date Range of Servicesndash Providerndash Patient IDndash DOSndash CPT ICD-10 and Modifiers

Sample selection can be done with only CPT but all the codes gives you a better picture ndash Include the payer if you want your sample to be specific to certain payersndash Include the site of service if you want the audit results to identify each site

o You will want this in excel so you can do lots of filtering and sorting

Sample Selection Methodology Turn your filters on Sort by

o Provider (unless you run a separate report for each provider)o CPT code

ndash If you did not do an bell curve analysis prior you can review the volume of each E amp M level here

ndash Determine what types of services (outpatient inpatient EM Surgery etc)ndash How many of each level of service (depends on the providers EM utilization patterns)

o Resort by Patientndash This will allow you to see all services performed for each DOSndash Helps to capture encounters that have both EM amp Procedures Preventive with EM etc

o Pay attention to the Modifiersndash Do you want to include resident documentation Look for GC or GEndash Do you want to include EM with procedure Look for 25

ndash ReportsSample Selectionxlsx

Scoring Methodology

Scoring Methodology

Establish an Accuracy Rateo The OIG recommends that physicians maintain an accuracy rate of 95

ndash Net Error Rate

o Is it realistic to establish a 95 accuracy rate for the providers

Scoring Examples (automated)

Total Visits Accurately Coded Under CodedBilled Over CodedBilled(+) Wrong Category (WC) Gross Financial Error ()

62 20 3226 4 645 13 2097 29 4677 4203

$123000 $14694 $37000 Provider RVUs User RVUs Points

0 129 5772 6200 (931)

EM Coding Total Sample Size 4 codes EM Detailed Review Total Sample Size 4 codes

Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

CPTreg HCPCS II Coding Total Sample Size 0 codes

Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0

Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0

ICD-CM Coding Total Sample Size 5 codes RVU Comparison

Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20

wRVU Comp Original Audited Change Total wRVU Value 523 429 -18

Dollar Comparison Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 -

EM Coding Total Sample Size 4 codes		EM Detailed Review Total Sample Size 4 codes
CPTreg HCPCS II Coding Total Sample Size 0 codes ICD-CM Coding Total Sample Size 5 codes RVU Comparison Dollar Comparison Scoring Methodology Evaluation amp Management 7 points if correct5 points if off by one level 0 points if wrong category or if off by 2 or more levels or if not coded Procedure(s) 7 points if correct4 points if units incorrect0 points if not correct CPT HCPCS 7 points if correct4 points if units incorrect0 points if not correct ICD-10-CM 3 points if correct2 points if the primary is correct but not the others1 point if the secondary is correct but not the primary Modifier(s) -1 if not correct or if missing Your scoring methodology is an essential component of your audit reports The scoring methodology should be defined in the Executive Summary Report In-Patient DRG Scoring Example Ttl DRG 10 Ttl Assign 12 DRG Accuracy Ttl Chg 3 I-10 Px Accuracy Ttl Chg 1 Accu 70 Ttl Code 13 Accu 92 Ttl Assign 159 Total Cht 10Coding AccuracyTtl Chng 16Disposition Acc Ttl Chg 0 Ttl Code 175 Accu 100 Accu 91 Ttl Assign 137 Total Cht 137Dx Accuracy Ttl Chg 12POA Accuracy Ttl Chg 0 Ttl Code 149 Accu 100 Accu 92 Coding Guidelines Coding Guidelines Standardized Coding Guidelines is criticaloCPT Guidelineso ICD-10 GuidelinesoCMS Guidelines ndash Follow your Medicare Carriers GuidelinesoCCI GuidelinesEditsoMedicaidMedi-Cal Guidelineso Internal Guidelines that define ndash Gray areas of codingndash Payer specific guidelines Coding Guidelines E amp M Guidelineso95 or 97oDefine the 95 detailed examo Is ldquonon contributoryrdquo allowedo2 out of 3 key components (Is MDM required) Coding Guidelines Other Risk AreasoMedical Necessityo Teaching Physician Guidelineso Incident To o SplitSharedoCopy amp PasteCloned noteso Scribeso SignatureAuthenticationsoOrders for diagnostic servicesoDate of ServiceoNew versus Established CodesoConsultations Audit Reports Goals of the Audit Report The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a recommendation Prioritize High Risk Findings Who will be reading the Audit Report What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team) Audit Report Format Tips Provide perspective for the readero Positive and Negative findings Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined Benefits of Automating your Audit Reports Results o Consistent Resultso Better Datao Increases Efficiency Trackingo Allows audit results to be tracked by provider and by specialty QAo Allows for an automated approach to your internal quality reviews Trendingo Allows for data analysis at a detailed level that can be tracked Productivityo Increases auditor productivityo Decreases re-work ProviderCoder Audit Reports Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date Detailed results for each encounteroMeaningful comments Key Findingso From all encounters Recommendations and Resources Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description 1 001 Patient A 02-19-16 Blue Cross 99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported 1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture 1 S92355D2 W109XXD 1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed 2 002 Patient B 02-05-16 Blue Cross 99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported Detailed Findings 135 822012 New Consultations - Office Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged Chart Level Comments Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM oReportsAudit Manager Macros 061218 (version 1)xlsx Recommendations and ReferencesCategory Short Description Long Description EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM ConsultationReview the consultation guidelines located in the CPT book EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a- preventive-service-with-a-sick-visit EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation) EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf EMEM Time billing suggestion Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EMConsultation Documentation Suggestion Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 - wRVU Comp Original Audited Change Total wRVU Value 523 429 -18 Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20 Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0 Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0 Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

Defining the Audit Scope Date Range

o Most audits will look at either current services (prospective) or a recent look back of 3-4 months (retrospective)

Scheduleo Frequency of the audits Annually Quarterlyo Will all providers be audits at onceo Will their be a rolling schedule of audits over a period of timeo How will re-audits be done

Types of Services to includeo E amp M Services onlyo E amp M with office procedureso Will the audit include diagnostic serviceso Surgery onlyo Will ICD-10-CM be included

Sample Sizeo How many encounters per provider

ndash 10-20 is average for a baseline or annual reviewo Types of services provided by each provider can affect sample sizeo Budget can affect sample sizeo Resources can affect sample size

Sample Selection Methodology

Sample Selection Methodologies

Define your sample selection methodologyoRandom Selection

ndash Totally RandomoRandomly Selective Selection

ndash Random within a set of parameterso Focused Selection

ndash Specific to certain services or codesoRATSTATS

ndash Only when a statistically valid sample selection is required

Sample Selection Methodology

Data AnalysisoBell Curve Analysis

ndash Use Medicare Utilization DataoPrior audit results

ndash Make sure your capturing the previous issuesoHigh Risk Areas

ndash Specialtyndash Groupndash Previously Identified issues

oOIG Work PlanoRAC or ZPIC audit findings

Sample Selection Methodology

Sample selection reportsoUtilization reports

ndash Specified Date Range of Servicesndash Providerndash Patient IDndash DOSndash CPT ICD-10 and Modifiers

Sample selection can be done with only CPT but all the codes gives you a better picture ndash Include the payer if you want your sample to be specific to certain payersndash Include the site of service if you want the audit results to identify each site

o You will want this in excel so you can do lots of filtering and sorting

Sample Selection Methodology Turn your filters on Sort by

o Provider (unless you run a separate report for each provider)o CPT code

ndash If you did not do an bell curve analysis prior you can review the volume of each E amp M level here

ndash Determine what types of services (outpatient inpatient EM Surgery etc)ndash How many of each level of service (depends on the providers EM utilization patterns)

o Resort by Patientndash This will allow you to see all services performed for each DOSndash Helps to capture encounters that have both EM amp Procedures Preventive with EM etc

o Pay attention to the Modifiersndash Do you want to include resident documentation Look for GC or GEndash Do you want to include EM with procedure Look for 25

ndash ReportsSample Selectionxlsx

Scoring Methodology

Scoring Methodology

Establish an Accuracy Rateo The OIG recommends that physicians maintain an accuracy rate of 95

ndash Net Error Rate

o Is it realistic to establish a 95 accuracy rate for the providers

Scoring Examples (automated)

Total Visits Accurately Coded Under CodedBilled Over CodedBilled(+) Wrong Category (WC) Gross Financial Error ()

62 20 3226 4 645 13 2097 29 4677 4203

$123000 $14694 $37000 Provider RVUs User RVUs Points

0 129 5772 6200 (931)

EM Coding Total Sample Size 4 codes EM Detailed Review Total Sample Size 4 codes

Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

CPTreg HCPCS II Coding Total Sample Size 0 codes

Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0

Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0

ICD-CM Coding Total Sample Size 5 codes RVU Comparison

Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20

wRVU Comp Original Audited Change Total wRVU Value 523 429 -18

Dollar Comparison Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 -

EM Coding Total Sample Size 4 codes		EM Detailed Review Total Sample Size 4 codes
CPTreg HCPCS II Coding Total Sample Size 0 codes ICD-CM Coding Total Sample Size 5 codes RVU Comparison Dollar Comparison Scoring Methodology Evaluation amp Management 7 points if correct5 points if off by one level 0 points if wrong category or if off by 2 or more levels or if not coded Procedure(s) 7 points if correct4 points if units incorrect0 points if not correct CPT HCPCS 7 points if correct4 points if units incorrect0 points if not correct ICD-10-CM 3 points if correct2 points if the primary is correct but not the others1 point if the secondary is correct but not the primary Modifier(s) -1 if not correct or if missing Your scoring methodology is an essential component of your audit reports The scoring methodology should be defined in the Executive Summary Report In-Patient DRG Scoring Example Ttl DRG 10 Ttl Assign 12 DRG Accuracy Ttl Chg 3 I-10 Px Accuracy Ttl Chg 1 Accu 70 Ttl Code 13 Accu 92 Ttl Assign 159 Total Cht 10Coding AccuracyTtl Chng 16Disposition Acc Ttl Chg 0 Ttl Code 175 Accu 100 Accu 91 Ttl Assign 137 Total Cht 137Dx Accuracy Ttl Chg 12POA Accuracy Ttl Chg 0 Ttl Code 149 Accu 100 Accu 92 Coding Guidelines Coding Guidelines Standardized Coding Guidelines is criticaloCPT Guidelineso ICD-10 GuidelinesoCMS Guidelines ndash Follow your Medicare Carriers GuidelinesoCCI GuidelinesEditsoMedicaidMedi-Cal Guidelineso Internal Guidelines that define ndash Gray areas of codingndash Payer specific guidelines Coding Guidelines E amp M Guidelineso95 or 97oDefine the 95 detailed examo Is ldquonon contributoryrdquo allowedo2 out of 3 key components (Is MDM required) Coding Guidelines Other Risk AreasoMedical Necessityo Teaching Physician Guidelineso Incident To o SplitSharedoCopy amp PasteCloned noteso Scribeso SignatureAuthenticationsoOrders for diagnostic servicesoDate of ServiceoNew versus Established CodesoConsultations Audit Reports Goals of the Audit Report The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a recommendation Prioritize High Risk Findings Who will be reading the Audit Report What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team) Audit Report Format Tips Provide perspective for the readero Positive and Negative findings Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined Benefits of Automating your Audit Reports Results o Consistent Resultso Better Datao Increases Efficiency Trackingo Allows audit results to be tracked by provider and by specialty QAo Allows for an automated approach to your internal quality reviews Trendingo Allows for data analysis at a detailed level that can be tracked Productivityo Increases auditor productivityo Decreases re-work ProviderCoder Audit Reports Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date Detailed results for each encounteroMeaningful comments Key Findingso From all encounters Recommendations and Resources Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description 1 001 Patient A 02-19-16 Blue Cross 99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported 1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture 1 S92355D2 W109XXD 1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed 2 002 Patient B 02-05-16 Blue Cross 99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported Detailed Findings 135 822012 New Consultations - Office Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged Chart Level Comments Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM oReportsAudit Manager Macros 061218 (version 1)xlsx Recommendations and ReferencesCategory Short Description Long Description EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM ConsultationReview the consultation guidelines located in the CPT book EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a- preventive-service-with-a-sick-visit EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation) EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf EMEM Time billing suggestion Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EMConsultation Documentation Suggestion Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 - wRVU Comp Original Audited Change Total wRVU Value 523 429 -18 Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20 Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0 Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0 Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

Sample Selection Methodology

Sample Selection Methodologies

Define your sample selection methodologyoRandom Selection

ndash Totally RandomoRandomly Selective Selection

ndash Random within a set of parameterso Focused Selection

ndash Specific to certain services or codesoRATSTATS

ndash Only when a statistically valid sample selection is required

Sample Selection Methodology

Data AnalysisoBell Curve Analysis

ndash Use Medicare Utilization DataoPrior audit results

ndash Make sure your capturing the previous issuesoHigh Risk Areas

ndash Specialtyndash Groupndash Previously Identified issues

oOIG Work PlanoRAC or ZPIC audit findings

Sample Selection Methodology

Sample selection reportsoUtilization reports

ndash Specified Date Range of Servicesndash Providerndash Patient IDndash DOSndash CPT ICD-10 and Modifiers

Sample selection can be done with only CPT but all the codes gives you a better picture ndash Include the payer if you want your sample to be specific to certain payersndash Include the site of service if you want the audit results to identify each site

o You will want this in excel so you can do lots of filtering and sorting

Sample Selection Methodology Turn your filters on Sort by

o Provider (unless you run a separate report for each provider)o CPT code

ndash If you did not do an bell curve analysis prior you can review the volume of each E amp M level here

ndash Determine what types of services (outpatient inpatient EM Surgery etc)ndash How many of each level of service (depends on the providers EM utilization patterns)

o Resort by Patientndash This will allow you to see all services performed for each DOSndash Helps to capture encounters that have both EM amp Procedures Preventive with EM etc

o Pay attention to the Modifiersndash Do you want to include resident documentation Look for GC or GEndash Do you want to include EM with procedure Look for 25

ndash ReportsSample Selectionxlsx

Scoring Methodology

Scoring Methodology

Establish an Accuracy Rateo The OIG recommends that physicians maintain an accuracy rate of 95

ndash Net Error Rate

o Is it realistic to establish a 95 accuracy rate for the providers

Scoring Examples (automated)

Total Visits Accurately Coded Under CodedBilled Over CodedBilled(+) Wrong Category (WC) Gross Financial Error ()

62 20 3226 4 645 13 2097 29 4677 4203

$123000 $14694 $37000 Provider RVUs User RVUs Points

0 129 5772 6200 (931)

EM Coding Total Sample Size 4 codes EM Detailed Review Total Sample Size 4 codes

Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

CPTreg HCPCS II Coding Total Sample Size 0 codes

Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0

Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0

ICD-CM Coding Total Sample Size 5 codes RVU Comparison

Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20

wRVU Comp Original Audited Change Total wRVU Value 523 429 -18

Dollar Comparison Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 -

EM Coding Total Sample Size 4 codes		EM Detailed Review Total Sample Size 4 codes
CPTreg HCPCS II Coding Total Sample Size 0 codes ICD-CM Coding Total Sample Size 5 codes RVU Comparison Dollar Comparison Scoring Methodology Evaluation amp Management 7 points if correct5 points if off by one level 0 points if wrong category or if off by 2 or more levels or if not coded Procedure(s) 7 points if correct4 points if units incorrect0 points if not correct CPT HCPCS 7 points if correct4 points if units incorrect0 points if not correct ICD-10-CM 3 points if correct2 points if the primary is correct but not the others1 point if the secondary is correct but not the primary Modifier(s) -1 if not correct or if missing Your scoring methodology is an essential component of your audit reports The scoring methodology should be defined in the Executive Summary Report In-Patient DRG Scoring Example Ttl DRG 10 Ttl Assign 12 DRG Accuracy Ttl Chg 3 I-10 Px Accuracy Ttl Chg 1 Accu 70 Ttl Code 13 Accu 92 Ttl Assign 159 Total Cht 10Coding AccuracyTtl Chng 16Disposition Acc Ttl Chg 0 Ttl Code 175 Accu 100 Accu 91 Ttl Assign 137 Total Cht 137Dx Accuracy Ttl Chg 12POA Accuracy Ttl Chg 0 Ttl Code 149 Accu 100 Accu 92 Coding Guidelines Coding Guidelines Standardized Coding Guidelines is criticaloCPT Guidelineso ICD-10 GuidelinesoCMS Guidelines ndash Follow your Medicare Carriers GuidelinesoCCI GuidelinesEditsoMedicaidMedi-Cal Guidelineso Internal Guidelines that define ndash Gray areas of codingndash Payer specific guidelines Coding Guidelines E amp M Guidelineso95 or 97oDefine the 95 detailed examo Is ldquonon contributoryrdquo allowedo2 out of 3 key components (Is MDM required) Coding Guidelines Other Risk AreasoMedical Necessityo Teaching Physician Guidelineso Incident To o SplitSharedoCopy amp PasteCloned noteso Scribeso SignatureAuthenticationsoOrders for diagnostic servicesoDate of ServiceoNew versus Established CodesoConsultations Audit Reports Goals of the Audit Report The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a recommendation Prioritize High Risk Findings Who will be reading the Audit Report What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team) Audit Report Format Tips Provide perspective for the readero Positive and Negative findings Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined Benefits of Automating your Audit Reports Results o Consistent Resultso Better Datao Increases Efficiency Trackingo Allows audit results to be tracked by provider and by specialty QAo Allows for an automated approach to your internal quality reviews Trendingo Allows for data analysis at a detailed level that can be tracked Productivityo Increases auditor productivityo Decreases re-work ProviderCoder Audit Reports Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date Detailed results for each encounteroMeaningful comments Key Findingso From all encounters Recommendations and Resources Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description 1 001 Patient A 02-19-16 Blue Cross 99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported 1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture 1 S92355D2 W109XXD 1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed 2 002 Patient B 02-05-16 Blue Cross 99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported Detailed Findings 135 822012 New Consultations - Office Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged Chart Level Comments Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM oReportsAudit Manager Macros 061218 (version 1)xlsx Recommendations and ReferencesCategory Short Description Long Description EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM ConsultationReview the consultation guidelines located in the CPT book EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a- preventive-service-with-a-sick-visit EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation) EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf EMEM Time billing suggestion Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EMConsultation Documentation Suggestion Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 - wRVU Comp Original Audited Change Total wRVU Value 523 429 -18 Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20 Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0 Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0 Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

Sample Selection Methodologies

Define your sample selection methodologyoRandom Selection

ndash Totally RandomoRandomly Selective Selection

ndash Random within a set of parameterso Focused Selection

ndash Specific to certain services or codesoRATSTATS

ndash Only when a statistically valid sample selection is required

Sample Selection Methodology

Data AnalysisoBell Curve Analysis

ndash Use Medicare Utilization DataoPrior audit results

ndash Make sure your capturing the previous issuesoHigh Risk Areas

ndash Specialtyndash Groupndash Previously Identified issues

oOIG Work PlanoRAC or ZPIC audit findings

Sample Selection Methodology

Sample selection reportsoUtilization reports

ndash Specified Date Range of Servicesndash Providerndash Patient IDndash DOSndash CPT ICD-10 and Modifiers

Sample selection can be done with only CPT but all the codes gives you a better picture ndash Include the payer if you want your sample to be specific to certain payersndash Include the site of service if you want the audit results to identify each site

o You will want this in excel so you can do lots of filtering and sorting

Sample Selection Methodology Turn your filters on Sort by

o Provider (unless you run a separate report for each provider)o CPT code

ndash If you did not do an bell curve analysis prior you can review the volume of each E amp M level here

ndash Determine what types of services (outpatient inpatient EM Surgery etc)ndash How many of each level of service (depends on the providers EM utilization patterns)

o Resort by Patientndash This will allow you to see all services performed for each DOSndash Helps to capture encounters that have both EM amp Procedures Preventive with EM etc

o Pay attention to the Modifiersndash Do you want to include resident documentation Look for GC or GEndash Do you want to include EM with procedure Look for 25

ndash ReportsSample Selectionxlsx

Scoring Methodology

Scoring Methodology

Establish an Accuracy Rateo The OIG recommends that physicians maintain an accuracy rate of 95

ndash Net Error Rate

o Is it realistic to establish a 95 accuracy rate for the providers

Scoring Examples (automated)

Total Visits Accurately Coded Under CodedBilled Over CodedBilled(+) Wrong Category (WC) Gross Financial Error ()

62 20 3226 4 645 13 2097 29 4677 4203

$123000 $14694 $37000 Provider RVUs User RVUs Points

0 129 5772 6200 (931)

EM Coding Total Sample Size 4 codes EM Detailed Review Total Sample Size 4 codes

Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

CPTreg HCPCS II Coding Total Sample Size 0 codes

Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0

Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0

ICD-CM Coding Total Sample Size 5 codes RVU Comparison

Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20

wRVU Comp Original Audited Change Total wRVU Value 523 429 -18

Dollar Comparison Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 -

EM Coding Total Sample Size 4 codes		EM Detailed Review Total Sample Size 4 codes
CPTreg HCPCS II Coding Total Sample Size 0 codes ICD-CM Coding Total Sample Size 5 codes RVU Comparison Dollar Comparison Scoring Methodology Evaluation amp Management 7 points if correct5 points if off by one level 0 points if wrong category or if off by 2 or more levels or if not coded Procedure(s) 7 points if correct4 points if units incorrect0 points if not correct CPT HCPCS 7 points if correct4 points if units incorrect0 points if not correct ICD-10-CM 3 points if correct2 points if the primary is correct but not the others1 point if the secondary is correct but not the primary Modifier(s) -1 if not correct or if missing Your scoring methodology is an essential component of your audit reports The scoring methodology should be defined in the Executive Summary Report In-Patient DRG Scoring Example Ttl DRG 10 Ttl Assign 12 DRG Accuracy Ttl Chg 3 I-10 Px Accuracy Ttl Chg 1 Accu 70 Ttl Code 13 Accu 92 Ttl Assign 159 Total Cht 10Coding AccuracyTtl Chng 16Disposition Acc Ttl Chg 0 Ttl Code 175 Accu 100 Accu 91 Ttl Assign 137 Total Cht 137Dx Accuracy Ttl Chg 12POA Accuracy Ttl Chg 0 Ttl Code 149 Accu 100 Accu 92 Coding Guidelines Coding Guidelines Standardized Coding Guidelines is criticaloCPT Guidelineso ICD-10 GuidelinesoCMS Guidelines ndash Follow your Medicare Carriers GuidelinesoCCI GuidelinesEditsoMedicaidMedi-Cal Guidelineso Internal Guidelines that define ndash Gray areas of codingndash Payer specific guidelines Coding Guidelines E amp M Guidelineso95 or 97oDefine the 95 detailed examo Is ldquonon contributoryrdquo allowedo2 out of 3 key components (Is MDM required) Coding Guidelines Other Risk AreasoMedical Necessityo Teaching Physician Guidelineso Incident To o SplitSharedoCopy amp PasteCloned noteso Scribeso SignatureAuthenticationsoOrders for diagnostic servicesoDate of ServiceoNew versus Established CodesoConsultations Audit Reports Goals of the Audit Report The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a recommendation Prioritize High Risk Findings Who will be reading the Audit Report What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team) Audit Report Format Tips Provide perspective for the readero Positive and Negative findings Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined Benefits of Automating your Audit Reports Results o Consistent Resultso Better Datao Increases Efficiency Trackingo Allows audit results to be tracked by provider and by specialty QAo Allows for an automated approach to your internal quality reviews Trendingo Allows for data analysis at a detailed level that can be tracked Productivityo Increases auditor productivityo Decreases re-work ProviderCoder Audit Reports Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date Detailed results for each encounteroMeaningful comments Key Findingso From all encounters Recommendations and Resources Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description 1 001 Patient A 02-19-16 Blue Cross 99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported 1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture 1 S92355D2 W109XXD 1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed 2 002 Patient B 02-05-16 Blue Cross 99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported Detailed Findings 135 822012 New Consultations - Office Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged Chart Level Comments Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM oReportsAudit Manager Macros 061218 (version 1)xlsx Recommendations and ReferencesCategory Short Description Long Description EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM ConsultationReview the consultation guidelines located in the CPT book EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a- preventive-service-with-a-sick-visit EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation) EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf EMEM Time billing suggestion Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EMConsultation Documentation Suggestion Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 - wRVU Comp Original Audited Change Total wRVU Value 523 429 -18 Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20 Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0 Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0 Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

Sample Selection Methodology

Data AnalysisoBell Curve Analysis

ndash Use Medicare Utilization DataoPrior audit results

ndash Make sure your capturing the previous issuesoHigh Risk Areas

ndash Specialtyndash Groupndash Previously Identified issues

oOIG Work PlanoRAC or ZPIC audit findings

Sample Selection Methodology

Sample selection reportsoUtilization reports

ndash Specified Date Range of Servicesndash Providerndash Patient IDndash DOSndash CPT ICD-10 and Modifiers

Sample selection can be done with only CPT but all the codes gives you a better picture ndash Include the payer if you want your sample to be specific to certain payersndash Include the site of service if you want the audit results to identify each site

o You will want this in excel so you can do lots of filtering and sorting

Sample Selection Methodology Turn your filters on Sort by

o Provider (unless you run a separate report for each provider)o CPT code

ndash If you did not do an bell curve analysis prior you can review the volume of each E amp M level here

ndash Determine what types of services (outpatient inpatient EM Surgery etc)ndash How many of each level of service (depends on the providers EM utilization patterns)

o Resort by Patientndash This will allow you to see all services performed for each DOSndash Helps to capture encounters that have both EM amp Procedures Preventive with EM etc

o Pay attention to the Modifiersndash Do you want to include resident documentation Look for GC or GEndash Do you want to include EM with procedure Look for 25

ndash ReportsSample Selectionxlsx

Scoring Methodology

Scoring Methodology

Establish an Accuracy Rateo The OIG recommends that physicians maintain an accuracy rate of 95

ndash Net Error Rate

o Is it realistic to establish a 95 accuracy rate for the providers

Scoring Examples (automated)

Total Visits Accurately Coded Under CodedBilled Over CodedBilled(+) Wrong Category (WC) Gross Financial Error ()

62 20 3226 4 645 13 2097 29 4677 4203

$123000 $14694 $37000 Provider RVUs User RVUs Points

0 129 5772 6200 (931)

EM Coding Total Sample Size 4 codes EM Detailed Review Total Sample Size 4 codes

Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

CPTreg HCPCS II Coding Total Sample Size 0 codes

Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0

Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0

ICD-CM Coding Total Sample Size 5 codes RVU Comparison

Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20

wRVU Comp Original Audited Change Total wRVU Value 523 429 -18

Dollar Comparison Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 -

EM Coding Total Sample Size 4 codes		EM Detailed Review Total Sample Size 4 codes
CPTreg HCPCS II Coding Total Sample Size 0 codes ICD-CM Coding Total Sample Size 5 codes RVU Comparison Dollar Comparison Scoring Methodology Evaluation amp Management 7 points if correct5 points if off by one level 0 points if wrong category or if off by 2 or more levels or if not coded Procedure(s) 7 points if correct4 points if units incorrect0 points if not correct CPT HCPCS 7 points if correct4 points if units incorrect0 points if not correct ICD-10-CM 3 points if correct2 points if the primary is correct but not the others1 point if the secondary is correct but not the primary Modifier(s) -1 if not correct or if missing Your scoring methodology is an essential component of your audit reports The scoring methodology should be defined in the Executive Summary Report In-Patient DRG Scoring Example Ttl DRG 10 Ttl Assign 12 DRG Accuracy Ttl Chg 3 I-10 Px Accuracy Ttl Chg 1 Accu 70 Ttl Code 13 Accu 92 Ttl Assign 159 Total Cht 10Coding AccuracyTtl Chng 16Disposition Acc Ttl Chg 0 Ttl Code 175 Accu 100 Accu 91 Ttl Assign 137 Total Cht 137Dx Accuracy Ttl Chg 12POA Accuracy Ttl Chg 0 Ttl Code 149 Accu 100 Accu 92 Coding Guidelines Coding Guidelines Standardized Coding Guidelines is criticaloCPT Guidelineso ICD-10 GuidelinesoCMS Guidelines ndash Follow your Medicare Carriers GuidelinesoCCI GuidelinesEditsoMedicaidMedi-Cal Guidelineso Internal Guidelines that define ndash Gray areas of codingndash Payer specific guidelines Coding Guidelines E amp M Guidelineso95 or 97oDefine the 95 detailed examo Is ldquonon contributoryrdquo allowedo2 out of 3 key components (Is MDM required) Coding Guidelines Other Risk AreasoMedical Necessityo Teaching Physician Guidelineso Incident To o SplitSharedoCopy amp PasteCloned noteso Scribeso SignatureAuthenticationsoOrders for diagnostic servicesoDate of ServiceoNew versus Established CodesoConsultations Audit Reports Goals of the Audit Report The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a recommendation Prioritize High Risk Findings Who will be reading the Audit Report What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team) Audit Report Format Tips Provide perspective for the readero Positive and Negative findings Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined Benefits of Automating your Audit Reports Results o Consistent Resultso Better Datao Increases Efficiency Trackingo Allows audit results to be tracked by provider and by specialty QAo Allows for an automated approach to your internal quality reviews Trendingo Allows for data analysis at a detailed level that can be tracked Productivityo Increases auditor productivityo Decreases re-work ProviderCoder Audit Reports Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date Detailed results for each encounteroMeaningful comments Key Findingso From all encounters Recommendations and Resources Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description 1 001 Patient A 02-19-16 Blue Cross 99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported 1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture 1 S92355D2 W109XXD 1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed 2 002 Patient B 02-05-16 Blue Cross 99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported Detailed Findings 135 822012 New Consultations - Office Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged Chart Level Comments Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM oReportsAudit Manager Macros 061218 (version 1)xlsx Recommendations and ReferencesCategory Short Description Long Description EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM ConsultationReview the consultation guidelines located in the CPT book EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a- preventive-service-with-a-sick-visit EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation) EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf EMEM Time billing suggestion Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EMConsultation Documentation Suggestion Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 - wRVU Comp Original Audited Change Total wRVU Value 523 429 -18 Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20 Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0 Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0 Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

Sample Selection Methodology

Sample selection reportsoUtilization reports

ndash Specified Date Range of Servicesndash Providerndash Patient IDndash DOSndash CPT ICD-10 and Modifiers

Sample selection can be done with only CPT but all the codes gives you a better picture ndash Include the payer if you want your sample to be specific to certain payersndash Include the site of service if you want the audit results to identify each site

o You will want this in excel so you can do lots of filtering and sorting

Sample Selection Methodology Turn your filters on Sort by

o Provider (unless you run a separate report for each provider)o CPT code

ndash If you did not do an bell curve analysis prior you can review the volume of each E amp M level here

ndash Determine what types of services (outpatient inpatient EM Surgery etc)ndash How many of each level of service (depends on the providers EM utilization patterns)

o Resort by Patientndash This will allow you to see all services performed for each DOSndash Helps to capture encounters that have both EM amp Procedures Preventive with EM etc

o Pay attention to the Modifiersndash Do you want to include resident documentation Look for GC or GEndash Do you want to include EM with procedure Look for 25

ndash ReportsSample Selectionxlsx

Scoring Methodology

Scoring Methodology

Establish an Accuracy Rateo The OIG recommends that physicians maintain an accuracy rate of 95

ndash Net Error Rate

o Is it realistic to establish a 95 accuracy rate for the providers

Scoring Examples (automated)

Total Visits Accurately Coded Under CodedBilled Over CodedBilled(+) Wrong Category (WC) Gross Financial Error ()

62 20 3226 4 645 13 2097 29 4677 4203

$123000 $14694 $37000 Provider RVUs User RVUs Points

0 129 5772 6200 (931)

EM Coding Total Sample Size 4 codes EM Detailed Review Total Sample Size 4 codes

Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

CPTreg HCPCS II Coding Total Sample Size 0 codes

Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0

Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0

ICD-CM Coding Total Sample Size 5 codes RVU Comparison

Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20

wRVU Comp Original Audited Change Total wRVU Value 523 429 -18

Dollar Comparison Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 -

EM Coding Total Sample Size 4 codes		EM Detailed Review Total Sample Size 4 codes
CPTreg HCPCS II Coding Total Sample Size 0 codes ICD-CM Coding Total Sample Size 5 codes RVU Comparison Dollar Comparison Scoring Methodology Evaluation amp Management 7 points if correct5 points if off by one level 0 points if wrong category or if off by 2 or more levels or if not coded Procedure(s) 7 points if correct4 points if units incorrect0 points if not correct CPT HCPCS 7 points if correct4 points if units incorrect0 points if not correct ICD-10-CM 3 points if correct2 points if the primary is correct but not the others1 point if the secondary is correct but not the primary Modifier(s) -1 if not correct or if missing Your scoring methodology is an essential component of your audit reports The scoring methodology should be defined in the Executive Summary Report In-Patient DRG Scoring Example Ttl DRG 10 Ttl Assign 12 DRG Accuracy Ttl Chg 3 I-10 Px Accuracy Ttl Chg 1 Accu 70 Ttl Code 13 Accu 92 Ttl Assign 159 Total Cht 10Coding AccuracyTtl Chng 16Disposition Acc Ttl Chg 0 Ttl Code 175 Accu 100 Accu 91 Ttl Assign 137 Total Cht 137Dx Accuracy Ttl Chg 12POA Accuracy Ttl Chg 0 Ttl Code 149 Accu 100 Accu 92 Coding Guidelines Coding Guidelines Standardized Coding Guidelines is criticaloCPT Guidelineso ICD-10 GuidelinesoCMS Guidelines ndash Follow your Medicare Carriers GuidelinesoCCI GuidelinesEditsoMedicaidMedi-Cal Guidelineso Internal Guidelines that define ndash Gray areas of codingndash Payer specific guidelines Coding Guidelines E amp M Guidelineso95 or 97oDefine the 95 detailed examo Is ldquonon contributoryrdquo allowedo2 out of 3 key components (Is MDM required) Coding Guidelines Other Risk AreasoMedical Necessityo Teaching Physician Guidelineso Incident To o SplitSharedoCopy amp PasteCloned noteso Scribeso SignatureAuthenticationsoOrders for diagnostic servicesoDate of ServiceoNew versus Established CodesoConsultations Audit Reports Goals of the Audit Report The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a recommendation Prioritize High Risk Findings Who will be reading the Audit Report What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team) Audit Report Format Tips Provide perspective for the readero Positive and Negative findings Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined Benefits of Automating your Audit Reports Results o Consistent Resultso Better Datao Increases Efficiency Trackingo Allows audit results to be tracked by provider and by specialty QAo Allows for an automated approach to your internal quality reviews Trendingo Allows for data analysis at a detailed level that can be tracked Productivityo Increases auditor productivityo Decreases re-work ProviderCoder Audit Reports Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date Detailed results for each encounteroMeaningful comments Key Findingso From all encounters Recommendations and Resources Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description 1 001 Patient A 02-19-16 Blue Cross 99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported 1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture 1 S92355D2 W109XXD 1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed 2 002 Patient B 02-05-16 Blue Cross 99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported Detailed Findings 135 822012 New Consultations - Office Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged Chart Level Comments Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM oReportsAudit Manager Macros 061218 (version 1)xlsx Recommendations and ReferencesCategory Short Description Long Description EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM ConsultationReview the consultation guidelines located in the CPT book EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a- preventive-service-with-a-sick-visit EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation) EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf EMEM Time billing suggestion Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EMConsultation Documentation Suggestion Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 - wRVU Comp Original Audited Change Total wRVU Value 523 429 -18 Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20 Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0 Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0 Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

Sample Selection Methodology Turn your filters on Sort by

o Provider (unless you run a separate report for each provider)o CPT code

ndash If you did not do an bell curve analysis prior you can review the volume of each E amp M level here

ndash Determine what types of services (outpatient inpatient EM Surgery etc)ndash How many of each level of service (depends on the providers EM utilization patterns)

o Resort by Patientndash This will allow you to see all services performed for each DOSndash Helps to capture encounters that have both EM amp Procedures Preventive with EM etc

o Pay attention to the Modifiersndash Do you want to include resident documentation Look for GC or GEndash Do you want to include EM with procedure Look for 25

ndash ReportsSample Selectionxlsx

Scoring Methodology

Scoring Methodology

Establish an Accuracy Rateo The OIG recommends that physicians maintain an accuracy rate of 95

ndash Net Error Rate

o Is it realistic to establish a 95 accuracy rate for the providers

Scoring Examples (automated)

Total Visits Accurately Coded Under CodedBilled Over CodedBilled(+) Wrong Category (WC) Gross Financial Error ()

62 20 3226 4 645 13 2097 29 4677 4203

$123000 $14694 $37000 Provider RVUs User RVUs Points

0 129 5772 6200 (931)

EM Coding Total Sample Size 4 codes EM Detailed Review Total Sample Size 4 codes

Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

CPTreg HCPCS II Coding Total Sample Size 0 codes

Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0

Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0

ICD-CM Coding Total Sample Size 5 codes RVU Comparison

Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20

wRVU Comp Original Audited Change Total wRVU Value 523 429 -18

Dollar Comparison Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 -

EM Coding Total Sample Size 4 codes		EM Detailed Review Total Sample Size 4 codes
CPTreg HCPCS II Coding Total Sample Size 0 codes ICD-CM Coding Total Sample Size 5 codes RVU Comparison Dollar Comparison Scoring Methodology Evaluation amp Management 7 points if correct5 points if off by one level 0 points if wrong category or if off by 2 or more levels or if not coded Procedure(s) 7 points if correct4 points if units incorrect0 points if not correct CPT HCPCS 7 points if correct4 points if units incorrect0 points if not correct ICD-10-CM 3 points if correct2 points if the primary is correct but not the others1 point if the secondary is correct but not the primary Modifier(s) -1 if not correct or if missing Your scoring methodology is an essential component of your audit reports The scoring methodology should be defined in the Executive Summary Report In-Patient DRG Scoring Example Ttl DRG 10 Ttl Assign 12 DRG Accuracy Ttl Chg 3 I-10 Px Accuracy Ttl Chg 1 Accu 70 Ttl Code 13 Accu 92 Ttl Assign 159 Total Cht 10Coding AccuracyTtl Chng 16Disposition Acc Ttl Chg 0 Ttl Code 175 Accu 100 Accu 91 Ttl Assign 137 Total Cht 137Dx Accuracy Ttl Chg 12POA Accuracy Ttl Chg 0 Ttl Code 149 Accu 100 Accu 92 Coding Guidelines Coding Guidelines Standardized Coding Guidelines is criticaloCPT Guidelineso ICD-10 GuidelinesoCMS Guidelines ndash Follow your Medicare Carriers GuidelinesoCCI GuidelinesEditsoMedicaidMedi-Cal Guidelineso Internal Guidelines that define ndash Gray areas of codingndash Payer specific guidelines Coding Guidelines E amp M Guidelineso95 or 97oDefine the 95 detailed examo Is ldquonon contributoryrdquo allowedo2 out of 3 key components (Is MDM required) Coding Guidelines Other Risk AreasoMedical Necessityo Teaching Physician Guidelineso Incident To o SplitSharedoCopy amp PasteCloned noteso Scribeso SignatureAuthenticationsoOrders for diagnostic servicesoDate of ServiceoNew versus Established CodesoConsultations Audit Reports Goals of the Audit Report The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a recommendation Prioritize High Risk Findings Who will be reading the Audit Report What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team) Audit Report Format Tips Provide perspective for the readero Positive and Negative findings Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined Benefits of Automating your Audit Reports Results o Consistent Resultso Better Datao Increases Efficiency Trackingo Allows audit results to be tracked by provider and by specialty QAo Allows for an automated approach to your internal quality reviews Trendingo Allows for data analysis at a detailed level that can be tracked Productivityo Increases auditor productivityo Decreases re-work ProviderCoder Audit Reports Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date Detailed results for each encounteroMeaningful comments Key Findingso From all encounters Recommendations and Resources Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description 1 001 Patient A 02-19-16 Blue Cross 99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported 1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture 1 S92355D2 W109XXD 1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed 2 002 Patient B 02-05-16 Blue Cross 99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported Detailed Findings 135 822012 New Consultations - Office Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged Chart Level Comments Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM oReportsAudit Manager Macros 061218 (version 1)xlsx Recommendations and ReferencesCategory Short Description Long Description EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM ConsultationReview the consultation guidelines located in the CPT book EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a- preventive-service-with-a-sick-visit EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation) EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf EMEM Time billing suggestion Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EMConsultation Documentation Suggestion Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 - wRVU Comp Original Audited Change Total wRVU Value 523 429 -18 Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20 Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0 Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0 Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

Scoring Methodology

Scoring Methodology

Establish an Accuracy Rateo The OIG recommends that physicians maintain an accuracy rate of 95

ndash Net Error Rate

o Is it realistic to establish a 95 accuracy rate for the providers

Scoring Examples (automated)

Total Visits Accurately Coded Under CodedBilled Over CodedBilled(+) Wrong Category (WC) Gross Financial Error ()

62 20 3226 4 645 13 2097 29 4677 4203

$123000 $14694 $37000 Provider RVUs User RVUs Points

0 129 5772 6200 (931)

EM Coding Total Sample Size 4 codes EM Detailed Review Total Sample Size 4 codes

Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

CPTreg HCPCS II Coding Total Sample Size 0 codes

Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0

Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0

ICD-CM Coding Total Sample Size 5 codes RVU Comparison

Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20

wRVU Comp Original Audited Change Total wRVU Value 523 429 -18

Dollar Comparison Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 -

EM Coding Total Sample Size 4 codes		EM Detailed Review Total Sample Size 4 codes
CPTreg HCPCS II Coding Total Sample Size 0 codes ICD-CM Coding Total Sample Size 5 codes RVU Comparison Dollar Comparison Scoring Methodology Evaluation amp Management 7 points if correct5 points if off by one level 0 points if wrong category or if off by 2 or more levels or if not coded Procedure(s) 7 points if correct4 points if units incorrect0 points if not correct CPT HCPCS 7 points if correct4 points if units incorrect0 points if not correct ICD-10-CM 3 points if correct2 points if the primary is correct but not the others1 point if the secondary is correct but not the primary Modifier(s) -1 if not correct or if missing Your scoring methodology is an essential component of your audit reports The scoring methodology should be defined in the Executive Summary Report In-Patient DRG Scoring Example Ttl DRG 10 Ttl Assign 12 DRG Accuracy Ttl Chg 3 I-10 Px Accuracy Ttl Chg 1 Accu 70 Ttl Code 13 Accu 92 Ttl Assign 159 Total Cht 10Coding AccuracyTtl Chng 16Disposition Acc Ttl Chg 0 Ttl Code 175 Accu 100 Accu 91 Ttl Assign 137 Total Cht 137Dx Accuracy Ttl Chg 12POA Accuracy Ttl Chg 0 Ttl Code 149 Accu 100 Accu 92 Coding Guidelines Coding Guidelines Standardized Coding Guidelines is criticaloCPT Guidelineso ICD-10 GuidelinesoCMS Guidelines ndash Follow your Medicare Carriers GuidelinesoCCI GuidelinesEditsoMedicaidMedi-Cal Guidelineso Internal Guidelines that define ndash Gray areas of codingndash Payer specific guidelines Coding Guidelines E amp M Guidelineso95 or 97oDefine the 95 detailed examo Is ldquonon contributoryrdquo allowedo2 out of 3 key components (Is MDM required) Coding Guidelines Other Risk AreasoMedical Necessityo Teaching Physician Guidelineso Incident To o SplitSharedoCopy amp PasteCloned noteso Scribeso SignatureAuthenticationsoOrders for diagnostic servicesoDate of ServiceoNew versus Established CodesoConsultations Audit Reports Goals of the Audit Report The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a recommendation Prioritize High Risk Findings Who will be reading the Audit Report What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team) Audit Report Format Tips Provide perspective for the readero Positive and Negative findings Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined Benefits of Automating your Audit Reports Results o Consistent Resultso Better Datao Increases Efficiency Trackingo Allows audit results to be tracked by provider and by specialty QAo Allows for an automated approach to your internal quality reviews Trendingo Allows for data analysis at a detailed level that can be tracked Productivityo Increases auditor productivityo Decreases re-work ProviderCoder Audit Reports Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date Detailed results for each encounteroMeaningful comments Key Findingso From all encounters Recommendations and Resources Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description 1 001 Patient A 02-19-16 Blue Cross 99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported 1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture 1 S92355D2 W109XXD 1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed 2 002 Patient B 02-05-16 Blue Cross 99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported Detailed Findings 135 822012 New Consultations - Office Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged Chart Level Comments Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM oReportsAudit Manager Macros 061218 (version 1)xlsx Recommendations and ReferencesCategory Short Description Long Description EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM ConsultationReview the consultation guidelines located in the CPT book EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a- preventive-service-with-a-sick-visit EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation) EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf EMEM Time billing suggestion Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EMConsultation Documentation Suggestion Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 - wRVU Comp Original Audited Change Total wRVU Value 523 429 -18 Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20 Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0 Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0 Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

Scoring Methodology

Establish an Accuracy Rateo The OIG recommends that physicians maintain an accuracy rate of 95

ndash Net Error Rate

o Is it realistic to establish a 95 accuracy rate for the providers

Scoring Examples (automated)

Total Visits Accurately Coded Under CodedBilled Over CodedBilled(+) Wrong Category (WC) Gross Financial Error ()

62 20 3226 4 645 13 2097 29 4677 4203

$123000 $14694 $37000 Provider RVUs User RVUs Points

0 129 5772 6200 (931)

EM Coding Total Sample Size 4 codes EM Detailed Review Total Sample Size 4 codes

Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

CPTreg HCPCS II Coding Total Sample Size 0 codes

Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0

Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0

ICD-CM Coding Total Sample Size 5 codes RVU Comparison

Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20

wRVU Comp Original Audited Change Total wRVU Value 523 429 -18

Dollar Comparison Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 -

EM Coding Total Sample Size 4 codes		EM Detailed Review Total Sample Size 4 codes
CPTreg HCPCS II Coding Total Sample Size 0 codes ICD-CM Coding Total Sample Size 5 codes RVU Comparison Dollar Comparison Scoring Methodology Evaluation amp Management 7 points if correct5 points if off by one level 0 points if wrong category or if off by 2 or more levels or if not coded Procedure(s) 7 points if correct4 points if units incorrect0 points if not correct CPT HCPCS 7 points if correct4 points if units incorrect0 points if not correct ICD-10-CM 3 points if correct2 points if the primary is correct but not the others1 point if the secondary is correct but not the primary Modifier(s) -1 if not correct or if missing Your scoring methodology is an essential component of your audit reports The scoring methodology should be defined in the Executive Summary Report In-Patient DRG Scoring Example Ttl DRG 10 Ttl Assign 12 DRG Accuracy Ttl Chg 3 I-10 Px Accuracy Ttl Chg 1 Accu 70 Ttl Code 13 Accu 92 Ttl Assign 159 Total Cht 10Coding AccuracyTtl Chng 16Disposition Acc Ttl Chg 0 Ttl Code 175 Accu 100 Accu 91 Ttl Assign 137 Total Cht 137Dx Accuracy Ttl Chg 12POA Accuracy Ttl Chg 0 Ttl Code 149 Accu 100 Accu 92 Coding Guidelines Coding Guidelines Standardized Coding Guidelines is criticaloCPT Guidelineso ICD-10 GuidelinesoCMS Guidelines ndash Follow your Medicare Carriers GuidelinesoCCI GuidelinesEditsoMedicaidMedi-Cal Guidelineso Internal Guidelines that define ndash Gray areas of codingndash Payer specific guidelines Coding Guidelines E amp M Guidelineso95 or 97oDefine the 95 detailed examo Is ldquonon contributoryrdquo allowedo2 out of 3 key components (Is MDM required) Coding Guidelines Other Risk AreasoMedical Necessityo Teaching Physician Guidelineso Incident To o SplitSharedoCopy amp PasteCloned noteso Scribeso SignatureAuthenticationsoOrders for diagnostic servicesoDate of ServiceoNew versus Established CodesoConsultations Audit Reports Goals of the Audit Report The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a recommendation Prioritize High Risk Findings Who will be reading the Audit Report What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team) Audit Report Format Tips Provide perspective for the readero Positive and Negative findings Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined Benefits of Automating your Audit Reports Results o Consistent Resultso Better Datao Increases Efficiency Trackingo Allows audit results to be tracked by provider and by specialty QAo Allows for an automated approach to your internal quality reviews Trendingo Allows for data analysis at a detailed level that can be tracked Productivityo Increases auditor productivityo Decreases re-work ProviderCoder Audit Reports Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date Detailed results for each encounteroMeaningful comments Key Findingso From all encounters Recommendations and Resources Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description 1 001 Patient A 02-19-16 Blue Cross 99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported 1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture 1 S92355D2 W109XXD 1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed 2 002 Patient B 02-05-16 Blue Cross 99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported Detailed Findings 135 822012 New Consultations - Office Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged Chart Level Comments Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM oReportsAudit Manager Macros 061218 (version 1)xlsx Recommendations and ReferencesCategory Short Description Long Description EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM ConsultationReview the consultation guidelines located in the CPT book EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a- preventive-service-with-a-sick-visit EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation) EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf EMEM Time billing suggestion Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EMConsultation Documentation Suggestion Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 - wRVU Comp Original Audited Change Total wRVU Value 523 429 -18 Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20 Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0 Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0 Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

Scoring Examples (automated)

Total Visits Accurately Coded Under CodedBilled Over CodedBilled(+) Wrong Category (WC) Gross Financial Error ()

62 20 3226 4 645 13 2097 29 4677 4203

$123000 $14694 $37000 Provider RVUs User RVUs Points

0 129 5772 6200 (931)

EM Coding Total Sample Size 4 codes EM Detailed Review Total Sample Size 4 codes

Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

CPTreg HCPCS II Coding Total Sample Size 0 codes

Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0

Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0

ICD-CM Coding Total Sample Size 5 codes RVU Comparison

Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20

wRVU Comp Original Audited Change Total wRVU Value 523 429 -18

Dollar Comparison Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 -

EM Coding Total Sample Size 4 codes		EM Detailed Review Total Sample Size 4 codes
CPTreg HCPCS II Coding Total Sample Size 0 codes ICD-CM Coding Total Sample Size 5 codes RVU Comparison Dollar Comparison Scoring Methodology Evaluation amp Management 7 points if correct5 points if off by one level 0 points if wrong category or if off by 2 or more levels or if not coded Procedure(s) 7 points if correct4 points if units incorrect0 points if not correct CPT HCPCS 7 points if correct4 points if units incorrect0 points if not correct ICD-10-CM 3 points if correct2 points if the primary is correct but not the others1 point if the secondary is correct but not the primary Modifier(s) -1 if not correct or if missing Your scoring methodology is an essential component of your audit reports The scoring methodology should be defined in the Executive Summary Report In-Patient DRG Scoring Example Ttl DRG 10 Ttl Assign 12 DRG Accuracy Ttl Chg 3 I-10 Px Accuracy Ttl Chg 1 Accu 70 Ttl Code 13 Accu 92 Ttl Assign 159 Total Cht 10Coding AccuracyTtl Chng 16Disposition Acc Ttl Chg 0 Ttl Code 175 Accu 100 Accu 91 Ttl Assign 137 Total Cht 137Dx Accuracy Ttl Chg 12POA Accuracy Ttl Chg 0 Ttl Code 149 Accu 100 Accu 92 Coding Guidelines Coding Guidelines Standardized Coding Guidelines is criticaloCPT Guidelineso ICD-10 GuidelinesoCMS Guidelines ndash Follow your Medicare Carriers GuidelinesoCCI GuidelinesEditsoMedicaidMedi-Cal Guidelineso Internal Guidelines that define ndash Gray areas of codingndash Payer specific guidelines Coding Guidelines E amp M Guidelineso95 or 97oDefine the 95 detailed examo Is ldquonon contributoryrdquo allowedo2 out of 3 key components (Is MDM required) Coding Guidelines Other Risk AreasoMedical Necessityo Teaching Physician Guidelineso Incident To o SplitSharedoCopy amp PasteCloned noteso Scribeso SignatureAuthenticationsoOrders for diagnostic servicesoDate of ServiceoNew versus Established CodesoConsultations Audit Reports Goals of the Audit Report The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a recommendation Prioritize High Risk Findings Who will be reading the Audit Report What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team) Audit Report Format Tips Provide perspective for the readero Positive and Negative findings Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined Benefits of Automating your Audit Reports Results o Consistent Resultso Better Datao Increases Efficiency Trackingo Allows audit results to be tracked by provider and by specialty QAo Allows for an automated approach to your internal quality reviews Trendingo Allows for data analysis at a detailed level that can be tracked Productivityo Increases auditor productivityo Decreases re-work ProviderCoder Audit Reports Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date Detailed results for each encounteroMeaningful comments Key Findingso From all encounters Recommendations and Resources Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description 1 001 Patient A 02-19-16 Blue Cross 99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported 1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture 1 S92355D2 W109XXD 1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed 2 002 Patient B 02-05-16 Blue Cross 99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe 1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported Detailed Findings 135 822012 New Consultations - Office Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged Chart Level Comments Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM oReportsAudit Manager Macros 061218 (version 1)xlsx Recommendations and ReferencesCategory Short Description Long Description EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM ConsultationReview the consultation guidelines located in the CPT book EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a- preventive-service-with-a-sick-visit EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation) EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf EMEM Time billing suggestion Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml EMConsultation Documentation Suggestion Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation Total Dollar Comp Original Audited Change Total Dollar Value $ 0 $ 0 - wRVU Comp Original Audited Change Total wRVU Value 523 429 -18 Findings Count Code(s) appear to be correct 3 60 Code(s) appear to be incorrect 1 20 Additional code(s) supported 1 20 Findings Count Over coded by 1 level 3 75 Over coded by 2 levels 0 0 Over coded by 3 levels 0 0 Over coded by 4 levels 0 0 Under coded by 1 level 1 25 Under coded by 2 levels 0 0 Under coded by 3 levels 0 0 Under coded by 4 levels 0 0 Number of category changes 0 0 Findings Count Code(s) appear to be correct 0 0 Code(s) appear to be incorrect 0 0 Additional code(s) supported 0 0 Findings Count EM Level appears to be correct 0 0 EM Level appears to be over-coded 3 75 EM Level appears to be under-coded 1 25

Scoring Methodology

Evaluation amp Management

7 points if correct5 points if off by one level

0 points if wrong category or if off by 2 or more levels or if not coded

Procedure(s) 7 points if correct4 points if units incorrect0 points if not correct

CPT HCPCS 7 points if correct4 points if units incorrect0 points if not correct

ICD-10-CM 3 points if correct2 points if the primary is correct but not the others1 point if the secondary is correct but not the primary

Modifier(s) -1 if not correct or if missing

Your scoring methodology is an essential component of your audit reports The scoring methodology should

be defined in the Executive Summary Report

In-Patient DRG Scoring Example

Ttl DRG 10 Ttl Assign 12

DRG Accuracy Ttl Chg 3 I-10 Px Accuracy Ttl Chg 1

Accu 70 Ttl Code 13 Accu 92

Ttl Assign 159 Total Cht 10Coding

AccuracyTtl

Chng 16Disposition Acc Ttl Chg 0

Ttl Code 175 Accu 100

Accu 91

Ttl Assign 137 Total Cht 137Dx

Accuracy Ttl Chg 12POA Accuracy Ttl Chg 0

Ttl Code 149 Accu 100

Accu 92

Coding Guidelines

Coding Guidelines

Standardized Coding Guidelines is criticaloCPT Guidelineso ICD-10 GuidelinesoCMS Guidelines

ndash Follow your Medicare Carriers GuidelinesoCCI GuidelinesEditsoMedicaidMedi-Cal Guidelineso Internal Guidelines that define

ndash Gray areas of codingndash Payer specific guidelines

Coding Guidelines

E amp M Guidelineso95 or 97oDefine the 95 detailed examo Is ldquonon contributoryrdquo allowedo2 out of 3 key components (Is MDM required)

Coding Guidelines

Other Risk AreasoMedical Necessityo Teaching Physician Guidelineso Incident To o SplitSharedoCopy amp PasteCloned noteso Scribeso SignatureAuthenticationsoOrders for diagnostic servicesoDate of ServiceoNew versus Established CodesoConsultations

Audit Reports

Goals of the Audit Report

The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation

Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a

recommendation Prioritize High Risk Findings

Who will be reading the Audit Report

What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team)

Audit Report Format Tips

Provide perspective for the readero Positive and Negative findings

Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it

clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined

Benefits of Automating your Audit Reports Results

o Consistent Resultso Better Datao Increases Efficiency

Trackingo Allows audit results to be tracked by provider and by specialty

QAo Allows for an automated approach to your internal quality reviews

Trendingo Allows for data analysis at a detailed level that can be tracked

Productivityo Increases auditor productivityo Decreases re-work

ProviderCoder Audit Reports

Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date

Detailed results for each encounteroMeaningful comments

Key Findingso From all encounters

Recommendations and Resources

Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description

1 001 Patient A 02-19-16 Blue Cross

99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported

1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture

1 S92355D2 W109XXD

1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter

1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if

not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient

was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed

2 002 Patient B 02-05-16 Blue Cross

99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe

1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be

carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported

Detailed Findings

135 822012 New Consultations - Office

Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N

Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC

bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note

bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged

Chart Level Comments

Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM

oReportsAudit Manager Macros 061218 (version 1)xlsx

Recommendations and ReferencesCategory Short Description Long Description

EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM ConsultationReview the consultation guidelines located in the CPT book

EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf

EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf

EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf

EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a-

preventive-service-with-a-sick-visit

EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation)

EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf

EMEM Time billing suggestion

Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf

EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements

httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EMConsultation Documentation Suggestion

Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation

In-Patient DRG Scoring Example

Ttl DRG 10 Ttl Assign 12

DRG Accuracy Ttl Chg 3 I-10 Px Accuracy Ttl Chg 1

Accu 70 Ttl Code 13 Accu 92

Ttl Assign 159 Total Cht 10Coding

AccuracyTtl

Chng 16Disposition Acc Ttl Chg 0

Ttl Code 175 Accu 100

Accu 91

Ttl Assign 137 Total Cht 137Dx

Accuracy Ttl Chg 12POA Accuracy Ttl Chg 0

Ttl Code 149 Accu 100

Accu 92

Coding Guidelines

Coding Guidelines

Standardized Coding Guidelines is criticaloCPT Guidelineso ICD-10 GuidelinesoCMS Guidelines

ndash Follow your Medicare Carriers GuidelinesoCCI GuidelinesEditsoMedicaidMedi-Cal Guidelineso Internal Guidelines that define

ndash Gray areas of codingndash Payer specific guidelines

Coding Guidelines

E amp M Guidelineso95 or 97oDefine the 95 detailed examo Is ldquonon contributoryrdquo allowedo2 out of 3 key components (Is MDM required)

Coding Guidelines

Other Risk AreasoMedical Necessityo Teaching Physician Guidelineso Incident To o SplitSharedoCopy amp PasteCloned noteso Scribeso SignatureAuthenticationsoOrders for diagnostic servicesoDate of ServiceoNew versus Established CodesoConsultations

Audit Reports

Goals of the Audit Report

The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation

Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a

recommendation Prioritize High Risk Findings

Who will be reading the Audit Report

What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team)

Audit Report Format Tips

Provide perspective for the readero Positive and Negative findings

Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it

clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined

Benefits of Automating your Audit Reports Results

o Consistent Resultso Better Datao Increases Efficiency

Trackingo Allows audit results to be tracked by provider and by specialty

QAo Allows for an automated approach to your internal quality reviews

Trendingo Allows for data analysis at a detailed level that can be tracked

Productivityo Increases auditor productivityo Decreases re-work

ProviderCoder Audit Reports

Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date

Detailed results for each encounteroMeaningful comments

Key Findingso From all encounters

Recommendations and Resources

Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description

1 001 Patient A 02-19-16 Blue Cross

99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported

1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture

1 S92355D2 W109XXD

1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter

1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if

not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient

was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed

2 002 Patient B 02-05-16 Blue Cross

99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe

1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be

carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported

Detailed Findings

135 822012 New Consultations - Office

Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N

Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC

bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note

bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged

Chart Level Comments

Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM

oReportsAudit Manager Macros 061218 (version 1)xlsx

Recommendations and ReferencesCategory Short Description Long Description

EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM ConsultationReview the consultation guidelines located in the CPT book

EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf

EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf

EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf

EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a-

preventive-service-with-a-sick-visit

EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation)

EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf

EMEM Time billing suggestion

Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf

EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements

httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EMConsultation Documentation Suggestion

Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation

Coding Guidelines

Coding Guidelines

Standardized Coding Guidelines is criticaloCPT Guidelineso ICD-10 GuidelinesoCMS Guidelines

ndash Follow your Medicare Carriers GuidelinesoCCI GuidelinesEditsoMedicaidMedi-Cal Guidelineso Internal Guidelines that define

ndash Gray areas of codingndash Payer specific guidelines

Coding Guidelines

E amp M Guidelineso95 or 97oDefine the 95 detailed examo Is ldquonon contributoryrdquo allowedo2 out of 3 key components (Is MDM required)

Coding Guidelines

Other Risk AreasoMedical Necessityo Teaching Physician Guidelineso Incident To o SplitSharedoCopy amp PasteCloned noteso Scribeso SignatureAuthenticationsoOrders for diagnostic servicesoDate of ServiceoNew versus Established CodesoConsultations

Audit Reports

Goals of the Audit Report

The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation

Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a

recommendation Prioritize High Risk Findings

Who will be reading the Audit Report

What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team)

Audit Report Format Tips

Provide perspective for the readero Positive and Negative findings

Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it

clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined

Benefits of Automating your Audit Reports Results

o Consistent Resultso Better Datao Increases Efficiency

Trackingo Allows audit results to be tracked by provider and by specialty

QAo Allows for an automated approach to your internal quality reviews

Trendingo Allows for data analysis at a detailed level that can be tracked

Productivityo Increases auditor productivityo Decreases re-work

ProviderCoder Audit Reports

Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date

Detailed results for each encounteroMeaningful comments

Key Findingso From all encounters

Recommendations and Resources

Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description

1 001 Patient A 02-19-16 Blue Cross

99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported

1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture

1 S92355D2 W109XXD

1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter

1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if

not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient

was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed

2 002 Patient B 02-05-16 Blue Cross

99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe

1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be

carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported

Detailed Findings

135 822012 New Consultations - Office

Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N

Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC

bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note

bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged

Chart Level Comments

Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM

oReportsAudit Manager Macros 061218 (version 1)xlsx

Recommendations and ReferencesCategory Short Description Long Description

EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM ConsultationReview the consultation guidelines located in the CPT book

EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf

EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf

EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf

EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a-

preventive-service-with-a-sick-visit

EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation)

EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf

EMEM Time billing suggestion

Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf

EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements

httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EMConsultation Documentation Suggestion

Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation

Coding Guidelines

Standardized Coding Guidelines is criticaloCPT Guidelineso ICD-10 GuidelinesoCMS Guidelines

ndash Follow your Medicare Carriers GuidelinesoCCI GuidelinesEditsoMedicaidMedi-Cal Guidelineso Internal Guidelines that define

ndash Gray areas of codingndash Payer specific guidelines

Coding Guidelines

E amp M Guidelineso95 or 97oDefine the 95 detailed examo Is ldquonon contributoryrdquo allowedo2 out of 3 key components (Is MDM required)

Coding Guidelines

Other Risk AreasoMedical Necessityo Teaching Physician Guidelineso Incident To o SplitSharedoCopy amp PasteCloned noteso Scribeso SignatureAuthenticationsoOrders for diagnostic servicesoDate of ServiceoNew versus Established CodesoConsultations

Audit Reports

Goals of the Audit Report

The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation

Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a

recommendation Prioritize High Risk Findings

Who will be reading the Audit Report

What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team)

Audit Report Format Tips

Provide perspective for the readero Positive and Negative findings

Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it

clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined

Benefits of Automating your Audit Reports Results

o Consistent Resultso Better Datao Increases Efficiency

Trackingo Allows audit results to be tracked by provider and by specialty

QAo Allows for an automated approach to your internal quality reviews

Trendingo Allows for data analysis at a detailed level that can be tracked

Productivityo Increases auditor productivityo Decreases re-work

ProviderCoder Audit Reports

Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date

Detailed results for each encounteroMeaningful comments

Key Findingso From all encounters

Recommendations and Resources

Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description

1 001 Patient A 02-19-16 Blue Cross

99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported

1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture

1 S92355D2 W109XXD

1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter

1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if

not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient

was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed

2 002 Patient B 02-05-16 Blue Cross

99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe

1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be

carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported

Detailed Findings

135 822012 New Consultations - Office

Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N

Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC

bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note

bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged

Chart Level Comments

Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM

oReportsAudit Manager Macros 061218 (version 1)xlsx

Recommendations and ReferencesCategory Short Description Long Description

EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM ConsultationReview the consultation guidelines located in the CPT book

EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf

EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf

EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf

EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a-

preventive-service-with-a-sick-visit

EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation)

EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf

EMEM Time billing suggestion

Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf

EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements

httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EMConsultation Documentation Suggestion

Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation

Coding Guidelines

E amp M Guidelineso95 or 97oDefine the 95 detailed examo Is ldquonon contributoryrdquo allowedo2 out of 3 key components (Is MDM required)

Coding Guidelines

Other Risk AreasoMedical Necessityo Teaching Physician Guidelineso Incident To o SplitSharedoCopy amp PasteCloned noteso Scribeso SignatureAuthenticationsoOrders for diagnostic servicesoDate of ServiceoNew versus Established CodesoConsultations

Audit Reports

Goals of the Audit Report

The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation

Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a

recommendation Prioritize High Risk Findings

Who will be reading the Audit Report

What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team)

Audit Report Format Tips

Provide perspective for the readero Positive and Negative findings

Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it

clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined

Benefits of Automating your Audit Reports Results

o Consistent Resultso Better Datao Increases Efficiency

Trackingo Allows audit results to be tracked by provider and by specialty

QAo Allows for an automated approach to your internal quality reviews

Trendingo Allows for data analysis at a detailed level that can be tracked

Productivityo Increases auditor productivityo Decreases re-work

ProviderCoder Audit Reports

Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date

Detailed results for each encounteroMeaningful comments

Key Findingso From all encounters

Recommendations and Resources

Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description

1 001 Patient A 02-19-16 Blue Cross

99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported

1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture

1 S92355D2 W109XXD

1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter

1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if

not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient

was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed

2 002 Patient B 02-05-16 Blue Cross

99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe

1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be

carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported

Detailed Findings

135 822012 New Consultations - Office

Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N

Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC

bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note

bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged

Chart Level Comments

Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM

oReportsAudit Manager Macros 061218 (version 1)xlsx

Recommendations and ReferencesCategory Short Description Long Description

EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM ConsultationReview the consultation guidelines located in the CPT book

EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf

EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf

EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf

EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a-

preventive-service-with-a-sick-visit

EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation)

EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf

EMEM Time billing suggestion

Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf

EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements

httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EMConsultation Documentation Suggestion

Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation

Coding Guidelines

Other Risk AreasoMedical Necessityo Teaching Physician Guidelineso Incident To o SplitSharedoCopy amp PasteCloned noteso Scribeso SignatureAuthenticationsoOrders for diagnostic servicesoDate of ServiceoNew versus Established CodesoConsultations

Audit Reports

Goals of the Audit Report

The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation

Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a

recommendation Prioritize High Risk Findings

Who will be reading the Audit Report

What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team)

Audit Report Format Tips

Provide perspective for the readero Positive and Negative findings

Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it

clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined

Benefits of Automating your Audit Reports Results

o Consistent Resultso Better Datao Increases Efficiency

Trackingo Allows audit results to be tracked by provider and by specialty

QAo Allows for an automated approach to your internal quality reviews

Trendingo Allows for data analysis at a detailed level that can be tracked

Productivityo Increases auditor productivityo Decreases re-work

ProviderCoder Audit Reports

Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date

Detailed results for each encounteroMeaningful comments

Key Findingso From all encounters

Recommendations and Resources

Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description

1 001 Patient A 02-19-16 Blue Cross

99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported

1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture

1 S92355D2 W109XXD

1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter

1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if

not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient

was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed

2 002 Patient B 02-05-16 Blue Cross

99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe

1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be

carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported

Detailed Findings

135 822012 New Consultations - Office

Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N

Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC

bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note

bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged

Chart Level Comments

Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM

oReportsAudit Manager Macros 061218 (version 1)xlsx

Recommendations and ReferencesCategory Short Description Long Description

EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM ConsultationReview the consultation guidelines located in the CPT book

EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf

EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf

EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf

EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a-

preventive-service-with-a-sick-visit

EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation)

EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf

EMEM Time billing suggestion

Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf

EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements

httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EMConsultation Documentation Suggestion

Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation

Audit Reports

Goals of the Audit Report

The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation

Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a

recommendation Prioritize High Risk Findings

Who will be reading the Audit Report

What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team)

Audit Report Format Tips

Provide perspective for the readero Positive and Negative findings

Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it

clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined

Benefits of Automating your Audit Reports Results

o Consistent Resultso Better Datao Increases Efficiency

Trackingo Allows audit results to be tracked by provider and by specialty

QAo Allows for an automated approach to your internal quality reviews

Trendingo Allows for data analysis at a detailed level that can be tracked

Productivityo Increases auditor productivityo Decreases re-work

ProviderCoder Audit Reports

Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date

Detailed results for each encounteroMeaningful comments

Key Findingso From all encounters

Recommendations and Resources

Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description

1 001 Patient A 02-19-16 Blue Cross

99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported

1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture

1 S92355D2 W109XXD

1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter

1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if

not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient

was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed

2 002 Patient B 02-05-16 Blue Cross

99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe

1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be

carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported

Detailed Findings

135 822012 New Consultations - Office

Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N

Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC

bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note

bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged

Chart Level Comments

Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM

oReportsAudit Manager Macros 061218 (version 1)xlsx

Recommendations and ReferencesCategory Short Description Long Description

EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM ConsultationReview the consultation guidelines located in the CPT book

EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf

EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf

EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf

EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a-

preventive-service-with-a-sick-visit

EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation)

EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf

EMEM Time billing suggestion

Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf

EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements

httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EMConsultation Documentation Suggestion

Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation

Goals of the Audit Report

The main goal of an audit report is to communicate where the organization specialty department provider or coder does or does not conform to regulatory standards guidelines and organizational policieso Each identified issue must have a standard it is measured againsto Site the regulation in your audit report or include a link to the regulation

Audit reports should not just contain negative findings Outline the Positives also Identify opportunities for improvement this can be in the form of a

recommendation Prioritize High Risk Findings

Who will be reading the Audit Report

What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team)

Audit Report Format Tips

Provide perspective for the readero Positive and Negative findings

Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it

clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined

Benefits of Automating your Audit Reports Results

o Consistent Resultso Better Datao Increases Efficiency

Trackingo Allows audit results to be tracked by provider and by specialty

QAo Allows for an automated approach to your internal quality reviews

Trendingo Allows for data analysis at a detailed level that can be tracked

Productivityo Increases auditor productivityo Decreases re-work

ProviderCoder Audit Reports

Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date

Detailed results for each encounteroMeaningful comments

Key Findingso From all encounters

Recommendations and Resources

Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description

1 001 Patient A 02-19-16 Blue Cross

99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported

1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture

1 S92355D2 W109XXD

1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter

1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if

not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient

was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed

2 002 Patient B 02-05-16 Blue Cross

99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe

1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be

carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported

Detailed Findings

135 822012 New Consultations - Office

Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N

Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC

bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note

bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged

Chart Level Comments

Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM

oReportsAudit Manager Macros 061218 (version 1)xlsx

Recommendations and ReferencesCategory Short Description Long Description

EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM ConsultationReview the consultation guidelines located in the CPT book

EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf

EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf

EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf

EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a-

preventive-service-with-a-sick-visit

EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation)

EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf

EMEM Time billing suggestion

Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf

EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements

httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EMConsultation Documentation Suggestion

Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation

Who will be reading the Audit Report

What is the technical knowledge of the readeroCodersHIM ProfessionalsoProvidersoClinical StaffoHIM DirectorsoBillingCoding DirectorsManagersoCEOCFO (Executive Team)

Audit Report Format Tips

Provide perspective for the readero Positive and Negative findings

Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it

clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined

Benefits of Automating your Audit Reports Results

o Consistent Resultso Better Datao Increases Efficiency

Trackingo Allows audit results to be tracked by provider and by specialty

QAo Allows for an automated approach to your internal quality reviews

Trendingo Allows for data analysis at a detailed level that can be tracked

Productivityo Increases auditor productivityo Decreases re-work

ProviderCoder Audit Reports

Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date

Detailed results for each encounteroMeaningful comments

Key Findingso From all encounters

Recommendations and Resources

Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description

1 001 Patient A 02-19-16 Blue Cross

99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported

1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture

1 S92355D2 W109XXD

1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter

1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if

not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient

was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed

2 002 Patient B 02-05-16 Blue Cross

99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe

1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be

carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported

Detailed Findings

135 822012 New Consultations - Office

Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N

Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC

bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note

bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged

Chart Level Comments

Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM

oReportsAudit Manager Macros 061218 (version 1)xlsx

Recommendations and ReferencesCategory Short Description Long Description

EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM ConsultationReview the consultation guidelines located in the CPT book

EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf

EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf

EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf

EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a-

preventive-service-with-a-sick-visit

EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation)

EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf

EMEM Time billing suggestion

Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf

EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements

httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EMConsultation Documentation Suggestion

Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation

Audit Report Format Tips

Provide perspective for the readero Positive and Negative findings

Be precise avoid redundant phrasing inexact terminology Avoid long sentences when a shorter one will work Avoid stating your opinion State the findings and facts Use bullet points this helps to break up difficult information and makes it

clearer for the reader Use gender neutral terms Avoid audit ldquobuzzwordsrdquo such as ldquogenerally improvedrdquo or ldquosignificant riskrdquo Avoid abbreviations unless they are clearly defined

Benefits of Automating your Audit Reports Results

o Consistent Resultso Better Datao Increases Efficiency

Trackingo Allows audit results to be tracked by provider and by specialty

QAo Allows for an automated approach to your internal quality reviews

Trendingo Allows for data analysis at a detailed level that can be tracked

Productivityo Increases auditor productivityo Decreases re-work

ProviderCoder Audit Reports

Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date

Detailed results for each encounteroMeaningful comments

Key Findingso From all encounters

Recommendations and Resources

Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description

1 001 Patient A 02-19-16 Blue Cross

99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported

1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture

1 S92355D2 W109XXD

1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter

1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if

not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient

was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed

2 002 Patient B 02-05-16 Blue Cross

99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe

1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be

carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported

Detailed Findings

135 822012 New Consultations - Office

Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N

Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC

bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note

bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged

Chart Level Comments

Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM

oReportsAudit Manager Macros 061218 (version 1)xlsx

Recommendations and ReferencesCategory Short Description Long Description

EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM ConsultationReview the consultation guidelines located in the CPT book

EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf

EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf

EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf

EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a-

preventive-service-with-a-sick-visit

EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation)

EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf

EMEM Time billing suggestion

Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf

EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements

httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EMConsultation Documentation Suggestion

Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation

Benefits of Automating your Audit Reports Results

o Consistent Resultso Better Datao Increases Efficiency

Trackingo Allows audit results to be tracked by provider and by specialty

QAo Allows for an automated approach to your internal quality reviews

Trendingo Allows for data analysis at a detailed level that can be tracked

Productivityo Increases auditor productivityo Decreases re-work

ProviderCoder Audit Reports

Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date

Detailed results for each encounteroMeaningful comments

Key Findingso From all encounters

Recommendations and Resources

Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description

1 001 Patient A 02-19-16 Blue Cross

99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported

1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture

1 S92355D2 W109XXD

1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter

1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if

not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient

was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed

2 002 Patient B 02-05-16 Blue Cross

99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe

1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be

carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported

Detailed Findings

135 822012 New Consultations - Office

Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N

Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC

bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note

bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged

Chart Level Comments

Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM

oReportsAudit Manager Macros 061218 (version 1)xlsx

Recommendations and ReferencesCategory Short Description Long Description

EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM ConsultationReview the consultation guidelines located in the CPT book

EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf

EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf

EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf

EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a-

preventive-service-with-a-sick-visit

EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation)

EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf

EMEM Time billing suggestion

Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf

EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements

httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EMConsultation Documentation Suggestion

Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation

ProviderCoder Audit Reports

Detailed Audit reports should have the ability to be sorted byoProvideroCodero Specialty or GroupoAudit Date

Detailed results for each encounteroMeaningful comments

Key Findingso From all encounters

Recommendations and Resources

Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description

1 001 Patient A 02-19-16 Blue Cross

99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported

1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture

1 S92355D2 W109XXD

1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter

1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if

not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient

was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed

2 002 Patient B 02-05-16 Blue Cross

99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe

1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be

carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported

Detailed Findings

135 822012 New Consultations - Office

Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N

Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC

bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note

bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged

Chart Level Comments

Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM

oReportsAudit Manager Macros 061218 (version 1)xlsx

Recommendations and ReferencesCategory Short Description Long Description

EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM ConsultationReview the consultation guidelines located in the CPT book

EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf

EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf

EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf

EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a-

preventive-service-with-a-sick-visit

EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation)

EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf

EMEM Time billing suggestion

Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf

EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements

httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EMConsultation Documentation Suggestion

Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation

Detailed Findings Patient ID Patient Name DOS Payer CPT Reported CPT Audited EM Level Key Component ICD Reported ICD Reported Description ICD Audited ICD Reported Description

1 001 Patient A 02-19-16 Blue Cross

99203 25 1 99202 1 +1 D E L 1 S92302A2 Not Reported

1 Fracture of unspecified metatarsal bone(s) left foot initial encounter for closed fracture

1 S92355D2 W109XXD

1 Nondisplaced fracture of fifth metatarsal bone left foot subsequent encounter for fracture with routine healing2 Fall (on) (from) unspecified stairs and steps subsequent encounter

1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 1997 Exam template suggestions Neurologic Exam-suggest adding the body part examined (upper extremitylow extremity) Dermatologic Exam-unable to determine if this was performed This should be deleted from the final note if

not examined5 EM time statement is insufficient documentation is lacking a required element total time of visit and counseling time greater than 506 CPT disallowed documentation is not present within the medical record to support the CPT code billed (28485-open treatment of metatarsal fracture includes internal fixation when performed) Fracture care is not supported patient

was seen in the ER 6 weeksrsquo prior ER doctor initiated treatment7 The incorrect pricing modifier was billed Removed modifier 25 (separate and significant EM on the same day as a minor procedure) Fracture care is not billable no modifier needed on EM service8 Diagnosis billed is not the most specific available according to the medical record documentation9 Documentation supports an additional diagnosis code not billed

2 002 Patient B 02-05-16 Blue Cross

99203 25 1 99202 25 1 +1 D E L 1 L03032 1 Cellulitis of left toe 1 L03032 1 Cellulitis of left toe

1 The documentation supports coding for an EM service that is one level below the billed code2 Lacking Exam documentation to support the EM level selected3 1997 MSK exam supports an Expanded Problem Focused exam (99202) 1995 exam supports a Detailed exam (99203)4 EM time statement is insufficient documentation is lacking one or more required elements (total time counseling time greater than 50) If a procedure is performed during a visit the time spent performing the procedure needs to be

carved out of the total visit time5 Allowed modifier 25 due to commercial payer Medicare and NCCI do not require modifier 25 on a new patient EM when a minor procedure is performed the same day 6 Diagnosis supported

Detailed Findings

135 822012 New Consultations - Office

Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N

Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC

bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note

bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged

Chart Level Comments

Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM

oReportsAudit Manager Macros 061218 (version 1)xlsx

Recommendations and ReferencesCategory Short Description Long Description

EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM ConsultationReview the consultation guidelines located in the CPT book

EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf

EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf

EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf

EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a-

preventive-service-with-a-sick-visit

EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation)

EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf

EMEM Time billing suggestion

Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf

EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements

httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EMConsultation Documentation Suggestion

Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation

Detailed Findings

135 822012 New Consultations - Office

Consultations Detailed Detailed (95) Moderate 99244 99243 1 $3500 N

Provider Code 99244 Reviewer Code 99243 Provider Diagnosis 1 3005 NEURASTHENIA Reviewer Diagnosis 1 3005 NEURASTHENIA Provider Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC Reviewer Diagnosis 2 7282 MUSC DISUSE ATROPHY NEC

bull Assessment (I) The assessment is not clearly stated for this encounter Documentation Guidelines states The documentation for each patient encounter should include assessment clinical impression or diagnosis bull Assessment (R) The assessment should be clearly documented for each encounter Since each note must stand alone it is imperative to accurately document the most specific diagnosis in the assessment impression section of the note

bull Documented Lower Level (I) The documentation substantiates a lower level of service than charged

Chart Level Comments

Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM

oReportsAudit Manager Macros 061218 (version 1)xlsx

Recommendations and ReferencesCategory Short Description Long Description

EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM ConsultationReview the consultation guidelines located in the CPT book

EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf

EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf

EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf

EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a-

preventive-service-with-a-sick-visit

EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation)

EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf

EMEM Time billing suggestion

Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf

EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements

httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EMConsultation Documentation Suggestion

Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation

Chart Level Comments

Group your comments in categoriesoDocumentationo E amp MoProceduresoModifierso ICD-10-CM

oReportsAudit Manager Macros 061218 (version 1)xlsx

Recommendations and ReferencesCategory Short Description Long Description

EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM ConsultationReview the consultation guidelines located in the CPT book

EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf

EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf

EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf

EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a-

preventive-service-with-a-sick-visit

EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation)

EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf

EMEM Time billing suggestion

Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf

EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements

httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EMConsultation Documentation Suggestion

Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation

Recommendations and ReferencesCategory Short Description Long Description

EM AdmissionDischarge Same Day Review the CMS AdmissionDischarge same day coding guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM ConsultationReview the consultation guidelines located in the CPT book

EM Consultation not billable to Medicare CMS no longer recognizes the consultation codeshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm6740pdf

EM Critical CareReview the CMS Critical Care guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5993pdf

EM Discharge ServicesReview the CMS Hospital Discharge Services guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5794pdf

EMEM and Preventive Visit Review AAPC guidance for documenting and billing an EM and Preventive visit same day httpswwwaapccomblog22580-successfully-bill-a-

preventive-service-with-a-sick-visit

EM EM documentation guidelines Review the CMS 1995 amp 1997 EM documentation guidelineshttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM EM Inpatient vs Outpatient Review the patientrsquos status on the hospital admission order to determine the appropriate EM category to bill (inpatient vs observation)

EM EM New vs EstablishedReview the CMS New vs Established patient guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNProductsDownloadseval-mgmt-serv-guide-ICN006764pdf

EMEM Time billing suggestion

Recommend a time statement is added to the EM medical record when a majority of the visit is spent counseling andor coordination of care Review the CMS 1995 amp 1997 EM documentation guidelines for EM time documentationhttpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EM Inpatient hospital servicesReview the CMS Hospital Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Nursing Facility Services Review the Nursing Facility Services guidelines provided by CMS The guidelines can be downloaded at this linkhttpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Observation Services Review the CMS Observation Services (Initial and Subsequent) guidelines httpswwwcmsgovRegulations-and-GuidanceGuidanceManualsDownloadsclm104c12pdf

EM Prolonged Services Review the CMS Prolonged Services guidelines httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesdownloadsmm5972pdf

EMReview of Systems Review the CMS 1995 amp 1997 EM documentation guidelines for Review of Systems requirements

httpswwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNEdWebGuideEMDOChtml

EMConsultation Documentation Suggestion

Recommend adding verbiage to consultation documentation that indicates the name of the referring provider and the reason for the consultation

Audit Report Examples Automated Solution

Letrsquos look at some report Examples

ReportsStandard Provider Audit SummarypdfReportsProvider Detailed Sample Reportdocx

ReportsProvider Audit Worksheets - Optionalpdf

Audit Report Examples Non Automated Solution

Error Findings by Volume Percentage

CPT Coded Accurately

8 8 Overcoded

8 8 Undercoded

Missed CPTHCPCS Code

Missed or Wrong Modifier

8 8 Incorrect CPT (or Category) Used

Incorrect ICD-9 Codes

8 8 Incorrect Quantity

Inadequate Documentation

Missing Documentation 8 8

Signature Illegible (No Log)

8 8

CLIENT NAME PROJECT TITLE

Review Line Item Detail Prepared Month Year

DRAFT

Client Claim Demographics Client Charge Data Review Result EampM ONLY Findings C C C C C C O OC O O O

Char

t Num

ber

Au

dit D

ate

Audi

tor (

initi

als)

QA

Initi

als

Fa

cilit

y Lo

catio

n Re

porte

d

Pr

ovid

er N

ame

Pa

tient

Nam

e

M

edic

al R

ecor

d Nu

mbe

r

Prim

ary

Carr

ier M

edica

re=

A M

edica

id =

B O

ther

=O

Da

te o

f Ser

vice

CP

T Co

de

Mod

ifier

(s) i

n or

der

Qua

ntity

Diag

nosi

s Co

de(s

) 1

thro

ugh

4

Fe

e ch

arge

d

Pr

imar

y Pa

ymen

t Am

ount

CPT

Code

Mod

ifier

(s) i

n or

der

Qua

ntity

Diag

nosi

s Co

de(s

) 1

thro

ugh

4

CO

RREC

T AL

LOW

ABLE

Prim

ary

PAYM

ENT

Va

rianc

e

Chie

f Com

plai

nt

Hist

ory

Leve

l Sup

port

ed

Exam

Lev

el S

uppo

rted

Med

ical

Dec

Mak

ing

Supp

orte

d (o

r TIM

E)

CPT

Cod

ed A

ccur

atel

y

Ove

rcod

ed

Und

erco

ded

Mis

sed

CPT

HC

PCS

Cod

e

Mis

sed

or W

rong

Mod

ifier

Inco

rrec

t CPT

(or C

ateg

ory)

Use

d

Inco

rrec

t IC

D-9

Cod

es

Inco

rrec

t Qua

ntity

Inad

equa

te D

ocum

enta

tion

Mis

sing

Doc

umen

tatio

n

Sign

atur

e Ill

egib

le (N

o Lo

g)

No

Sign

atur

e by

Pro

vide

r of

Ser

vice

COMMENTS (abbreviations used) PF- PROBLEM FOCUSED EPF- EXPANDED PF DET- DETAILED COMP- COMPREHENSIVE SFWD- STRAIGHT FORWARD MOD- MODERATE MDM- MEDICAL DECISION MAKING

Char

t Num

ber

SAMPLE SAMPLE S MD SAMPLE SAMPLE XXXXX XXX 112001 99212 25 1 1 1234 2 5678 3 4

$30000 $2200 99212 25 1 1 1234 2 5678 3 4

$56400 $54200 YES

DET

CO

MP

MO

D

COMMENTS COMMENTS COMMENTS

0

1 2 3 4

1 2 3 4

$000 0

$30000 $2200 $56400 $54200 10 10 10 10 10 10 10 10 10 10 10 10 TOTALS 917 Error Rate by Volume

Error Findings by Volume 8 CPT Coded Accurately 8 Overcoded 8 Undercoded 8 Missed CPTHCPCS Code 8 Missed or Wrong Modifier 8 Incorrect CPT (or Category) Used 8 Incorrect ICD-9 Codes 8 Incorrect Quantity

Inadequate Documentation 8 8 Missing Documentation 8 Signature Illegible (No Log) 8 No Signature by Provider of Service

1200 Total

Net Payment Error Rate -24636

Primary Payments Total $ Audited Payment Total $ (Total Under Payments)

Total Over Payments

Net OverUnder Payment $

2200 56400

(54200)

Resources Used HCPCS and CPT CodeBook (Current or applilcable year) ICD-10-CM CodeBook (Current or applicable year) CMS 1995 and 1997 EM Guidelines CMS Claims Processing Manual 100-04 Medicare Claims Processing (PUB 100-04) CMS - National Coverage Determinations (NCDs) National Correct Coding Policy Manual Applicable Physician Version

Executive Summary Report

The executive summary provides readers with a short complete document highlighting import information included in the detailed report Executive summaries are created for the senior management readers that donrsquot have time to read the full report and need to walk away with an understanding of the issues and corrective actions

Some would say the executive summary could be written before the detailed report however it is difficult to make sure the most important elements are included until you have spent time reviewing the detail If you want to make sure the most important messages are in the executive

summary this step should be completed after the detail is written As auditors become more seasoned this step could move to the front of the process

Executive Summary Report Structure of the ES Report

o Backgroundndash Specialtyndash Providersndash Sample Selection sizendash Date range of audit

o Audit Scopeo Regulatory Resourceso Type of Medical records reviewedo Overall Accuracy (all providers)o Detailed Audit Findings

ndash Business Impactndash Summary of Findings

o Department Findingso Summary

o ReportsStandard Executive Summary Professional Servicespdf

Department Findings Top Issues

Date ofServiceErrors

MissingDocuments

Missing orInvalid

Signature

TeachingPhysician

Errors

InsufficientConsultation

Documents

OverCoding

EMBundled

IntoGlobal

SurgicalPackage

SplitSharedServiceError

Incorrector

MissingPricing

Modifier

ICD-10Errors

Family Practice

CardiologyInternal Medicine

TOTALS

Top Findings by Provider

E amp M Accuracy Rates

ICD-10-CM Accuracy Rates

Procedure Accuracy Rates

Inpatient DRG Audit Report

TABLE OF CONTENTS

Executive Summaryo Scope of Work

Reimbursement Changes Department Results

o InpatientGeneral Recommendations and Comments

o Secondary DiagnosesoProcedure CodingoPresent on AdmissionoQueries

Scope of WorkCodingAID performed coding audit review of 175 inpatient records The review completed was a random sample that included cases coded by twenty coders for dates of service from May 2016 ndash July 2016

The objective was to determine if the medical record documentation supported the following coding and documentation requirements and any other regulatory requirement for that code set Criteria reviewed

1 ICD-10-CM Official Coding Guidelines for accurate diagnosis code reporting 2 ICD-10-PCS Official Coding Guidelines for accurate procedure code reporting 3 Documentation of procedure compared to the CPT code assigned 4 Identify opportunities for education and training 5 Financial impact of current coding practices

The regulatory agencies and reference materials relied upon include the following in addition to Medicare and Medicaid regulations Additional resources are located in the sub sections below

bull ICD-10-CM and ICD-10-PCS for Hospitals current volume bull Centers for Medicare and Medicaid Services CMS NCCI Edits-Centers for Medicaid and

Medicare Services CMS website wwwcmsgov bull AHA Coding Clinic

The following electronic medical record documents were reviewed and relied upon to compare to the actual codes submitted to the third party payer

bull Discharge summaries HampPs Progress Notes and other provider notes located in the EMR Records

bull Patient History Forms Ancillary Staff Notes bull Procedure Notes bull Orders bull Diagnostic Report

Reimbursement Changes

Coder Acct

Billed Audited

Reimbursement ChangesMS DRG SOI ROM Weight Expected

Payment MS DRG SOI ROM Weight Expected Payment

Coder 1 001 790 52300 $2615000 792 21552 $1077600 -$1537400

Coder 2002

749 26452 $1322600 758 10090 $504500 -$818100

Coder 3 003 669 13111 $655550 694 07294 $364700 -$290850

Coder 4 004 389 08707 $435350 394 09502 $475100 $39750

Coder 5 005 312 07630 $381500 812 08572 $428600 $47100

Coder 6 006 384 08481 $424050 378 09949 $497450 $73400

Coder 7 007 206 08164 $408200 794 12987 $649350 $241150

Coder 8008

344 31029 $1551450 853 51334 $2566700 $1015250

TOTAL $7793700 $6564000 -$1229700

General Recommendations and CommentsFinding Pertinent secondary diagnoses are not coded and diagnoses are code which are not supported in provider documentation Code only those diagnoses which are documented by the provider on the current chart Not all codes are coded to the highest degree of specificity and combination codes were sometimes missed

Recommendation It is important to assign codes for all conditions which meet the definition of a reportable diagnosis Documentation from all providers should be used including but not limited to radiologists pathologists anesthesiologists CRNAs and FNPs

Reference Coding Clinic Official Coding Guidelines

bull Report all secondary diagnoses which meet the definition of a secondary diagnosis which is defined as all conditions that coexist at the time of admission that develop subsequently or that affect the treatment received andor the length of stay Codes which enhance the overall picture of the patientrsquos visit should be added

o Add T45515A to report adverse effect of Coumadin which caused the GI bleed

o Add I2690 for septic pulmonary emboli (MCCSOI4ROM4)

o Add N179 for acute kidney failure (S3M2CC) per the nephrology consult and the 628 progress note

o Add code I429 cardiomyopathy per HampP

o Add B964 to report proteus in a UTI per the 620 hospitalist progress note

o Code for D649 anemia and I701 stenosis of renal artery should be added as secondary diagnoses per the HampP

bull Only report diagnoses which are substantiated by provider documentation in the current chart notes If a suspected condition is not verified at discharge on an inpatient account it cannot be coded

o Remove G4734 (idiopathic sleep related non-obstructive alveolar hypoventilation) as patient was noted to have the sleep study and the hypoventilation was shown to be a possibility but not noted as such on discharge

o Remove G629 (S21) the neuropathy is documented as due to diabetes

o Remove K529 colitis noted on HP as possible but not further noted or confirmed at discharge

Procedure CodingFinding Procedures were sometimes coded incorrectly

Recommendation The entire medical record should be reviewed and all procedures coded as documented Coding procedures incorrectly or assigning incorrect CPT codes may result in lost revenue

bull Incorrect root operation

o Revise principal procedure to 0DQ68ZZ for clipping of the ulcer per OP report clipping is root operation repair

bull Biopsy versus Excision

o Procedure 0DBA0ZX (biopsy of jejunum) should change to 0DBA0ZZ (excision of jejunum) per op note this was not a biopsy procedure

bull Coding Guideline error

o Remove 0RG10K0 for allograft due to being inclusive in principal procedure

o Remove codes for adhesiolysis 0DN80ZZ 0UN10ZZ and 0UN90ZZ due to no significance noted per OP report

bull Incorrect approach

o Revise 0TF63ZZ (fragmentation percutaneous approach) to 0TF68ZZ (fragmentation endoscopic) for procedure performed via scope per the operative report

bull Procedure coded without provider documentation

o Remove secondary procedure of excisional debridement (0JB90ZZ) due to lack of documentation of excisional debridement per operative report The header in the operative report documents IampD and debridement but the body of the operative report only documents an IampD

bull Incorrect CPT code assignment

o Post-op note supports the nerve block injections of four nerves therefore code 64421 (multiple nerve block) should replace 64420 (injection of one intercostal nerve)

Queries Finding Conflicting incomplete and vague documentation is found within provider chart notes

Recommendation Prior to code assignment if the coder finds ambiguous or conflicting documentation the provider should be queried

Reference AHA Coding Clinic 2002 2nd Quarter pages 17-18

bull Query for acute blood loss anemia since hgb has dropped and patient is being transfused PRBC

bull Recommend query to clarify if cardiorenal syndrome is current as it is documented per 627 nephrology consult but unclear if current

bull Documentation does not support SIRS noninfectious without organ failure It is conflicting since patient has respiratory failure Query should be initiated for clarification with or without organ failure or infectious or non-infectious Patient has pneumonia per query as well as last progress note therefore if SIRS is not further specified per query PNA should be sequenced as principal diagnosis and SIRS should be removed

bull Recommend provider query necrotizing lung consolidation noted on DS as principal diagnosis-unclear does the patient have lobar pneumonia Secondary dx states necrotic pneumonia which is coded as principal diagnosis-this diagnosis is clear but consolidation portion is unclear

bull Recommend query for preterm labor delivery at 301 weeks

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull Query the provider regarding pathology report notation of endometriosis andor possible re-sequence of stenosis as principal diagnosis as it also meets principal diagnosis guidelines This would result in an MS-DRG change to 742 and APR-DRG change to 513

bull QUERY secondary diagnosis MCC and ROM 4 code T3166 (60 TBSA of which 60 are third degree burns) Chart notes do not specify how much of TBSA was actually third degree If after query TBSA is found to be less than 50 (T3164) then ROM will change from 4 to 3 but no change to overall APR-DRG or weight

Auditor Quality amp Productivity

Audit Productivity Standards

It takes twice as long to audit a chart as it does to code it a statistic that takes into account the time to document an explanation of any coding decision the auditor is not in agreement with o For example in an emergency department audit with a productivity of 12

charts per hour for a coder our auditors would probably be able to review six per hour

o If there are multiple services to audit on each encounter the productivity may only be 4 per hour

o The amount of detail you put into your audit report will also be a factorndash Are you using an automated audit softwarendash Are you using a spreadsheet to auditndash How many Systems are needed to complete the audit

Coder Quality Audits

Quality Audits (QA) should be done on your coders and auditors regularly Frequent reviews with smaller sample size will allow more consistent

review and feedbacko Example 10 charts per month per coder if the coder passes 2-3 months

consecutively with 95 or better score move them to quarterly reviewso Some QA programs review a percentage of the coders work This

methodology requires more time and resources

Auditor QA should also score and comment on the accuracy of the audit comments and recommendations

Presenting the Audit Results

Presenting the Audit Results

Communicating the Audit FindingsoWho requested the AuditoWho are you reporting the finding to

ndash CEOndash CFOndash Physicianndash Revenue Cycle Managerndash HIM Directorndash Billing Managerndash Coding Manager

ReportsAudit Resultspptx

Post Audit Education

Provider Education

Provider Education is best received when it is specific to the provider(s) 11 sessions going over the audit result Look at their notes with them

oHighlight areas for documentation improvementoReinforce Coding Guidelines that are specific to themoAsk them to share how they establish their LOS for E amp M serviceso Integrate their EMR system into the training

Provider Education

Group Training SessionsoUse the audit results to identify common issues within a specialty group

ndash Refer to the Executive Summary reportoVery effective for identifying system issues

ndash Teaching Attestationsndash Templatesndash Copy and Pastendash Cloned notes

o Everyone hears the same messagesoAn Issue may not appear on the individual audit but is still a concern for the

group

Education Delivery

In person or remote sessionso Factors to consider

ndash Providers scheduleavailabilityndash Location(s)ndash Personality of the providerndash Budget

Coder Education

Coders do well in group training so they can learn from each other 11 training allows the coder to get feedback on their coding

Handling Audit Disputes

Handling Audit Disputes

Be open to all points of viewo Let the documentation tell the story

Refer to the guidelines Ask

oCan we defend the reported service with the current documentation

Self Disclosures Refunds and Corrected Billing

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Audit Report Examples Non Automated Solution

Error Findings by Volume Percentage

CPT Coded Accurately

8 8 Overcoded

8 8 Undercoded

Missed CPTHCPCS Code

Missed or Wrong Modifier

8 8 Incorrect CPT (or Category) Used

Incorrect ICD-9 Codes

8 8 Incorrect Quantity

Inadequate Documentation

Missing Documentation 8 8

Signature Illegible (No Log)

8 8

CLIENT NAME PROJECT TITLE

Review Line Item Detail Prepared Month Year

DRAFT

Client Claim Demographics Client Charge Data Review Result EampM ONLY Findings C C C C C C O OC O O O

Char

t Num

ber

Au

dit D

ate

Audi

tor (

initi

als)

QA

Initi

als

Fa

cilit

y Lo

catio

n Re

porte

d

Pr

ovid

er N

ame

Pa

tient

Nam

e

M

edic

al R

ecor

d Nu

mbe

r

Prim

ary

Carr

ier M

edica

re=

A M

edica

id =

B O

ther

=O

Da

te o

f Ser

vice

CP

T Co

de

Mod

ifier

(s) i

n or

der

Qua

ntity

Diag

nosi

s Co

de(s

) 1

thro

ugh

4

Fe

e ch

arge

d

Pr

imar

y Pa

ymen

t Am

ount

CPT

Code

Mod

ifier

(s) i

n or

der

Qua

ntity

Diag

nosi

s Co

de(s

) 1

thro

ugh

4

CO

RREC

T AL

LOW

ABLE

Prim

ary

PAYM

ENT

Va

rianc

e

Chie

f Com

plai

nt

Hist

ory

Leve

l Sup

port

ed

Exam

Lev

el S

uppo

rted

Med

ical

Dec

Mak

ing

Supp

orte

d (o

r TIM

E)

CPT

Cod

ed A

ccur

atel

y

Ove

rcod

ed

Und

erco

ded

Mis

sed

CPT

HC

PCS

Cod

e

Mis

sed

or W

rong

Mod

ifier

Inco

rrec

t CPT

(or C

ateg

ory)

Use

d

Inco

rrec

t IC

D-9

Cod

es

Inco

rrec

t Qua

ntity

Inad

equa

te D

ocum

enta

tion

Mis

sing

Doc

umen

tatio

n

Sign

atur

e Ill

egib

le (N

o Lo

g)

No

Sign

atur

e by

Pro

vide

r of

Ser

vice

COMMENTS (abbreviations used) PF- PROBLEM FOCUSED EPF- EXPANDED PF DET- DETAILED COMP- COMPREHENSIVE SFWD- STRAIGHT FORWARD MOD- MODERATE MDM- MEDICAL DECISION MAKING

Char

t Num

ber

SAMPLE SAMPLE S MD SAMPLE SAMPLE XXXXX XXX 112001 99212 25 1 1 1234 2 5678 3 4

$30000 $2200 99212 25 1 1 1234 2 5678 3 4

$56400 $54200 YES

DET

CO

MP

MO

D

COMMENTS COMMENTS COMMENTS

0

1 2 3 4

1 2 3 4

$000 0

$30000 $2200 $56400 $54200 10 10 10 10 10 10 10 10 10 10 10 10 TOTALS 917 Error Rate by Volume

Error Findings by Volume 8 CPT Coded Accurately 8 Overcoded 8 Undercoded 8 Missed CPTHCPCS Code 8 Missed or Wrong Modifier 8 Incorrect CPT (or Category) Used 8 Incorrect ICD-9 Codes 8 Incorrect Quantity

Inadequate Documentation 8 8 Missing Documentation 8 Signature Illegible (No Log) 8 No Signature by Provider of Service

1200 Total

Net Payment Error Rate -24636

Primary Payments Total $ Audited Payment Total $ (Total Under Payments)

Total Over Payments

Net OverUnder Payment $

2200 56400

(54200)

Resources Used HCPCS and CPT CodeBook (Current or applilcable year) ICD-10-CM CodeBook (Current or applicable year) CMS 1995 and 1997 EM Guidelines CMS Claims Processing Manual 100-04 Medicare Claims Processing (PUB 100-04) CMS - National Coverage Determinations (NCDs) National Correct Coding Policy Manual Applicable Physician Version

Executive Summary Report

The executive summary provides readers with a short complete document highlighting import information included in the detailed report Executive summaries are created for the senior management readers that donrsquot have time to read the full report and need to walk away with an understanding of the issues and corrective actions

Some would say the executive summary could be written before the detailed report however it is difficult to make sure the most important elements are included until you have spent time reviewing the detail If you want to make sure the most important messages are in the executive

summary this step should be completed after the detail is written As auditors become more seasoned this step could move to the front of the process

Executive Summary Report Structure of the ES Report

o Backgroundndash Specialtyndash Providersndash Sample Selection sizendash Date range of audit

o Audit Scopeo Regulatory Resourceso Type of Medical records reviewedo Overall Accuracy (all providers)o Detailed Audit Findings

ndash Business Impactndash Summary of Findings

o Department Findingso Summary

o ReportsStandard Executive Summary Professional Servicespdf

Department Findings Top Issues

Date ofServiceErrors

MissingDocuments

Missing orInvalid

Signature

TeachingPhysician

Errors

InsufficientConsultation

Documents

OverCoding

EMBundled

IntoGlobal

SurgicalPackage

SplitSharedServiceError

Incorrector

MissingPricing

Modifier

ICD-10Errors

Family Practice

CardiologyInternal Medicine

TOTALS

Top Findings by Provider

E amp M Accuracy Rates

ICD-10-CM Accuracy Rates

Procedure Accuracy Rates

Inpatient DRG Audit Report

TABLE OF CONTENTS

Executive Summaryo Scope of Work

Reimbursement Changes Department Results

o InpatientGeneral Recommendations and Comments

o Secondary DiagnosesoProcedure CodingoPresent on AdmissionoQueries

Scope of WorkCodingAID performed coding audit review of 175 inpatient records The review completed was a random sample that included cases coded by twenty coders for dates of service from May 2016 ndash July 2016

The objective was to determine if the medical record documentation supported the following coding and documentation requirements and any other regulatory requirement for that code set Criteria reviewed

1 ICD-10-CM Official Coding Guidelines for accurate diagnosis code reporting 2 ICD-10-PCS Official Coding Guidelines for accurate procedure code reporting 3 Documentation of procedure compared to the CPT code assigned 4 Identify opportunities for education and training 5 Financial impact of current coding practices

The regulatory agencies and reference materials relied upon include the following in addition to Medicare and Medicaid regulations Additional resources are located in the sub sections below

bull ICD-10-CM and ICD-10-PCS for Hospitals current volume bull Centers for Medicare and Medicaid Services CMS NCCI Edits-Centers for Medicaid and

Medicare Services CMS website wwwcmsgov bull AHA Coding Clinic

The following electronic medical record documents were reviewed and relied upon to compare to the actual codes submitted to the third party payer

bull Discharge summaries HampPs Progress Notes and other provider notes located in the EMR Records

bull Patient History Forms Ancillary Staff Notes bull Procedure Notes bull Orders bull Diagnostic Report

Reimbursement Changes

Coder Acct

Billed Audited

Reimbursement ChangesMS DRG SOI ROM Weight Expected

Payment MS DRG SOI ROM Weight Expected Payment

Coder 1 001 790 52300 $2615000 792 21552 $1077600 -$1537400

Coder 2002

749 26452 $1322600 758 10090 $504500 -$818100

Coder 3 003 669 13111 $655550 694 07294 $364700 -$290850

Coder 4 004 389 08707 $435350 394 09502 $475100 $39750

Coder 5 005 312 07630 $381500 812 08572 $428600 $47100

Coder 6 006 384 08481 $424050 378 09949 $497450 $73400

Coder 7 007 206 08164 $408200 794 12987 $649350 $241150

Coder 8008

344 31029 $1551450 853 51334 $2566700 $1015250

TOTAL $7793700 $6564000 -$1229700

General Recommendations and CommentsFinding Pertinent secondary diagnoses are not coded and diagnoses are code which are not supported in provider documentation Code only those diagnoses which are documented by the provider on the current chart Not all codes are coded to the highest degree of specificity and combination codes were sometimes missed

Recommendation It is important to assign codes for all conditions which meet the definition of a reportable diagnosis Documentation from all providers should be used including but not limited to radiologists pathologists anesthesiologists CRNAs and FNPs

Reference Coding Clinic Official Coding Guidelines

bull Report all secondary diagnoses which meet the definition of a secondary diagnosis which is defined as all conditions that coexist at the time of admission that develop subsequently or that affect the treatment received andor the length of stay Codes which enhance the overall picture of the patientrsquos visit should be added

o Add T45515A to report adverse effect of Coumadin which caused the GI bleed

o Add I2690 for septic pulmonary emboli (MCCSOI4ROM4)

o Add N179 for acute kidney failure (S3M2CC) per the nephrology consult and the 628 progress note

o Add code I429 cardiomyopathy per HampP

o Add B964 to report proteus in a UTI per the 620 hospitalist progress note

o Code for D649 anemia and I701 stenosis of renal artery should be added as secondary diagnoses per the HampP

bull Only report diagnoses which are substantiated by provider documentation in the current chart notes If a suspected condition is not verified at discharge on an inpatient account it cannot be coded

o Remove G4734 (idiopathic sleep related non-obstructive alveolar hypoventilation) as patient was noted to have the sleep study and the hypoventilation was shown to be a possibility but not noted as such on discharge

o Remove G629 (S21) the neuropathy is documented as due to diabetes

o Remove K529 colitis noted on HP as possible but not further noted or confirmed at discharge

Procedure CodingFinding Procedures were sometimes coded incorrectly

Recommendation The entire medical record should be reviewed and all procedures coded as documented Coding procedures incorrectly or assigning incorrect CPT codes may result in lost revenue

bull Incorrect root operation

o Revise principal procedure to 0DQ68ZZ for clipping of the ulcer per OP report clipping is root operation repair

bull Biopsy versus Excision

o Procedure 0DBA0ZX (biopsy of jejunum) should change to 0DBA0ZZ (excision of jejunum) per op note this was not a biopsy procedure

bull Coding Guideline error

o Remove 0RG10K0 for allograft due to being inclusive in principal procedure

o Remove codes for adhesiolysis 0DN80ZZ 0UN10ZZ and 0UN90ZZ due to no significance noted per OP report

bull Incorrect approach

o Revise 0TF63ZZ (fragmentation percutaneous approach) to 0TF68ZZ (fragmentation endoscopic) for procedure performed via scope per the operative report

bull Procedure coded without provider documentation

o Remove secondary procedure of excisional debridement (0JB90ZZ) due to lack of documentation of excisional debridement per operative report The header in the operative report documents IampD and debridement but the body of the operative report only documents an IampD

bull Incorrect CPT code assignment

o Post-op note supports the nerve block injections of four nerves therefore code 64421 (multiple nerve block) should replace 64420 (injection of one intercostal nerve)

Queries Finding Conflicting incomplete and vague documentation is found within provider chart notes

Recommendation Prior to code assignment if the coder finds ambiguous or conflicting documentation the provider should be queried

Reference AHA Coding Clinic 2002 2nd Quarter pages 17-18

bull Query for acute blood loss anemia since hgb has dropped and patient is being transfused PRBC

bull Recommend query to clarify if cardiorenal syndrome is current as it is documented per 627 nephrology consult but unclear if current

bull Documentation does not support SIRS noninfectious without organ failure It is conflicting since patient has respiratory failure Query should be initiated for clarification with or without organ failure or infectious or non-infectious Patient has pneumonia per query as well as last progress note therefore if SIRS is not further specified per query PNA should be sequenced as principal diagnosis and SIRS should be removed

bull Recommend provider query necrotizing lung consolidation noted on DS as principal diagnosis-unclear does the patient have lobar pneumonia Secondary dx states necrotic pneumonia which is coded as principal diagnosis-this diagnosis is clear but consolidation portion is unclear

bull Recommend query for preterm labor delivery at 301 weeks

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull Query the provider regarding pathology report notation of endometriosis andor possible re-sequence of stenosis as principal diagnosis as it also meets principal diagnosis guidelines This would result in an MS-DRG change to 742 and APR-DRG change to 513

bull QUERY secondary diagnosis MCC and ROM 4 code T3166 (60 TBSA of which 60 are third degree burns) Chart notes do not specify how much of TBSA was actually third degree If after query TBSA is found to be less than 50 (T3164) then ROM will change from 4 to 3 but no change to overall APR-DRG or weight

Auditor Quality amp Productivity

Audit Productivity Standards

It takes twice as long to audit a chart as it does to code it a statistic that takes into account the time to document an explanation of any coding decision the auditor is not in agreement with o For example in an emergency department audit with a productivity of 12

charts per hour for a coder our auditors would probably be able to review six per hour

o If there are multiple services to audit on each encounter the productivity may only be 4 per hour

o The amount of detail you put into your audit report will also be a factorndash Are you using an automated audit softwarendash Are you using a spreadsheet to auditndash How many Systems are needed to complete the audit

Coder Quality Audits

Quality Audits (QA) should be done on your coders and auditors regularly Frequent reviews with smaller sample size will allow more consistent

review and feedbacko Example 10 charts per month per coder if the coder passes 2-3 months

consecutively with 95 or better score move them to quarterly reviewso Some QA programs review a percentage of the coders work This

methodology requires more time and resources

Auditor QA should also score and comment on the accuracy of the audit comments and recommendations

Presenting the Audit Results

Presenting the Audit Results

Communicating the Audit FindingsoWho requested the AuditoWho are you reporting the finding to

ndash CEOndash CFOndash Physicianndash Revenue Cycle Managerndash HIM Directorndash Billing Managerndash Coding Manager

ReportsAudit Resultspptx

Post Audit Education

Provider Education

Provider Education is best received when it is specific to the provider(s) 11 sessions going over the audit result Look at their notes with them

oHighlight areas for documentation improvementoReinforce Coding Guidelines that are specific to themoAsk them to share how they establish their LOS for E amp M serviceso Integrate their EMR system into the training

Provider Education

Group Training SessionsoUse the audit results to identify common issues within a specialty group

ndash Refer to the Executive Summary reportoVery effective for identifying system issues

ndash Teaching Attestationsndash Templatesndash Copy and Pastendash Cloned notes

o Everyone hears the same messagesoAn Issue may not appear on the individual audit but is still a concern for the

group

Education Delivery

In person or remote sessionso Factors to consider

ndash Providers scheduleavailabilityndash Location(s)ndash Personality of the providerndash Budget

Coder Education

Coders do well in group training so they can learn from each other 11 training allows the coder to get feedback on their coding

Handling Audit Disputes

Handling Audit Disputes

Be open to all points of viewo Let the documentation tell the story

Refer to the guidelines Ask

oCan we defend the reported service with the current documentation

Self Disclosures Refunds and Corrected Billing

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Executive Summary Report

The executive summary provides readers with a short complete document highlighting import information included in the detailed report Executive summaries are created for the senior management readers that donrsquot have time to read the full report and need to walk away with an understanding of the issues and corrective actions

Some would say the executive summary could be written before the detailed report however it is difficult to make sure the most important elements are included until you have spent time reviewing the detail If you want to make sure the most important messages are in the executive

summary this step should be completed after the detail is written As auditors become more seasoned this step could move to the front of the process

Executive Summary Report Structure of the ES Report

o Backgroundndash Specialtyndash Providersndash Sample Selection sizendash Date range of audit

o Audit Scopeo Regulatory Resourceso Type of Medical records reviewedo Overall Accuracy (all providers)o Detailed Audit Findings

ndash Business Impactndash Summary of Findings

o Department Findingso Summary

o ReportsStandard Executive Summary Professional Servicespdf

Department Findings Top Issues

Date ofServiceErrors

MissingDocuments

Missing orInvalid

Signature

TeachingPhysician

Errors

InsufficientConsultation

Documents

OverCoding

EMBundled

IntoGlobal

SurgicalPackage

SplitSharedServiceError

Incorrector

MissingPricing

Modifier

ICD-10Errors

Family Practice

CardiologyInternal Medicine

TOTALS

Top Findings by Provider

E amp M Accuracy Rates

ICD-10-CM Accuracy Rates

Procedure Accuracy Rates

Inpatient DRG Audit Report

TABLE OF CONTENTS

Executive Summaryo Scope of Work

Reimbursement Changes Department Results

o InpatientGeneral Recommendations and Comments

o Secondary DiagnosesoProcedure CodingoPresent on AdmissionoQueries

Scope of WorkCodingAID performed coding audit review of 175 inpatient records The review completed was a random sample that included cases coded by twenty coders for dates of service from May 2016 ndash July 2016

The objective was to determine if the medical record documentation supported the following coding and documentation requirements and any other regulatory requirement for that code set Criteria reviewed

1 ICD-10-CM Official Coding Guidelines for accurate diagnosis code reporting 2 ICD-10-PCS Official Coding Guidelines for accurate procedure code reporting 3 Documentation of procedure compared to the CPT code assigned 4 Identify opportunities for education and training 5 Financial impact of current coding practices

The regulatory agencies and reference materials relied upon include the following in addition to Medicare and Medicaid regulations Additional resources are located in the sub sections below

bull ICD-10-CM and ICD-10-PCS for Hospitals current volume bull Centers for Medicare and Medicaid Services CMS NCCI Edits-Centers for Medicaid and

Medicare Services CMS website wwwcmsgov bull AHA Coding Clinic

The following electronic medical record documents were reviewed and relied upon to compare to the actual codes submitted to the third party payer

bull Discharge summaries HampPs Progress Notes and other provider notes located in the EMR Records

bull Patient History Forms Ancillary Staff Notes bull Procedure Notes bull Orders bull Diagnostic Report

Reimbursement Changes

Coder Acct

Billed Audited

Reimbursement ChangesMS DRG SOI ROM Weight Expected

Payment MS DRG SOI ROM Weight Expected Payment

Coder 1 001 790 52300 $2615000 792 21552 $1077600 -$1537400

Coder 2002

749 26452 $1322600 758 10090 $504500 -$818100

Coder 3 003 669 13111 $655550 694 07294 $364700 -$290850

Coder 4 004 389 08707 $435350 394 09502 $475100 $39750

Coder 5 005 312 07630 $381500 812 08572 $428600 $47100

Coder 6 006 384 08481 $424050 378 09949 $497450 $73400

Coder 7 007 206 08164 $408200 794 12987 $649350 $241150

Coder 8008

344 31029 $1551450 853 51334 $2566700 $1015250

TOTAL $7793700 $6564000 -$1229700

General Recommendations and CommentsFinding Pertinent secondary diagnoses are not coded and diagnoses are code which are not supported in provider documentation Code only those diagnoses which are documented by the provider on the current chart Not all codes are coded to the highest degree of specificity and combination codes were sometimes missed

Recommendation It is important to assign codes for all conditions which meet the definition of a reportable diagnosis Documentation from all providers should be used including but not limited to radiologists pathologists anesthesiologists CRNAs and FNPs

Reference Coding Clinic Official Coding Guidelines

bull Report all secondary diagnoses which meet the definition of a secondary diagnosis which is defined as all conditions that coexist at the time of admission that develop subsequently or that affect the treatment received andor the length of stay Codes which enhance the overall picture of the patientrsquos visit should be added

o Add T45515A to report adverse effect of Coumadin which caused the GI bleed

o Add I2690 for septic pulmonary emboli (MCCSOI4ROM4)

o Add N179 for acute kidney failure (S3M2CC) per the nephrology consult and the 628 progress note

o Add code I429 cardiomyopathy per HampP

o Add B964 to report proteus in a UTI per the 620 hospitalist progress note

o Code for D649 anemia and I701 stenosis of renal artery should be added as secondary diagnoses per the HampP

bull Only report diagnoses which are substantiated by provider documentation in the current chart notes If a suspected condition is not verified at discharge on an inpatient account it cannot be coded

o Remove G4734 (idiopathic sleep related non-obstructive alveolar hypoventilation) as patient was noted to have the sleep study and the hypoventilation was shown to be a possibility but not noted as such on discharge

o Remove G629 (S21) the neuropathy is documented as due to diabetes

o Remove K529 colitis noted on HP as possible but not further noted or confirmed at discharge

Procedure CodingFinding Procedures were sometimes coded incorrectly

Recommendation The entire medical record should be reviewed and all procedures coded as documented Coding procedures incorrectly or assigning incorrect CPT codes may result in lost revenue

bull Incorrect root operation

o Revise principal procedure to 0DQ68ZZ for clipping of the ulcer per OP report clipping is root operation repair

bull Biopsy versus Excision

o Procedure 0DBA0ZX (biopsy of jejunum) should change to 0DBA0ZZ (excision of jejunum) per op note this was not a biopsy procedure

bull Coding Guideline error

o Remove 0RG10K0 for allograft due to being inclusive in principal procedure

o Remove codes for adhesiolysis 0DN80ZZ 0UN10ZZ and 0UN90ZZ due to no significance noted per OP report

bull Incorrect approach

o Revise 0TF63ZZ (fragmentation percutaneous approach) to 0TF68ZZ (fragmentation endoscopic) for procedure performed via scope per the operative report

bull Procedure coded without provider documentation

o Remove secondary procedure of excisional debridement (0JB90ZZ) due to lack of documentation of excisional debridement per operative report The header in the operative report documents IampD and debridement but the body of the operative report only documents an IampD

bull Incorrect CPT code assignment

o Post-op note supports the nerve block injections of four nerves therefore code 64421 (multiple nerve block) should replace 64420 (injection of one intercostal nerve)

Queries Finding Conflicting incomplete and vague documentation is found within provider chart notes

Recommendation Prior to code assignment if the coder finds ambiguous or conflicting documentation the provider should be queried

Reference AHA Coding Clinic 2002 2nd Quarter pages 17-18

bull Query for acute blood loss anemia since hgb has dropped and patient is being transfused PRBC

bull Recommend query to clarify if cardiorenal syndrome is current as it is documented per 627 nephrology consult but unclear if current

bull Documentation does not support SIRS noninfectious without organ failure It is conflicting since patient has respiratory failure Query should be initiated for clarification with or without organ failure or infectious or non-infectious Patient has pneumonia per query as well as last progress note therefore if SIRS is not further specified per query PNA should be sequenced as principal diagnosis and SIRS should be removed

bull Recommend provider query necrotizing lung consolidation noted on DS as principal diagnosis-unclear does the patient have lobar pneumonia Secondary dx states necrotic pneumonia which is coded as principal diagnosis-this diagnosis is clear but consolidation portion is unclear

bull Recommend query for preterm labor delivery at 301 weeks

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull Query the provider regarding pathology report notation of endometriosis andor possible re-sequence of stenosis as principal diagnosis as it also meets principal diagnosis guidelines This would result in an MS-DRG change to 742 and APR-DRG change to 513

bull QUERY secondary diagnosis MCC and ROM 4 code T3166 (60 TBSA of which 60 are third degree burns) Chart notes do not specify how much of TBSA was actually third degree If after query TBSA is found to be less than 50 (T3164) then ROM will change from 4 to 3 but no change to overall APR-DRG or weight

Auditor Quality amp Productivity

Audit Productivity Standards

It takes twice as long to audit a chart as it does to code it a statistic that takes into account the time to document an explanation of any coding decision the auditor is not in agreement with o For example in an emergency department audit with a productivity of 12

charts per hour for a coder our auditors would probably be able to review six per hour

o If there are multiple services to audit on each encounter the productivity may only be 4 per hour

o The amount of detail you put into your audit report will also be a factorndash Are you using an automated audit softwarendash Are you using a spreadsheet to auditndash How many Systems are needed to complete the audit

Coder Quality Audits

Quality Audits (QA) should be done on your coders and auditors regularly Frequent reviews with smaller sample size will allow more consistent

review and feedbacko Example 10 charts per month per coder if the coder passes 2-3 months

consecutively with 95 or better score move them to quarterly reviewso Some QA programs review a percentage of the coders work This

methodology requires more time and resources

Auditor QA should also score and comment on the accuracy of the audit comments and recommendations

Presenting the Audit Results

Presenting the Audit Results

Communicating the Audit FindingsoWho requested the AuditoWho are you reporting the finding to

ndash CEOndash CFOndash Physicianndash Revenue Cycle Managerndash HIM Directorndash Billing Managerndash Coding Manager

ReportsAudit Resultspptx

Post Audit Education

Provider Education

Provider Education is best received when it is specific to the provider(s) 11 sessions going over the audit result Look at their notes with them

oHighlight areas for documentation improvementoReinforce Coding Guidelines that are specific to themoAsk them to share how they establish their LOS for E amp M serviceso Integrate their EMR system into the training

Provider Education

Group Training SessionsoUse the audit results to identify common issues within a specialty group

ndash Refer to the Executive Summary reportoVery effective for identifying system issues

ndash Teaching Attestationsndash Templatesndash Copy and Pastendash Cloned notes

o Everyone hears the same messagesoAn Issue may not appear on the individual audit but is still a concern for the

group

Education Delivery

In person or remote sessionso Factors to consider

ndash Providers scheduleavailabilityndash Location(s)ndash Personality of the providerndash Budget

Coder Education

Coders do well in group training so they can learn from each other 11 training allows the coder to get feedback on their coding

Handling Audit Disputes

Handling Audit Disputes

Be open to all points of viewo Let the documentation tell the story

Refer to the guidelines Ask

oCan we defend the reported service with the current documentation

Self Disclosures Refunds and Corrected Billing

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Executive Summary Report Structure of the ES Report

o Backgroundndash Specialtyndash Providersndash Sample Selection sizendash Date range of audit

o Audit Scopeo Regulatory Resourceso Type of Medical records reviewedo Overall Accuracy (all providers)o Detailed Audit Findings

ndash Business Impactndash Summary of Findings

o Department Findingso Summary

o ReportsStandard Executive Summary Professional Servicespdf

Department Findings Top Issues

Date ofServiceErrors

MissingDocuments

Missing orInvalid

Signature

TeachingPhysician

Errors

InsufficientConsultation

Documents

OverCoding

EMBundled

IntoGlobal

SurgicalPackage

SplitSharedServiceError

Incorrector

MissingPricing

Modifier

ICD-10Errors

Family Practice

CardiologyInternal Medicine

TOTALS

Top Findings by Provider

E amp M Accuracy Rates

ICD-10-CM Accuracy Rates

Procedure Accuracy Rates

Inpatient DRG Audit Report

TABLE OF CONTENTS

Executive Summaryo Scope of Work

Reimbursement Changes Department Results

o InpatientGeneral Recommendations and Comments

o Secondary DiagnosesoProcedure CodingoPresent on AdmissionoQueries

Scope of WorkCodingAID performed coding audit review of 175 inpatient records The review completed was a random sample that included cases coded by twenty coders for dates of service from May 2016 ndash July 2016

The objective was to determine if the medical record documentation supported the following coding and documentation requirements and any other regulatory requirement for that code set Criteria reviewed

1 ICD-10-CM Official Coding Guidelines for accurate diagnosis code reporting 2 ICD-10-PCS Official Coding Guidelines for accurate procedure code reporting 3 Documentation of procedure compared to the CPT code assigned 4 Identify opportunities for education and training 5 Financial impact of current coding practices

The regulatory agencies and reference materials relied upon include the following in addition to Medicare and Medicaid regulations Additional resources are located in the sub sections below

bull ICD-10-CM and ICD-10-PCS for Hospitals current volume bull Centers for Medicare and Medicaid Services CMS NCCI Edits-Centers for Medicaid and

Medicare Services CMS website wwwcmsgov bull AHA Coding Clinic

The following electronic medical record documents were reviewed and relied upon to compare to the actual codes submitted to the third party payer

bull Discharge summaries HampPs Progress Notes and other provider notes located in the EMR Records

bull Patient History Forms Ancillary Staff Notes bull Procedure Notes bull Orders bull Diagnostic Report

Reimbursement Changes

Coder Acct

Billed Audited

Reimbursement ChangesMS DRG SOI ROM Weight Expected

Payment MS DRG SOI ROM Weight Expected Payment

Coder 1 001 790 52300 $2615000 792 21552 $1077600 -$1537400

Coder 2002

749 26452 $1322600 758 10090 $504500 -$818100

Coder 3 003 669 13111 $655550 694 07294 $364700 -$290850

Coder 4 004 389 08707 $435350 394 09502 $475100 $39750

Coder 5 005 312 07630 $381500 812 08572 $428600 $47100

Coder 6 006 384 08481 $424050 378 09949 $497450 $73400

Coder 7 007 206 08164 $408200 794 12987 $649350 $241150

Coder 8008

344 31029 $1551450 853 51334 $2566700 $1015250

TOTAL $7793700 $6564000 -$1229700

General Recommendations and CommentsFinding Pertinent secondary diagnoses are not coded and diagnoses are code which are not supported in provider documentation Code only those diagnoses which are documented by the provider on the current chart Not all codes are coded to the highest degree of specificity and combination codes were sometimes missed

Recommendation It is important to assign codes for all conditions which meet the definition of a reportable diagnosis Documentation from all providers should be used including but not limited to radiologists pathologists anesthesiologists CRNAs and FNPs

Reference Coding Clinic Official Coding Guidelines

bull Report all secondary diagnoses which meet the definition of a secondary diagnosis which is defined as all conditions that coexist at the time of admission that develop subsequently or that affect the treatment received andor the length of stay Codes which enhance the overall picture of the patientrsquos visit should be added

o Add T45515A to report adverse effect of Coumadin which caused the GI bleed

o Add I2690 for septic pulmonary emboli (MCCSOI4ROM4)

o Add N179 for acute kidney failure (S3M2CC) per the nephrology consult and the 628 progress note

o Add code I429 cardiomyopathy per HampP

o Add B964 to report proteus in a UTI per the 620 hospitalist progress note

o Code for D649 anemia and I701 stenosis of renal artery should be added as secondary diagnoses per the HampP

bull Only report diagnoses which are substantiated by provider documentation in the current chart notes If a suspected condition is not verified at discharge on an inpatient account it cannot be coded

o Remove G4734 (idiopathic sleep related non-obstructive alveolar hypoventilation) as patient was noted to have the sleep study and the hypoventilation was shown to be a possibility but not noted as such on discharge

o Remove G629 (S21) the neuropathy is documented as due to diabetes

o Remove K529 colitis noted on HP as possible but not further noted or confirmed at discharge

Procedure CodingFinding Procedures were sometimes coded incorrectly

Recommendation The entire medical record should be reviewed and all procedures coded as documented Coding procedures incorrectly or assigning incorrect CPT codes may result in lost revenue

bull Incorrect root operation

o Revise principal procedure to 0DQ68ZZ for clipping of the ulcer per OP report clipping is root operation repair

bull Biopsy versus Excision

o Procedure 0DBA0ZX (biopsy of jejunum) should change to 0DBA0ZZ (excision of jejunum) per op note this was not a biopsy procedure

bull Coding Guideline error

o Remove 0RG10K0 for allograft due to being inclusive in principal procedure

o Remove codes for adhesiolysis 0DN80ZZ 0UN10ZZ and 0UN90ZZ due to no significance noted per OP report

bull Incorrect approach

o Revise 0TF63ZZ (fragmentation percutaneous approach) to 0TF68ZZ (fragmentation endoscopic) for procedure performed via scope per the operative report

bull Procedure coded without provider documentation

o Remove secondary procedure of excisional debridement (0JB90ZZ) due to lack of documentation of excisional debridement per operative report The header in the operative report documents IampD and debridement but the body of the operative report only documents an IampD

bull Incorrect CPT code assignment

o Post-op note supports the nerve block injections of four nerves therefore code 64421 (multiple nerve block) should replace 64420 (injection of one intercostal nerve)

Queries Finding Conflicting incomplete and vague documentation is found within provider chart notes

Recommendation Prior to code assignment if the coder finds ambiguous or conflicting documentation the provider should be queried

Reference AHA Coding Clinic 2002 2nd Quarter pages 17-18

bull Query for acute blood loss anemia since hgb has dropped and patient is being transfused PRBC

bull Recommend query to clarify if cardiorenal syndrome is current as it is documented per 627 nephrology consult but unclear if current

bull Documentation does not support SIRS noninfectious without organ failure It is conflicting since patient has respiratory failure Query should be initiated for clarification with or without organ failure or infectious or non-infectious Patient has pneumonia per query as well as last progress note therefore if SIRS is not further specified per query PNA should be sequenced as principal diagnosis and SIRS should be removed

bull Recommend provider query necrotizing lung consolidation noted on DS as principal diagnosis-unclear does the patient have lobar pneumonia Secondary dx states necrotic pneumonia which is coded as principal diagnosis-this diagnosis is clear but consolidation portion is unclear

bull Recommend query for preterm labor delivery at 301 weeks

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull Query the provider regarding pathology report notation of endometriosis andor possible re-sequence of stenosis as principal diagnosis as it also meets principal diagnosis guidelines This would result in an MS-DRG change to 742 and APR-DRG change to 513

bull QUERY secondary diagnosis MCC and ROM 4 code T3166 (60 TBSA of which 60 are third degree burns) Chart notes do not specify how much of TBSA was actually third degree If after query TBSA is found to be less than 50 (T3164) then ROM will change from 4 to 3 but no change to overall APR-DRG or weight

Auditor Quality amp Productivity

Audit Productivity Standards

It takes twice as long to audit a chart as it does to code it a statistic that takes into account the time to document an explanation of any coding decision the auditor is not in agreement with o For example in an emergency department audit with a productivity of 12

charts per hour for a coder our auditors would probably be able to review six per hour

o If there are multiple services to audit on each encounter the productivity may only be 4 per hour

o The amount of detail you put into your audit report will also be a factorndash Are you using an automated audit softwarendash Are you using a spreadsheet to auditndash How many Systems are needed to complete the audit

Coder Quality Audits

Quality Audits (QA) should be done on your coders and auditors regularly Frequent reviews with smaller sample size will allow more consistent

review and feedbacko Example 10 charts per month per coder if the coder passes 2-3 months

consecutively with 95 or better score move them to quarterly reviewso Some QA programs review a percentage of the coders work This

methodology requires more time and resources

Auditor QA should also score and comment on the accuracy of the audit comments and recommendations

Presenting the Audit Results

Presenting the Audit Results

Communicating the Audit FindingsoWho requested the AuditoWho are you reporting the finding to

ndash CEOndash CFOndash Physicianndash Revenue Cycle Managerndash HIM Directorndash Billing Managerndash Coding Manager

ReportsAudit Resultspptx

Post Audit Education

Provider Education

Provider Education is best received when it is specific to the provider(s) 11 sessions going over the audit result Look at their notes with them

oHighlight areas for documentation improvementoReinforce Coding Guidelines that are specific to themoAsk them to share how they establish their LOS for E amp M serviceso Integrate their EMR system into the training

Provider Education

Group Training SessionsoUse the audit results to identify common issues within a specialty group

ndash Refer to the Executive Summary reportoVery effective for identifying system issues

ndash Teaching Attestationsndash Templatesndash Copy and Pastendash Cloned notes

o Everyone hears the same messagesoAn Issue may not appear on the individual audit but is still a concern for the

group

Education Delivery

In person or remote sessionso Factors to consider

ndash Providers scheduleavailabilityndash Location(s)ndash Personality of the providerndash Budget

Coder Education

Coders do well in group training so they can learn from each other 11 training allows the coder to get feedback on their coding

Handling Audit Disputes

Handling Audit Disputes

Be open to all points of viewo Let the documentation tell the story

Refer to the guidelines Ask

oCan we defend the reported service with the current documentation

Self Disclosures Refunds and Corrected Billing

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Department Findings Top Issues

Date ofServiceErrors

MissingDocuments

Missing orInvalid

Signature

TeachingPhysician

Errors

InsufficientConsultation

Documents

OverCoding

EMBundled

IntoGlobal

SurgicalPackage

SplitSharedServiceError

Incorrector

MissingPricing

Modifier

ICD-10Errors

Family Practice

CardiologyInternal Medicine

TOTALS

Top Findings by Provider

E amp M Accuracy Rates

ICD-10-CM Accuracy Rates

Procedure Accuracy Rates

Inpatient DRG Audit Report

TABLE OF CONTENTS

Executive Summaryo Scope of Work

Reimbursement Changes Department Results

o InpatientGeneral Recommendations and Comments

o Secondary DiagnosesoProcedure CodingoPresent on AdmissionoQueries

Scope of WorkCodingAID performed coding audit review of 175 inpatient records The review completed was a random sample that included cases coded by twenty coders for dates of service from May 2016 ndash July 2016

The objective was to determine if the medical record documentation supported the following coding and documentation requirements and any other regulatory requirement for that code set Criteria reviewed

1 ICD-10-CM Official Coding Guidelines for accurate diagnosis code reporting 2 ICD-10-PCS Official Coding Guidelines for accurate procedure code reporting 3 Documentation of procedure compared to the CPT code assigned 4 Identify opportunities for education and training 5 Financial impact of current coding practices

The regulatory agencies and reference materials relied upon include the following in addition to Medicare and Medicaid regulations Additional resources are located in the sub sections below

bull ICD-10-CM and ICD-10-PCS for Hospitals current volume bull Centers for Medicare and Medicaid Services CMS NCCI Edits-Centers for Medicaid and

Medicare Services CMS website wwwcmsgov bull AHA Coding Clinic

The following electronic medical record documents were reviewed and relied upon to compare to the actual codes submitted to the third party payer

bull Discharge summaries HampPs Progress Notes and other provider notes located in the EMR Records

bull Patient History Forms Ancillary Staff Notes bull Procedure Notes bull Orders bull Diagnostic Report

Reimbursement Changes

Coder Acct

Billed Audited

Reimbursement ChangesMS DRG SOI ROM Weight Expected

Payment MS DRG SOI ROM Weight Expected Payment

Coder 1 001 790 52300 $2615000 792 21552 $1077600 -$1537400

Coder 2002

749 26452 $1322600 758 10090 $504500 -$818100

Coder 3 003 669 13111 $655550 694 07294 $364700 -$290850

Coder 4 004 389 08707 $435350 394 09502 $475100 $39750

Coder 5 005 312 07630 $381500 812 08572 $428600 $47100

Coder 6 006 384 08481 $424050 378 09949 $497450 $73400

Coder 7 007 206 08164 $408200 794 12987 $649350 $241150

Coder 8008

344 31029 $1551450 853 51334 $2566700 $1015250

TOTAL $7793700 $6564000 -$1229700

General Recommendations and CommentsFinding Pertinent secondary diagnoses are not coded and diagnoses are code which are not supported in provider documentation Code only those diagnoses which are documented by the provider on the current chart Not all codes are coded to the highest degree of specificity and combination codes were sometimes missed

Recommendation It is important to assign codes for all conditions which meet the definition of a reportable diagnosis Documentation from all providers should be used including but not limited to radiologists pathologists anesthesiologists CRNAs and FNPs

Reference Coding Clinic Official Coding Guidelines

bull Report all secondary diagnoses which meet the definition of a secondary diagnosis which is defined as all conditions that coexist at the time of admission that develop subsequently or that affect the treatment received andor the length of stay Codes which enhance the overall picture of the patientrsquos visit should be added

o Add T45515A to report adverse effect of Coumadin which caused the GI bleed

o Add I2690 for septic pulmonary emboli (MCCSOI4ROM4)

o Add N179 for acute kidney failure (S3M2CC) per the nephrology consult and the 628 progress note

o Add code I429 cardiomyopathy per HampP

o Add B964 to report proteus in a UTI per the 620 hospitalist progress note

o Code for D649 anemia and I701 stenosis of renal artery should be added as secondary diagnoses per the HampP

bull Only report diagnoses which are substantiated by provider documentation in the current chart notes If a suspected condition is not verified at discharge on an inpatient account it cannot be coded

o Remove G4734 (idiopathic sleep related non-obstructive alveolar hypoventilation) as patient was noted to have the sleep study and the hypoventilation was shown to be a possibility but not noted as such on discharge

o Remove G629 (S21) the neuropathy is documented as due to diabetes

o Remove K529 colitis noted on HP as possible but not further noted or confirmed at discharge

Procedure CodingFinding Procedures were sometimes coded incorrectly

Recommendation The entire medical record should be reviewed and all procedures coded as documented Coding procedures incorrectly or assigning incorrect CPT codes may result in lost revenue

bull Incorrect root operation

o Revise principal procedure to 0DQ68ZZ for clipping of the ulcer per OP report clipping is root operation repair

bull Biopsy versus Excision

o Procedure 0DBA0ZX (biopsy of jejunum) should change to 0DBA0ZZ (excision of jejunum) per op note this was not a biopsy procedure

bull Coding Guideline error

o Remove 0RG10K0 for allograft due to being inclusive in principal procedure

o Remove codes for adhesiolysis 0DN80ZZ 0UN10ZZ and 0UN90ZZ due to no significance noted per OP report

bull Incorrect approach

o Revise 0TF63ZZ (fragmentation percutaneous approach) to 0TF68ZZ (fragmentation endoscopic) for procedure performed via scope per the operative report

bull Procedure coded without provider documentation

o Remove secondary procedure of excisional debridement (0JB90ZZ) due to lack of documentation of excisional debridement per operative report The header in the operative report documents IampD and debridement but the body of the operative report only documents an IampD

bull Incorrect CPT code assignment

o Post-op note supports the nerve block injections of four nerves therefore code 64421 (multiple nerve block) should replace 64420 (injection of one intercostal nerve)

Queries Finding Conflicting incomplete and vague documentation is found within provider chart notes

Recommendation Prior to code assignment if the coder finds ambiguous or conflicting documentation the provider should be queried

Reference AHA Coding Clinic 2002 2nd Quarter pages 17-18

bull Query for acute blood loss anemia since hgb has dropped and patient is being transfused PRBC

bull Recommend query to clarify if cardiorenal syndrome is current as it is documented per 627 nephrology consult but unclear if current

bull Documentation does not support SIRS noninfectious without organ failure It is conflicting since patient has respiratory failure Query should be initiated for clarification with or without organ failure or infectious or non-infectious Patient has pneumonia per query as well as last progress note therefore if SIRS is not further specified per query PNA should be sequenced as principal diagnosis and SIRS should be removed

bull Recommend provider query necrotizing lung consolidation noted on DS as principal diagnosis-unclear does the patient have lobar pneumonia Secondary dx states necrotic pneumonia which is coded as principal diagnosis-this diagnosis is clear but consolidation portion is unclear

bull Recommend query for preterm labor delivery at 301 weeks

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull Query the provider regarding pathology report notation of endometriosis andor possible re-sequence of stenosis as principal diagnosis as it also meets principal diagnosis guidelines This would result in an MS-DRG change to 742 and APR-DRG change to 513

bull QUERY secondary diagnosis MCC and ROM 4 code T3166 (60 TBSA of which 60 are third degree burns) Chart notes do not specify how much of TBSA was actually third degree If after query TBSA is found to be less than 50 (T3164) then ROM will change from 4 to 3 but no change to overall APR-DRG or weight

Auditor Quality amp Productivity

Audit Productivity Standards

It takes twice as long to audit a chart as it does to code it a statistic that takes into account the time to document an explanation of any coding decision the auditor is not in agreement with o For example in an emergency department audit with a productivity of 12

charts per hour for a coder our auditors would probably be able to review six per hour

o If there are multiple services to audit on each encounter the productivity may only be 4 per hour

o The amount of detail you put into your audit report will also be a factorndash Are you using an automated audit softwarendash Are you using a spreadsheet to auditndash How many Systems are needed to complete the audit

Coder Quality Audits

Quality Audits (QA) should be done on your coders and auditors regularly Frequent reviews with smaller sample size will allow more consistent

review and feedbacko Example 10 charts per month per coder if the coder passes 2-3 months

consecutively with 95 or better score move them to quarterly reviewso Some QA programs review a percentage of the coders work This

methodology requires more time and resources

Auditor QA should also score and comment on the accuracy of the audit comments and recommendations

Presenting the Audit Results

Presenting the Audit Results

Communicating the Audit FindingsoWho requested the AuditoWho are you reporting the finding to

ndash CEOndash CFOndash Physicianndash Revenue Cycle Managerndash HIM Directorndash Billing Managerndash Coding Manager

ReportsAudit Resultspptx

Post Audit Education

Provider Education

Provider Education is best received when it is specific to the provider(s) 11 sessions going over the audit result Look at their notes with them

oHighlight areas for documentation improvementoReinforce Coding Guidelines that are specific to themoAsk them to share how they establish their LOS for E amp M serviceso Integrate their EMR system into the training

Provider Education

Group Training SessionsoUse the audit results to identify common issues within a specialty group

ndash Refer to the Executive Summary reportoVery effective for identifying system issues

ndash Teaching Attestationsndash Templatesndash Copy and Pastendash Cloned notes

o Everyone hears the same messagesoAn Issue may not appear on the individual audit but is still a concern for the

group

Education Delivery

In person or remote sessionso Factors to consider

ndash Providers scheduleavailabilityndash Location(s)ndash Personality of the providerndash Budget

Coder Education

Coders do well in group training so they can learn from each other 11 training allows the coder to get feedback on their coding

Handling Audit Disputes

Handling Audit Disputes

Be open to all points of viewo Let the documentation tell the story

Refer to the guidelines Ask

oCan we defend the reported service with the current documentation

Self Disclosures Refunds and Corrected Billing

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Top Findings by Provider

E amp M Accuracy Rates

ICD-10-CM Accuracy Rates

Procedure Accuracy Rates

Inpatient DRG Audit Report

TABLE OF CONTENTS

Executive Summaryo Scope of Work

Reimbursement Changes Department Results

o InpatientGeneral Recommendations and Comments

o Secondary DiagnosesoProcedure CodingoPresent on AdmissionoQueries

Scope of WorkCodingAID performed coding audit review of 175 inpatient records The review completed was a random sample that included cases coded by twenty coders for dates of service from May 2016 ndash July 2016

The objective was to determine if the medical record documentation supported the following coding and documentation requirements and any other regulatory requirement for that code set Criteria reviewed

1 ICD-10-CM Official Coding Guidelines for accurate diagnosis code reporting 2 ICD-10-PCS Official Coding Guidelines for accurate procedure code reporting 3 Documentation of procedure compared to the CPT code assigned 4 Identify opportunities for education and training 5 Financial impact of current coding practices

The regulatory agencies and reference materials relied upon include the following in addition to Medicare and Medicaid regulations Additional resources are located in the sub sections below

bull ICD-10-CM and ICD-10-PCS for Hospitals current volume bull Centers for Medicare and Medicaid Services CMS NCCI Edits-Centers for Medicaid and

Medicare Services CMS website wwwcmsgov bull AHA Coding Clinic

The following electronic medical record documents were reviewed and relied upon to compare to the actual codes submitted to the third party payer

bull Discharge summaries HampPs Progress Notes and other provider notes located in the EMR Records

bull Patient History Forms Ancillary Staff Notes bull Procedure Notes bull Orders bull Diagnostic Report

Reimbursement Changes

Coder Acct

Billed Audited

Reimbursement ChangesMS DRG SOI ROM Weight Expected

Payment MS DRG SOI ROM Weight Expected Payment

Coder 1 001 790 52300 $2615000 792 21552 $1077600 -$1537400

Coder 2002

749 26452 $1322600 758 10090 $504500 -$818100

Coder 3 003 669 13111 $655550 694 07294 $364700 -$290850

Coder 4 004 389 08707 $435350 394 09502 $475100 $39750

Coder 5 005 312 07630 $381500 812 08572 $428600 $47100

Coder 6 006 384 08481 $424050 378 09949 $497450 $73400

Coder 7 007 206 08164 $408200 794 12987 $649350 $241150

Coder 8008

344 31029 $1551450 853 51334 $2566700 $1015250

TOTAL $7793700 $6564000 -$1229700

General Recommendations and CommentsFinding Pertinent secondary diagnoses are not coded and diagnoses are code which are not supported in provider documentation Code only those diagnoses which are documented by the provider on the current chart Not all codes are coded to the highest degree of specificity and combination codes were sometimes missed

Recommendation It is important to assign codes for all conditions which meet the definition of a reportable diagnosis Documentation from all providers should be used including but not limited to radiologists pathologists anesthesiologists CRNAs and FNPs

Reference Coding Clinic Official Coding Guidelines

bull Report all secondary diagnoses which meet the definition of a secondary diagnosis which is defined as all conditions that coexist at the time of admission that develop subsequently or that affect the treatment received andor the length of stay Codes which enhance the overall picture of the patientrsquos visit should be added

o Add T45515A to report adverse effect of Coumadin which caused the GI bleed

o Add I2690 for septic pulmonary emboli (MCCSOI4ROM4)

o Add N179 for acute kidney failure (S3M2CC) per the nephrology consult and the 628 progress note

o Add code I429 cardiomyopathy per HampP

o Add B964 to report proteus in a UTI per the 620 hospitalist progress note

o Code for D649 anemia and I701 stenosis of renal artery should be added as secondary diagnoses per the HampP

bull Only report diagnoses which are substantiated by provider documentation in the current chart notes If a suspected condition is not verified at discharge on an inpatient account it cannot be coded

o Remove G4734 (idiopathic sleep related non-obstructive alveolar hypoventilation) as patient was noted to have the sleep study and the hypoventilation was shown to be a possibility but not noted as such on discharge

o Remove G629 (S21) the neuropathy is documented as due to diabetes

o Remove K529 colitis noted on HP as possible but not further noted or confirmed at discharge

Procedure CodingFinding Procedures were sometimes coded incorrectly

Recommendation The entire medical record should be reviewed and all procedures coded as documented Coding procedures incorrectly or assigning incorrect CPT codes may result in lost revenue

bull Incorrect root operation

o Revise principal procedure to 0DQ68ZZ for clipping of the ulcer per OP report clipping is root operation repair

bull Biopsy versus Excision

o Procedure 0DBA0ZX (biopsy of jejunum) should change to 0DBA0ZZ (excision of jejunum) per op note this was not a biopsy procedure

bull Coding Guideline error

o Remove 0RG10K0 for allograft due to being inclusive in principal procedure

o Remove codes for adhesiolysis 0DN80ZZ 0UN10ZZ and 0UN90ZZ due to no significance noted per OP report

bull Incorrect approach

o Revise 0TF63ZZ (fragmentation percutaneous approach) to 0TF68ZZ (fragmentation endoscopic) for procedure performed via scope per the operative report

bull Procedure coded without provider documentation

o Remove secondary procedure of excisional debridement (0JB90ZZ) due to lack of documentation of excisional debridement per operative report The header in the operative report documents IampD and debridement but the body of the operative report only documents an IampD

bull Incorrect CPT code assignment

o Post-op note supports the nerve block injections of four nerves therefore code 64421 (multiple nerve block) should replace 64420 (injection of one intercostal nerve)

Queries Finding Conflicting incomplete and vague documentation is found within provider chart notes

Recommendation Prior to code assignment if the coder finds ambiguous or conflicting documentation the provider should be queried

Reference AHA Coding Clinic 2002 2nd Quarter pages 17-18

bull Query for acute blood loss anemia since hgb has dropped and patient is being transfused PRBC

bull Recommend query to clarify if cardiorenal syndrome is current as it is documented per 627 nephrology consult but unclear if current

bull Documentation does not support SIRS noninfectious without organ failure It is conflicting since patient has respiratory failure Query should be initiated for clarification with or without organ failure or infectious or non-infectious Patient has pneumonia per query as well as last progress note therefore if SIRS is not further specified per query PNA should be sequenced as principal diagnosis and SIRS should be removed

bull Recommend provider query necrotizing lung consolidation noted on DS as principal diagnosis-unclear does the patient have lobar pneumonia Secondary dx states necrotic pneumonia which is coded as principal diagnosis-this diagnosis is clear but consolidation portion is unclear

bull Recommend query for preterm labor delivery at 301 weeks

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull Query the provider regarding pathology report notation of endometriosis andor possible re-sequence of stenosis as principal diagnosis as it also meets principal diagnosis guidelines This would result in an MS-DRG change to 742 and APR-DRG change to 513

bull QUERY secondary diagnosis MCC and ROM 4 code T3166 (60 TBSA of which 60 are third degree burns) Chart notes do not specify how much of TBSA was actually third degree If after query TBSA is found to be less than 50 (T3164) then ROM will change from 4 to 3 but no change to overall APR-DRG or weight

Auditor Quality amp Productivity

Audit Productivity Standards

It takes twice as long to audit a chart as it does to code it a statistic that takes into account the time to document an explanation of any coding decision the auditor is not in agreement with o For example in an emergency department audit with a productivity of 12

charts per hour for a coder our auditors would probably be able to review six per hour

o If there are multiple services to audit on each encounter the productivity may only be 4 per hour

o The amount of detail you put into your audit report will also be a factorndash Are you using an automated audit softwarendash Are you using a spreadsheet to auditndash How many Systems are needed to complete the audit

Coder Quality Audits

Quality Audits (QA) should be done on your coders and auditors regularly Frequent reviews with smaller sample size will allow more consistent

review and feedbacko Example 10 charts per month per coder if the coder passes 2-3 months

consecutively with 95 or better score move them to quarterly reviewso Some QA programs review a percentage of the coders work This

methodology requires more time and resources

Auditor QA should also score and comment on the accuracy of the audit comments and recommendations

Presenting the Audit Results

Presenting the Audit Results

Communicating the Audit FindingsoWho requested the AuditoWho are you reporting the finding to

ndash CEOndash CFOndash Physicianndash Revenue Cycle Managerndash HIM Directorndash Billing Managerndash Coding Manager

ReportsAudit Resultspptx

Post Audit Education

Provider Education

Provider Education is best received when it is specific to the provider(s) 11 sessions going over the audit result Look at their notes with them

oHighlight areas for documentation improvementoReinforce Coding Guidelines that are specific to themoAsk them to share how they establish their LOS for E amp M serviceso Integrate their EMR system into the training

Provider Education

Group Training SessionsoUse the audit results to identify common issues within a specialty group

ndash Refer to the Executive Summary reportoVery effective for identifying system issues

ndash Teaching Attestationsndash Templatesndash Copy and Pastendash Cloned notes

o Everyone hears the same messagesoAn Issue may not appear on the individual audit but is still a concern for the

group

Education Delivery

In person or remote sessionso Factors to consider

ndash Providers scheduleavailabilityndash Location(s)ndash Personality of the providerndash Budget

Coder Education

Coders do well in group training so they can learn from each other 11 training allows the coder to get feedback on their coding

Handling Audit Disputes

Handling Audit Disputes

Be open to all points of viewo Let the documentation tell the story

Refer to the guidelines Ask

oCan we defend the reported service with the current documentation

Self Disclosures Refunds and Corrected Billing

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

E amp M Accuracy Rates

ICD-10-CM Accuracy Rates

Procedure Accuracy Rates

Inpatient DRG Audit Report

TABLE OF CONTENTS

Executive Summaryo Scope of Work

Reimbursement Changes Department Results

o InpatientGeneral Recommendations and Comments

o Secondary DiagnosesoProcedure CodingoPresent on AdmissionoQueries

Scope of WorkCodingAID performed coding audit review of 175 inpatient records The review completed was a random sample that included cases coded by twenty coders for dates of service from May 2016 ndash July 2016

The objective was to determine if the medical record documentation supported the following coding and documentation requirements and any other regulatory requirement for that code set Criteria reviewed

1 ICD-10-CM Official Coding Guidelines for accurate diagnosis code reporting 2 ICD-10-PCS Official Coding Guidelines for accurate procedure code reporting 3 Documentation of procedure compared to the CPT code assigned 4 Identify opportunities for education and training 5 Financial impact of current coding practices

The regulatory agencies and reference materials relied upon include the following in addition to Medicare and Medicaid regulations Additional resources are located in the sub sections below

bull ICD-10-CM and ICD-10-PCS for Hospitals current volume bull Centers for Medicare and Medicaid Services CMS NCCI Edits-Centers for Medicaid and

Medicare Services CMS website wwwcmsgov bull AHA Coding Clinic

The following electronic medical record documents were reviewed and relied upon to compare to the actual codes submitted to the third party payer

bull Discharge summaries HampPs Progress Notes and other provider notes located in the EMR Records

bull Patient History Forms Ancillary Staff Notes bull Procedure Notes bull Orders bull Diagnostic Report

Reimbursement Changes

Coder Acct

Billed Audited

Reimbursement ChangesMS DRG SOI ROM Weight Expected

Payment MS DRG SOI ROM Weight Expected Payment

Coder 1 001 790 52300 $2615000 792 21552 $1077600 -$1537400

Coder 2002

749 26452 $1322600 758 10090 $504500 -$818100

Coder 3 003 669 13111 $655550 694 07294 $364700 -$290850

Coder 4 004 389 08707 $435350 394 09502 $475100 $39750

Coder 5 005 312 07630 $381500 812 08572 $428600 $47100

Coder 6 006 384 08481 $424050 378 09949 $497450 $73400

Coder 7 007 206 08164 $408200 794 12987 $649350 $241150

Coder 8008

344 31029 $1551450 853 51334 $2566700 $1015250

TOTAL $7793700 $6564000 -$1229700

General Recommendations and CommentsFinding Pertinent secondary diagnoses are not coded and diagnoses are code which are not supported in provider documentation Code only those diagnoses which are documented by the provider on the current chart Not all codes are coded to the highest degree of specificity and combination codes were sometimes missed

Recommendation It is important to assign codes for all conditions which meet the definition of a reportable diagnosis Documentation from all providers should be used including but not limited to radiologists pathologists anesthesiologists CRNAs and FNPs

Reference Coding Clinic Official Coding Guidelines

bull Report all secondary diagnoses which meet the definition of a secondary diagnosis which is defined as all conditions that coexist at the time of admission that develop subsequently or that affect the treatment received andor the length of stay Codes which enhance the overall picture of the patientrsquos visit should be added

o Add T45515A to report adverse effect of Coumadin which caused the GI bleed

o Add I2690 for septic pulmonary emboli (MCCSOI4ROM4)

o Add N179 for acute kidney failure (S3M2CC) per the nephrology consult and the 628 progress note

o Add code I429 cardiomyopathy per HampP

o Add B964 to report proteus in a UTI per the 620 hospitalist progress note

o Code for D649 anemia and I701 stenosis of renal artery should be added as secondary diagnoses per the HampP

bull Only report diagnoses which are substantiated by provider documentation in the current chart notes If a suspected condition is not verified at discharge on an inpatient account it cannot be coded

o Remove G4734 (idiopathic sleep related non-obstructive alveolar hypoventilation) as patient was noted to have the sleep study and the hypoventilation was shown to be a possibility but not noted as such on discharge

o Remove G629 (S21) the neuropathy is documented as due to diabetes

o Remove K529 colitis noted on HP as possible but not further noted or confirmed at discharge

Procedure CodingFinding Procedures were sometimes coded incorrectly

Recommendation The entire medical record should be reviewed and all procedures coded as documented Coding procedures incorrectly or assigning incorrect CPT codes may result in lost revenue

bull Incorrect root operation

o Revise principal procedure to 0DQ68ZZ for clipping of the ulcer per OP report clipping is root operation repair

bull Biopsy versus Excision

o Procedure 0DBA0ZX (biopsy of jejunum) should change to 0DBA0ZZ (excision of jejunum) per op note this was not a biopsy procedure

bull Coding Guideline error

o Remove 0RG10K0 for allograft due to being inclusive in principal procedure

o Remove codes for adhesiolysis 0DN80ZZ 0UN10ZZ and 0UN90ZZ due to no significance noted per OP report

bull Incorrect approach

o Revise 0TF63ZZ (fragmentation percutaneous approach) to 0TF68ZZ (fragmentation endoscopic) for procedure performed via scope per the operative report

bull Procedure coded without provider documentation

o Remove secondary procedure of excisional debridement (0JB90ZZ) due to lack of documentation of excisional debridement per operative report The header in the operative report documents IampD and debridement but the body of the operative report only documents an IampD

bull Incorrect CPT code assignment

o Post-op note supports the nerve block injections of four nerves therefore code 64421 (multiple nerve block) should replace 64420 (injection of one intercostal nerve)

Queries Finding Conflicting incomplete and vague documentation is found within provider chart notes

Recommendation Prior to code assignment if the coder finds ambiguous or conflicting documentation the provider should be queried

Reference AHA Coding Clinic 2002 2nd Quarter pages 17-18

bull Query for acute blood loss anemia since hgb has dropped and patient is being transfused PRBC

bull Recommend query to clarify if cardiorenal syndrome is current as it is documented per 627 nephrology consult but unclear if current

bull Documentation does not support SIRS noninfectious without organ failure It is conflicting since patient has respiratory failure Query should be initiated for clarification with or without organ failure or infectious or non-infectious Patient has pneumonia per query as well as last progress note therefore if SIRS is not further specified per query PNA should be sequenced as principal diagnosis and SIRS should be removed

bull Recommend provider query necrotizing lung consolidation noted on DS as principal diagnosis-unclear does the patient have lobar pneumonia Secondary dx states necrotic pneumonia which is coded as principal diagnosis-this diagnosis is clear but consolidation portion is unclear

bull Recommend query for preterm labor delivery at 301 weeks

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull Query the provider regarding pathology report notation of endometriosis andor possible re-sequence of stenosis as principal diagnosis as it also meets principal diagnosis guidelines This would result in an MS-DRG change to 742 and APR-DRG change to 513

bull QUERY secondary diagnosis MCC and ROM 4 code T3166 (60 TBSA of which 60 are third degree burns) Chart notes do not specify how much of TBSA was actually third degree If after query TBSA is found to be less than 50 (T3164) then ROM will change from 4 to 3 but no change to overall APR-DRG or weight

Auditor Quality amp Productivity

Audit Productivity Standards

It takes twice as long to audit a chart as it does to code it a statistic that takes into account the time to document an explanation of any coding decision the auditor is not in agreement with o For example in an emergency department audit with a productivity of 12

charts per hour for a coder our auditors would probably be able to review six per hour

o If there are multiple services to audit on each encounter the productivity may only be 4 per hour

o The amount of detail you put into your audit report will also be a factorndash Are you using an automated audit softwarendash Are you using a spreadsheet to auditndash How many Systems are needed to complete the audit

Coder Quality Audits

Quality Audits (QA) should be done on your coders and auditors regularly Frequent reviews with smaller sample size will allow more consistent

review and feedbacko Example 10 charts per month per coder if the coder passes 2-3 months

consecutively with 95 or better score move them to quarterly reviewso Some QA programs review a percentage of the coders work This

methodology requires more time and resources

Auditor QA should also score and comment on the accuracy of the audit comments and recommendations

Presenting the Audit Results

Presenting the Audit Results

Communicating the Audit FindingsoWho requested the AuditoWho are you reporting the finding to

ndash CEOndash CFOndash Physicianndash Revenue Cycle Managerndash HIM Directorndash Billing Managerndash Coding Manager

ReportsAudit Resultspptx

Post Audit Education

Provider Education

Provider Education is best received when it is specific to the provider(s) 11 sessions going over the audit result Look at their notes with them

oHighlight areas for documentation improvementoReinforce Coding Guidelines that are specific to themoAsk them to share how they establish their LOS for E amp M serviceso Integrate their EMR system into the training

Provider Education

Group Training SessionsoUse the audit results to identify common issues within a specialty group

ndash Refer to the Executive Summary reportoVery effective for identifying system issues

ndash Teaching Attestationsndash Templatesndash Copy and Pastendash Cloned notes

o Everyone hears the same messagesoAn Issue may not appear on the individual audit but is still a concern for the

group

Education Delivery

In person or remote sessionso Factors to consider

ndash Providers scheduleavailabilityndash Location(s)ndash Personality of the providerndash Budget

Coder Education

Coders do well in group training so they can learn from each other 11 training allows the coder to get feedback on their coding

Handling Audit Disputes

Handling Audit Disputes

Be open to all points of viewo Let the documentation tell the story

Refer to the guidelines Ask

oCan we defend the reported service with the current documentation

Self Disclosures Refunds and Corrected Billing

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

ICD-10-CM Accuracy Rates

Procedure Accuracy Rates

Inpatient DRG Audit Report

TABLE OF CONTENTS

Executive Summaryo Scope of Work

Reimbursement Changes Department Results

o InpatientGeneral Recommendations and Comments

o Secondary DiagnosesoProcedure CodingoPresent on AdmissionoQueries

Scope of WorkCodingAID performed coding audit review of 175 inpatient records The review completed was a random sample that included cases coded by twenty coders for dates of service from May 2016 ndash July 2016

The objective was to determine if the medical record documentation supported the following coding and documentation requirements and any other regulatory requirement for that code set Criteria reviewed

1 ICD-10-CM Official Coding Guidelines for accurate diagnosis code reporting 2 ICD-10-PCS Official Coding Guidelines for accurate procedure code reporting 3 Documentation of procedure compared to the CPT code assigned 4 Identify opportunities for education and training 5 Financial impact of current coding practices

The regulatory agencies and reference materials relied upon include the following in addition to Medicare and Medicaid regulations Additional resources are located in the sub sections below

bull ICD-10-CM and ICD-10-PCS for Hospitals current volume bull Centers for Medicare and Medicaid Services CMS NCCI Edits-Centers for Medicaid and

Medicare Services CMS website wwwcmsgov bull AHA Coding Clinic

The following electronic medical record documents were reviewed and relied upon to compare to the actual codes submitted to the third party payer

bull Discharge summaries HampPs Progress Notes and other provider notes located in the EMR Records

bull Patient History Forms Ancillary Staff Notes bull Procedure Notes bull Orders bull Diagnostic Report

Reimbursement Changes

Coder Acct

Billed Audited

Reimbursement ChangesMS DRG SOI ROM Weight Expected

Payment MS DRG SOI ROM Weight Expected Payment

Coder 1 001 790 52300 $2615000 792 21552 $1077600 -$1537400

Coder 2002

749 26452 $1322600 758 10090 $504500 -$818100

Coder 3 003 669 13111 $655550 694 07294 $364700 -$290850

Coder 4 004 389 08707 $435350 394 09502 $475100 $39750

Coder 5 005 312 07630 $381500 812 08572 $428600 $47100

Coder 6 006 384 08481 $424050 378 09949 $497450 $73400

Coder 7 007 206 08164 $408200 794 12987 $649350 $241150

Coder 8008

344 31029 $1551450 853 51334 $2566700 $1015250

TOTAL $7793700 $6564000 -$1229700

General Recommendations and CommentsFinding Pertinent secondary diagnoses are not coded and diagnoses are code which are not supported in provider documentation Code only those diagnoses which are documented by the provider on the current chart Not all codes are coded to the highest degree of specificity and combination codes were sometimes missed

Recommendation It is important to assign codes for all conditions which meet the definition of a reportable diagnosis Documentation from all providers should be used including but not limited to radiologists pathologists anesthesiologists CRNAs and FNPs

Reference Coding Clinic Official Coding Guidelines

bull Report all secondary diagnoses which meet the definition of a secondary diagnosis which is defined as all conditions that coexist at the time of admission that develop subsequently or that affect the treatment received andor the length of stay Codes which enhance the overall picture of the patientrsquos visit should be added

o Add T45515A to report adverse effect of Coumadin which caused the GI bleed

o Add I2690 for septic pulmonary emboli (MCCSOI4ROM4)

o Add N179 for acute kidney failure (S3M2CC) per the nephrology consult and the 628 progress note

o Add code I429 cardiomyopathy per HampP

o Add B964 to report proteus in a UTI per the 620 hospitalist progress note

o Code for D649 anemia and I701 stenosis of renal artery should be added as secondary diagnoses per the HampP

bull Only report diagnoses which are substantiated by provider documentation in the current chart notes If a suspected condition is not verified at discharge on an inpatient account it cannot be coded

o Remove G4734 (idiopathic sleep related non-obstructive alveolar hypoventilation) as patient was noted to have the sleep study and the hypoventilation was shown to be a possibility but not noted as such on discharge

o Remove G629 (S21) the neuropathy is documented as due to diabetes

o Remove K529 colitis noted on HP as possible but not further noted or confirmed at discharge

Procedure CodingFinding Procedures were sometimes coded incorrectly

Recommendation The entire medical record should be reviewed and all procedures coded as documented Coding procedures incorrectly or assigning incorrect CPT codes may result in lost revenue

bull Incorrect root operation

o Revise principal procedure to 0DQ68ZZ for clipping of the ulcer per OP report clipping is root operation repair

bull Biopsy versus Excision

o Procedure 0DBA0ZX (biopsy of jejunum) should change to 0DBA0ZZ (excision of jejunum) per op note this was not a biopsy procedure

bull Coding Guideline error

o Remove 0RG10K0 for allograft due to being inclusive in principal procedure

o Remove codes for adhesiolysis 0DN80ZZ 0UN10ZZ and 0UN90ZZ due to no significance noted per OP report

bull Incorrect approach

o Revise 0TF63ZZ (fragmentation percutaneous approach) to 0TF68ZZ (fragmentation endoscopic) for procedure performed via scope per the operative report

bull Procedure coded without provider documentation

o Remove secondary procedure of excisional debridement (0JB90ZZ) due to lack of documentation of excisional debridement per operative report The header in the operative report documents IampD and debridement but the body of the operative report only documents an IampD

bull Incorrect CPT code assignment

o Post-op note supports the nerve block injections of four nerves therefore code 64421 (multiple nerve block) should replace 64420 (injection of one intercostal nerve)

Queries Finding Conflicting incomplete and vague documentation is found within provider chart notes

Recommendation Prior to code assignment if the coder finds ambiguous or conflicting documentation the provider should be queried

Reference AHA Coding Clinic 2002 2nd Quarter pages 17-18

bull Query for acute blood loss anemia since hgb has dropped and patient is being transfused PRBC

bull Recommend query to clarify if cardiorenal syndrome is current as it is documented per 627 nephrology consult but unclear if current

bull Documentation does not support SIRS noninfectious without organ failure It is conflicting since patient has respiratory failure Query should be initiated for clarification with or without organ failure or infectious or non-infectious Patient has pneumonia per query as well as last progress note therefore if SIRS is not further specified per query PNA should be sequenced as principal diagnosis and SIRS should be removed

bull Recommend provider query necrotizing lung consolidation noted on DS as principal diagnosis-unclear does the patient have lobar pneumonia Secondary dx states necrotic pneumonia which is coded as principal diagnosis-this diagnosis is clear but consolidation portion is unclear

bull Recommend query for preterm labor delivery at 301 weeks

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull Query the provider regarding pathology report notation of endometriosis andor possible re-sequence of stenosis as principal diagnosis as it also meets principal diagnosis guidelines This would result in an MS-DRG change to 742 and APR-DRG change to 513

bull QUERY secondary diagnosis MCC and ROM 4 code T3166 (60 TBSA of which 60 are third degree burns) Chart notes do not specify how much of TBSA was actually third degree If after query TBSA is found to be less than 50 (T3164) then ROM will change from 4 to 3 but no change to overall APR-DRG or weight

Auditor Quality amp Productivity

Audit Productivity Standards

It takes twice as long to audit a chart as it does to code it a statistic that takes into account the time to document an explanation of any coding decision the auditor is not in agreement with o For example in an emergency department audit with a productivity of 12

charts per hour for a coder our auditors would probably be able to review six per hour

o If there are multiple services to audit on each encounter the productivity may only be 4 per hour

o The amount of detail you put into your audit report will also be a factorndash Are you using an automated audit softwarendash Are you using a spreadsheet to auditndash How many Systems are needed to complete the audit

Coder Quality Audits

Quality Audits (QA) should be done on your coders and auditors regularly Frequent reviews with smaller sample size will allow more consistent

review and feedbacko Example 10 charts per month per coder if the coder passes 2-3 months

consecutively with 95 or better score move them to quarterly reviewso Some QA programs review a percentage of the coders work This

methodology requires more time and resources

Auditor QA should also score and comment on the accuracy of the audit comments and recommendations

Presenting the Audit Results

Presenting the Audit Results

Communicating the Audit FindingsoWho requested the AuditoWho are you reporting the finding to

ndash CEOndash CFOndash Physicianndash Revenue Cycle Managerndash HIM Directorndash Billing Managerndash Coding Manager

ReportsAudit Resultspptx

Post Audit Education

Provider Education

Provider Education is best received when it is specific to the provider(s) 11 sessions going over the audit result Look at their notes with them

oHighlight areas for documentation improvementoReinforce Coding Guidelines that are specific to themoAsk them to share how they establish their LOS for E amp M serviceso Integrate their EMR system into the training

Provider Education

Group Training SessionsoUse the audit results to identify common issues within a specialty group

ndash Refer to the Executive Summary reportoVery effective for identifying system issues

ndash Teaching Attestationsndash Templatesndash Copy and Pastendash Cloned notes

o Everyone hears the same messagesoAn Issue may not appear on the individual audit but is still a concern for the

group

Education Delivery

In person or remote sessionso Factors to consider

ndash Providers scheduleavailabilityndash Location(s)ndash Personality of the providerndash Budget

Coder Education

Coders do well in group training so they can learn from each other 11 training allows the coder to get feedback on their coding

Handling Audit Disputes

Handling Audit Disputes

Be open to all points of viewo Let the documentation tell the story

Refer to the guidelines Ask

oCan we defend the reported service with the current documentation

Self Disclosures Refunds and Corrected Billing

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Procedure Accuracy Rates

Inpatient DRG Audit Report

TABLE OF CONTENTS

Executive Summaryo Scope of Work

Reimbursement Changes Department Results

o InpatientGeneral Recommendations and Comments

o Secondary DiagnosesoProcedure CodingoPresent on AdmissionoQueries

Scope of WorkCodingAID performed coding audit review of 175 inpatient records The review completed was a random sample that included cases coded by twenty coders for dates of service from May 2016 ndash July 2016

The objective was to determine if the medical record documentation supported the following coding and documentation requirements and any other regulatory requirement for that code set Criteria reviewed

1 ICD-10-CM Official Coding Guidelines for accurate diagnosis code reporting 2 ICD-10-PCS Official Coding Guidelines for accurate procedure code reporting 3 Documentation of procedure compared to the CPT code assigned 4 Identify opportunities for education and training 5 Financial impact of current coding practices

The regulatory agencies and reference materials relied upon include the following in addition to Medicare and Medicaid regulations Additional resources are located in the sub sections below

bull ICD-10-CM and ICD-10-PCS for Hospitals current volume bull Centers for Medicare and Medicaid Services CMS NCCI Edits-Centers for Medicaid and

Medicare Services CMS website wwwcmsgov bull AHA Coding Clinic

The following electronic medical record documents were reviewed and relied upon to compare to the actual codes submitted to the third party payer

bull Discharge summaries HampPs Progress Notes and other provider notes located in the EMR Records

bull Patient History Forms Ancillary Staff Notes bull Procedure Notes bull Orders bull Diagnostic Report

Reimbursement Changes

Coder Acct

Billed Audited

Reimbursement ChangesMS DRG SOI ROM Weight Expected

Payment MS DRG SOI ROM Weight Expected Payment

Coder 1 001 790 52300 $2615000 792 21552 $1077600 -$1537400

Coder 2002

749 26452 $1322600 758 10090 $504500 -$818100

Coder 3 003 669 13111 $655550 694 07294 $364700 -$290850

Coder 4 004 389 08707 $435350 394 09502 $475100 $39750

Coder 5 005 312 07630 $381500 812 08572 $428600 $47100

Coder 6 006 384 08481 $424050 378 09949 $497450 $73400

Coder 7 007 206 08164 $408200 794 12987 $649350 $241150

Coder 8008

344 31029 $1551450 853 51334 $2566700 $1015250

TOTAL $7793700 $6564000 -$1229700

General Recommendations and CommentsFinding Pertinent secondary diagnoses are not coded and diagnoses are code which are not supported in provider documentation Code only those diagnoses which are documented by the provider on the current chart Not all codes are coded to the highest degree of specificity and combination codes were sometimes missed

Recommendation It is important to assign codes for all conditions which meet the definition of a reportable diagnosis Documentation from all providers should be used including but not limited to radiologists pathologists anesthesiologists CRNAs and FNPs

Reference Coding Clinic Official Coding Guidelines

bull Report all secondary diagnoses which meet the definition of a secondary diagnosis which is defined as all conditions that coexist at the time of admission that develop subsequently or that affect the treatment received andor the length of stay Codes which enhance the overall picture of the patientrsquos visit should be added

o Add T45515A to report adverse effect of Coumadin which caused the GI bleed

o Add I2690 for septic pulmonary emboli (MCCSOI4ROM4)

o Add N179 for acute kidney failure (S3M2CC) per the nephrology consult and the 628 progress note

o Add code I429 cardiomyopathy per HampP

o Add B964 to report proteus in a UTI per the 620 hospitalist progress note

o Code for D649 anemia and I701 stenosis of renal artery should be added as secondary diagnoses per the HampP

bull Only report diagnoses which are substantiated by provider documentation in the current chart notes If a suspected condition is not verified at discharge on an inpatient account it cannot be coded

o Remove G4734 (idiopathic sleep related non-obstructive alveolar hypoventilation) as patient was noted to have the sleep study and the hypoventilation was shown to be a possibility but not noted as such on discharge

o Remove G629 (S21) the neuropathy is documented as due to diabetes

o Remove K529 colitis noted on HP as possible but not further noted or confirmed at discharge

Procedure CodingFinding Procedures were sometimes coded incorrectly

Recommendation The entire medical record should be reviewed and all procedures coded as documented Coding procedures incorrectly or assigning incorrect CPT codes may result in lost revenue

bull Incorrect root operation

o Revise principal procedure to 0DQ68ZZ for clipping of the ulcer per OP report clipping is root operation repair

bull Biopsy versus Excision

o Procedure 0DBA0ZX (biopsy of jejunum) should change to 0DBA0ZZ (excision of jejunum) per op note this was not a biopsy procedure

bull Coding Guideline error

o Remove 0RG10K0 for allograft due to being inclusive in principal procedure

o Remove codes for adhesiolysis 0DN80ZZ 0UN10ZZ and 0UN90ZZ due to no significance noted per OP report

bull Incorrect approach

o Revise 0TF63ZZ (fragmentation percutaneous approach) to 0TF68ZZ (fragmentation endoscopic) for procedure performed via scope per the operative report

bull Procedure coded without provider documentation

o Remove secondary procedure of excisional debridement (0JB90ZZ) due to lack of documentation of excisional debridement per operative report The header in the operative report documents IampD and debridement but the body of the operative report only documents an IampD

bull Incorrect CPT code assignment

o Post-op note supports the nerve block injections of four nerves therefore code 64421 (multiple nerve block) should replace 64420 (injection of one intercostal nerve)

Queries Finding Conflicting incomplete and vague documentation is found within provider chart notes

Recommendation Prior to code assignment if the coder finds ambiguous or conflicting documentation the provider should be queried

Reference AHA Coding Clinic 2002 2nd Quarter pages 17-18

bull Query for acute blood loss anemia since hgb has dropped and patient is being transfused PRBC

bull Recommend query to clarify if cardiorenal syndrome is current as it is documented per 627 nephrology consult but unclear if current

bull Documentation does not support SIRS noninfectious without organ failure It is conflicting since patient has respiratory failure Query should be initiated for clarification with or without organ failure or infectious or non-infectious Patient has pneumonia per query as well as last progress note therefore if SIRS is not further specified per query PNA should be sequenced as principal diagnosis and SIRS should be removed

bull Recommend provider query necrotizing lung consolidation noted on DS as principal diagnosis-unclear does the patient have lobar pneumonia Secondary dx states necrotic pneumonia which is coded as principal diagnosis-this diagnosis is clear but consolidation portion is unclear

bull Recommend query for preterm labor delivery at 301 weeks

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull Query the provider regarding pathology report notation of endometriosis andor possible re-sequence of stenosis as principal diagnosis as it also meets principal diagnosis guidelines This would result in an MS-DRG change to 742 and APR-DRG change to 513

bull QUERY secondary diagnosis MCC and ROM 4 code T3166 (60 TBSA of which 60 are third degree burns) Chart notes do not specify how much of TBSA was actually third degree If after query TBSA is found to be less than 50 (T3164) then ROM will change from 4 to 3 but no change to overall APR-DRG or weight

Auditor Quality amp Productivity

Audit Productivity Standards

It takes twice as long to audit a chart as it does to code it a statistic that takes into account the time to document an explanation of any coding decision the auditor is not in agreement with o For example in an emergency department audit with a productivity of 12

charts per hour for a coder our auditors would probably be able to review six per hour

o If there are multiple services to audit on each encounter the productivity may only be 4 per hour

o The amount of detail you put into your audit report will also be a factorndash Are you using an automated audit softwarendash Are you using a spreadsheet to auditndash How many Systems are needed to complete the audit

Coder Quality Audits

Quality Audits (QA) should be done on your coders and auditors regularly Frequent reviews with smaller sample size will allow more consistent

review and feedbacko Example 10 charts per month per coder if the coder passes 2-3 months

consecutively with 95 or better score move them to quarterly reviewso Some QA programs review a percentage of the coders work This

methodology requires more time and resources

Auditor QA should also score and comment on the accuracy of the audit comments and recommendations

Presenting the Audit Results

Presenting the Audit Results

Communicating the Audit FindingsoWho requested the AuditoWho are you reporting the finding to

ndash CEOndash CFOndash Physicianndash Revenue Cycle Managerndash HIM Directorndash Billing Managerndash Coding Manager

ReportsAudit Resultspptx

Post Audit Education

Provider Education

Provider Education is best received when it is specific to the provider(s) 11 sessions going over the audit result Look at their notes with them

oHighlight areas for documentation improvementoReinforce Coding Guidelines that are specific to themoAsk them to share how they establish their LOS for E amp M serviceso Integrate their EMR system into the training

Provider Education

Group Training SessionsoUse the audit results to identify common issues within a specialty group

ndash Refer to the Executive Summary reportoVery effective for identifying system issues

ndash Teaching Attestationsndash Templatesndash Copy and Pastendash Cloned notes

o Everyone hears the same messagesoAn Issue may not appear on the individual audit but is still a concern for the

group

Education Delivery

In person or remote sessionso Factors to consider

ndash Providers scheduleavailabilityndash Location(s)ndash Personality of the providerndash Budget

Coder Education

Coders do well in group training so they can learn from each other 11 training allows the coder to get feedback on their coding

Handling Audit Disputes

Handling Audit Disputes

Be open to all points of viewo Let the documentation tell the story

Refer to the guidelines Ask

oCan we defend the reported service with the current documentation

Self Disclosures Refunds and Corrected Billing

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Inpatient DRG Audit Report

TABLE OF CONTENTS

Executive Summaryo Scope of Work

Reimbursement Changes Department Results

o InpatientGeneral Recommendations and Comments

o Secondary DiagnosesoProcedure CodingoPresent on AdmissionoQueries

Scope of WorkCodingAID performed coding audit review of 175 inpatient records The review completed was a random sample that included cases coded by twenty coders for dates of service from May 2016 ndash July 2016

The objective was to determine if the medical record documentation supported the following coding and documentation requirements and any other regulatory requirement for that code set Criteria reviewed

1 ICD-10-CM Official Coding Guidelines for accurate diagnosis code reporting 2 ICD-10-PCS Official Coding Guidelines for accurate procedure code reporting 3 Documentation of procedure compared to the CPT code assigned 4 Identify opportunities for education and training 5 Financial impact of current coding practices

The regulatory agencies and reference materials relied upon include the following in addition to Medicare and Medicaid regulations Additional resources are located in the sub sections below

bull ICD-10-CM and ICD-10-PCS for Hospitals current volume bull Centers for Medicare and Medicaid Services CMS NCCI Edits-Centers for Medicaid and

Medicare Services CMS website wwwcmsgov bull AHA Coding Clinic

The following electronic medical record documents were reviewed and relied upon to compare to the actual codes submitted to the third party payer

bull Discharge summaries HampPs Progress Notes and other provider notes located in the EMR Records

bull Patient History Forms Ancillary Staff Notes bull Procedure Notes bull Orders bull Diagnostic Report

Reimbursement Changes

Coder Acct

Billed Audited

Reimbursement ChangesMS DRG SOI ROM Weight Expected

Payment MS DRG SOI ROM Weight Expected Payment

Coder 1 001 790 52300 $2615000 792 21552 $1077600 -$1537400

Coder 2002

749 26452 $1322600 758 10090 $504500 -$818100

Coder 3 003 669 13111 $655550 694 07294 $364700 -$290850

Coder 4 004 389 08707 $435350 394 09502 $475100 $39750

Coder 5 005 312 07630 $381500 812 08572 $428600 $47100

Coder 6 006 384 08481 $424050 378 09949 $497450 $73400

Coder 7 007 206 08164 $408200 794 12987 $649350 $241150

Coder 8008

344 31029 $1551450 853 51334 $2566700 $1015250

TOTAL $7793700 $6564000 -$1229700

General Recommendations and CommentsFinding Pertinent secondary diagnoses are not coded and diagnoses are code which are not supported in provider documentation Code only those diagnoses which are documented by the provider on the current chart Not all codes are coded to the highest degree of specificity and combination codes were sometimes missed

Recommendation It is important to assign codes for all conditions which meet the definition of a reportable diagnosis Documentation from all providers should be used including but not limited to radiologists pathologists anesthesiologists CRNAs and FNPs

Reference Coding Clinic Official Coding Guidelines

bull Report all secondary diagnoses which meet the definition of a secondary diagnosis which is defined as all conditions that coexist at the time of admission that develop subsequently or that affect the treatment received andor the length of stay Codes which enhance the overall picture of the patientrsquos visit should be added

o Add T45515A to report adverse effect of Coumadin which caused the GI bleed

o Add I2690 for septic pulmonary emboli (MCCSOI4ROM4)

o Add N179 for acute kidney failure (S3M2CC) per the nephrology consult and the 628 progress note

o Add code I429 cardiomyopathy per HampP

o Add B964 to report proteus in a UTI per the 620 hospitalist progress note

o Code for D649 anemia and I701 stenosis of renal artery should be added as secondary diagnoses per the HampP

bull Only report diagnoses which are substantiated by provider documentation in the current chart notes If a suspected condition is not verified at discharge on an inpatient account it cannot be coded

o Remove G4734 (idiopathic sleep related non-obstructive alveolar hypoventilation) as patient was noted to have the sleep study and the hypoventilation was shown to be a possibility but not noted as such on discharge

o Remove G629 (S21) the neuropathy is documented as due to diabetes

o Remove K529 colitis noted on HP as possible but not further noted or confirmed at discharge

Procedure CodingFinding Procedures were sometimes coded incorrectly

Recommendation The entire medical record should be reviewed and all procedures coded as documented Coding procedures incorrectly or assigning incorrect CPT codes may result in lost revenue

bull Incorrect root operation

o Revise principal procedure to 0DQ68ZZ for clipping of the ulcer per OP report clipping is root operation repair

bull Biopsy versus Excision

o Procedure 0DBA0ZX (biopsy of jejunum) should change to 0DBA0ZZ (excision of jejunum) per op note this was not a biopsy procedure

bull Coding Guideline error

o Remove 0RG10K0 for allograft due to being inclusive in principal procedure

o Remove codes for adhesiolysis 0DN80ZZ 0UN10ZZ and 0UN90ZZ due to no significance noted per OP report

bull Incorrect approach

o Revise 0TF63ZZ (fragmentation percutaneous approach) to 0TF68ZZ (fragmentation endoscopic) for procedure performed via scope per the operative report

bull Procedure coded without provider documentation

o Remove secondary procedure of excisional debridement (0JB90ZZ) due to lack of documentation of excisional debridement per operative report The header in the operative report documents IampD and debridement but the body of the operative report only documents an IampD

bull Incorrect CPT code assignment

o Post-op note supports the nerve block injections of four nerves therefore code 64421 (multiple nerve block) should replace 64420 (injection of one intercostal nerve)

Queries Finding Conflicting incomplete and vague documentation is found within provider chart notes

Recommendation Prior to code assignment if the coder finds ambiguous or conflicting documentation the provider should be queried

Reference AHA Coding Clinic 2002 2nd Quarter pages 17-18

bull Query for acute blood loss anemia since hgb has dropped and patient is being transfused PRBC

bull Recommend query to clarify if cardiorenal syndrome is current as it is documented per 627 nephrology consult but unclear if current

bull Documentation does not support SIRS noninfectious without organ failure It is conflicting since patient has respiratory failure Query should be initiated for clarification with or without organ failure or infectious or non-infectious Patient has pneumonia per query as well as last progress note therefore if SIRS is not further specified per query PNA should be sequenced as principal diagnosis and SIRS should be removed

bull Recommend provider query necrotizing lung consolidation noted on DS as principal diagnosis-unclear does the patient have lobar pneumonia Secondary dx states necrotic pneumonia which is coded as principal diagnosis-this diagnosis is clear but consolidation portion is unclear

bull Recommend query for preterm labor delivery at 301 weeks

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull Query the provider regarding pathology report notation of endometriosis andor possible re-sequence of stenosis as principal diagnosis as it also meets principal diagnosis guidelines This would result in an MS-DRG change to 742 and APR-DRG change to 513

bull QUERY secondary diagnosis MCC and ROM 4 code T3166 (60 TBSA of which 60 are third degree burns) Chart notes do not specify how much of TBSA was actually third degree If after query TBSA is found to be less than 50 (T3164) then ROM will change from 4 to 3 but no change to overall APR-DRG or weight

Auditor Quality amp Productivity

Audit Productivity Standards

It takes twice as long to audit a chart as it does to code it a statistic that takes into account the time to document an explanation of any coding decision the auditor is not in agreement with o For example in an emergency department audit with a productivity of 12

charts per hour for a coder our auditors would probably be able to review six per hour

o If there are multiple services to audit on each encounter the productivity may only be 4 per hour

o The amount of detail you put into your audit report will also be a factorndash Are you using an automated audit softwarendash Are you using a spreadsheet to auditndash How many Systems are needed to complete the audit

Coder Quality Audits

Quality Audits (QA) should be done on your coders and auditors regularly Frequent reviews with smaller sample size will allow more consistent

review and feedbacko Example 10 charts per month per coder if the coder passes 2-3 months

consecutively with 95 or better score move them to quarterly reviewso Some QA programs review a percentage of the coders work This

methodology requires more time and resources

Auditor QA should also score and comment on the accuracy of the audit comments and recommendations

Presenting the Audit Results

Presenting the Audit Results

Communicating the Audit FindingsoWho requested the AuditoWho are you reporting the finding to

ndash CEOndash CFOndash Physicianndash Revenue Cycle Managerndash HIM Directorndash Billing Managerndash Coding Manager

ReportsAudit Resultspptx

Post Audit Education

Provider Education

Provider Education is best received when it is specific to the provider(s) 11 sessions going over the audit result Look at their notes with them

oHighlight areas for documentation improvementoReinforce Coding Guidelines that are specific to themoAsk them to share how they establish their LOS for E amp M serviceso Integrate their EMR system into the training

Provider Education

Group Training SessionsoUse the audit results to identify common issues within a specialty group

ndash Refer to the Executive Summary reportoVery effective for identifying system issues

ndash Teaching Attestationsndash Templatesndash Copy and Pastendash Cloned notes

o Everyone hears the same messagesoAn Issue may not appear on the individual audit but is still a concern for the

group

Education Delivery

In person or remote sessionso Factors to consider

ndash Providers scheduleavailabilityndash Location(s)ndash Personality of the providerndash Budget

Coder Education

Coders do well in group training so they can learn from each other 11 training allows the coder to get feedback on their coding

Handling Audit Disputes

Handling Audit Disputes

Be open to all points of viewo Let the documentation tell the story

Refer to the guidelines Ask

oCan we defend the reported service with the current documentation

Self Disclosures Refunds and Corrected Billing

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Scope of WorkCodingAID performed coding audit review of 175 inpatient records The review completed was a random sample that included cases coded by twenty coders for dates of service from May 2016 ndash July 2016

The objective was to determine if the medical record documentation supported the following coding and documentation requirements and any other regulatory requirement for that code set Criteria reviewed

1 ICD-10-CM Official Coding Guidelines for accurate diagnosis code reporting 2 ICD-10-PCS Official Coding Guidelines for accurate procedure code reporting 3 Documentation of procedure compared to the CPT code assigned 4 Identify opportunities for education and training 5 Financial impact of current coding practices

The regulatory agencies and reference materials relied upon include the following in addition to Medicare and Medicaid regulations Additional resources are located in the sub sections below

bull ICD-10-CM and ICD-10-PCS for Hospitals current volume bull Centers for Medicare and Medicaid Services CMS NCCI Edits-Centers for Medicaid and

Medicare Services CMS website wwwcmsgov bull AHA Coding Clinic

The following electronic medical record documents were reviewed and relied upon to compare to the actual codes submitted to the third party payer

bull Discharge summaries HampPs Progress Notes and other provider notes located in the EMR Records

bull Patient History Forms Ancillary Staff Notes bull Procedure Notes bull Orders bull Diagnostic Report

Reimbursement Changes

Coder Acct

Billed Audited

Reimbursement ChangesMS DRG SOI ROM Weight Expected

Payment MS DRG SOI ROM Weight Expected Payment

Coder 1 001 790 52300 $2615000 792 21552 $1077600 -$1537400

Coder 2002

749 26452 $1322600 758 10090 $504500 -$818100

Coder 3 003 669 13111 $655550 694 07294 $364700 -$290850

Coder 4 004 389 08707 $435350 394 09502 $475100 $39750

Coder 5 005 312 07630 $381500 812 08572 $428600 $47100

Coder 6 006 384 08481 $424050 378 09949 $497450 $73400

Coder 7 007 206 08164 $408200 794 12987 $649350 $241150

Coder 8008

344 31029 $1551450 853 51334 $2566700 $1015250

TOTAL $7793700 $6564000 -$1229700

General Recommendations and CommentsFinding Pertinent secondary diagnoses are not coded and diagnoses are code which are not supported in provider documentation Code only those diagnoses which are documented by the provider on the current chart Not all codes are coded to the highest degree of specificity and combination codes were sometimes missed

Recommendation It is important to assign codes for all conditions which meet the definition of a reportable diagnosis Documentation from all providers should be used including but not limited to radiologists pathologists anesthesiologists CRNAs and FNPs

Reference Coding Clinic Official Coding Guidelines

bull Report all secondary diagnoses which meet the definition of a secondary diagnosis which is defined as all conditions that coexist at the time of admission that develop subsequently or that affect the treatment received andor the length of stay Codes which enhance the overall picture of the patientrsquos visit should be added

o Add T45515A to report adverse effect of Coumadin which caused the GI bleed

o Add I2690 for septic pulmonary emboli (MCCSOI4ROM4)

o Add N179 for acute kidney failure (S3M2CC) per the nephrology consult and the 628 progress note

o Add code I429 cardiomyopathy per HampP

o Add B964 to report proteus in a UTI per the 620 hospitalist progress note

o Code for D649 anemia and I701 stenosis of renal artery should be added as secondary diagnoses per the HampP

bull Only report diagnoses which are substantiated by provider documentation in the current chart notes If a suspected condition is not verified at discharge on an inpatient account it cannot be coded

o Remove G4734 (idiopathic sleep related non-obstructive alveolar hypoventilation) as patient was noted to have the sleep study and the hypoventilation was shown to be a possibility but not noted as such on discharge

o Remove G629 (S21) the neuropathy is documented as due to diabetes

o Remove K529 colitis noted on HP as possible but not further noted or confirmed at discharge

Procedure CodingFinding Procedures were sometimes coded incorrectly

Recommendation The entire medical record should be reviewed and all procedures coded as documented Coding procedures incorrectly or assigning incorrect CPT codes may result in lost revenue

bull Incorrect root operation

o Revise principal procedure to 0DQ68ZZ for clipping of the ulcer per OP report clipping is root operation repair

bull Biopsy versus Excision

o Procedure 0DBA0ZX (biopsy of jejunum) should change to 0DBA0ZZ (excision of jejunum) per op note this was not a biopsy procedure

bull Coding Guideline error

o Remove 0RG10K0 for allograft due to being inclusive in principal procedure

o Remove codes for adhesiolysis 0DN80ZZ 0UN10ZZ and 0UN90ZZ due to no significance noted per OP report

bull Incorrect approach

o Revise 0TF63ZZ (fragmentation percutaneous approach) to 0TF68ZZ (fragmentation endoscopic) for procedure performed via scope per the operative report

bull Procedure coded without provider documentation

o Remove secondary procedure of excisional debridement (0JB90ZZ) due to lack of documentation of excisional debridement per operative report The header in the operative report documents IampD and debridement but the body of the operative report only documents an IampD

bull Incorrect CPT code assignment

o Post-op note supports the nerve block injections of four nerves therefore code 64421 (multiple nerve block) should replace 64420 (injection of one intercostal nerve)

Queries Finding Conflicting incomplete and vague documentation is found within provider chart notes

Recommendation Prior to code assignment if the coder finds ambiguous or conflicting documentation the provider should be queried

Reference AHA Coding Clinic 2002 2nd Quarter pages 17-18

bull Query for acute blood loss anemia since hgb has dropped and patient is being transfused PRBC

bull Recommend query to clarify if cardiorenal syndrome is current as it is documented per 627 nephrology consult but unclear if current

bull Documentation does not support SIRS noninfectious without organ failure It is conflicting since patient has respiratory failure Query should be initiated for clarification with or without organ failure or infectious or non-infectious Patient has pneumonia per query as well as last progress note therefore if SIRS is not further specified per query PNA should be sequenced as principal diagnosis and SIRS should be removed

bull Recommend provider query necrotizing lung consolidation noted on DS as principal diagnosis-unclear does the patient have lobar pneumonia Secondary dx states necrotic pneumonia which is coded as principal diagnosis-this diagnosis is clear but consolidation portion is unclear

bull Recommend query for preterm labor delivery at 301 weeks

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull Query the provider regarding pathology report notation of endometriosis andor possible re-sequence of stenosis as principal diagnosis as it also meets principal diagnosis guidelines This would result in an MS-DRG change to 742 and APR-DRG change to 513

bull QUERY secondary diagnosis MCC and ROM 4 code T3166 (60 TBSA of which 60 are third degree burns) Chart notes do not specify how much of TBSA was actually third degree If after query TBSA is found to be less than 50 (T3164) then ROM will change from 4 to 3 but no change to overall APR-DRG or weight

Auditor Quality amp Productivity

Audit Productivity Standards

It takes twice as long to audit a chart as it does to code it a statistic that takes into account the time to document an explanation of any coding decision the auditor is not in agreement with o For example in an emergency department audit with a productivity of 12

charts per hour for a coder our auditors would probably be able to review six per hour

o If there are multiple services to audit on each encounter the productivity may only be 4 per hour

o The amount of detail you put into your audit report will also be a factorndash Are you using an automated audit softwarendash Are you using a spreadsheet to auditndash How many Systems are needed to complete the audit

Coder Quality Audits

Quality Audits (QA) should be done on your coders and auditors regularly Frequent reviews with smaller sample size will allow more consistent

review and feedbacko Example 10 charts per month per coder if the coder passes 2-3 months

consecutively with 95 or better score move them to quarterly reviewso Some QA programs review a percentage of the coders work This

methodology requires more time and resources

Auditor QA should also score and comment on the accuracy of the audit comments and recommendations

Presenting the Audit Results

Presenting the Audit Results

Communicating the Audit FindingsoWho requested the AuditoWho are you reporting the finding to

ndash CEOndash CFOndash Physicianndash Revenue Cycle Managerndash HIM Directorndash Billing Managerndash Coding Manager

ReportsAudit Resultspptx

Post Audit Education

Provider Education

Provider Education is best received when it is specific to the provider(s) 11 sessions going over the audit result Look at their notes with them

oHighlight areas for documentation improvementoReinforce Coding Guidelines that are specific to themoAsk them to share how they establish their LOS for E amp M serviceso Integrate their EMR system into the training

Provider Education

Group Training SessionsoUse the audit results to identify common issues within a specialty group

ndash Refer to the Executive Summary reportoVery effective for identifying system issues

ndash Teaching Attestationsndash Templatesndash Copy and Pastendash Cloned notes

o Everyone hears the same messagesoAn Issue may not appear on the individual audit but is still a concern for the

group

Education Delivery

In person or remote sessionso Factors to consider

ndash Providers scheduleavailabilityndash Location(s)ndash Personality of the providerndash Budget

Coder Education

Coders do well in group training so they can learn from each other 11 training allows the coder to get feedback on their coding

Handling Audit Disputes

Handling Audit Disputes

Be open to all points of viewo Let the documentation tell the story

Refer to the guidelines Ask

oCan we defend the reported service with the current documentation

Self Disclosures Refunds and Corrected Billing

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Reimbursement Changes

Coder Acct

Billed Audited

Reimbursement ChangesMS DRG SOI ROM Weight Expected

Payment MS DRG SOI ROM Weight Expected Payment

Coder 1 001 790 52300 $2615000 792 21552 $1077600 -$1537400

Coder 2002

749 26452 $1322600 758 10090 $504500 -$818100

Coder 3 003 669 13111 $655550 694 07294 $364700 -$290850

Coder 4 004 389 08707 $435350 394 09502 $475100 $39750

Coder 5 005 312 07630 $381500 812 08572 $428600 $47100

Coder 6 006 384 08481 $424050 378 09949 $497450 $73400

Coder 7 007 206 08164 $408200 794 12987 $649350 $241150

Coder 8008

344 31029 $1551450 853 51334 $2566700 $1015250

TOTAL $7793700 $6564000 -$1229700

General Recommendations and CommentsFinding Pertinent secondary diagnoses are not coded and diagnoses are code which are not supported in provider documentation Code only those diagnoses which are documented by the provider on the current chart Not all codes are coded to the highest degree of specificity and combination codes were sometimes missed

Recommendation It is important to assign codes for all conditions which meet the definition of a reportable diagnosis Documentation from all providers should be used including but not limited to radiologists pathologists anesthesiologists CRNAs and FNPs

Reference Coding Clinic Official Coding Guidelines

bull Report all secondary diagnoses which meet the definition of a secondary diagnosis which is defined as all conditions that coexist at the time of admission that develop subsequently or that affect the treatment received andor the length of stay Codes which enhance the overall picture of the patientrsquos visit should be added

o Add T45515A to report adverse effect of Coumadin which caused the GI bleed

o Add I2690 for septic pulmonary emboli (MCCSOI4ROM4)

o Add N179 for acute kidney failure (S3M2CC) per the nephrology consult and the 628 progress note

o Add code I429 cardiomyopathy per HampP

o Add B964 to report proteus in a UTI per the 620 hospitalist progress note

o Code for D649 anemia and I701 stenosis of renal artery should be added as secondary diagnoses per the HampP

bull Only report diagnoses which are substantiated by provider documentation in the current chart notes If a suspected condition is not verified at discharge on an inpatient account it cannot be coded

o Remove G4734 (idiopathic sleep related non-obstructive alveolar hypoventilation) as patient was noted to have the sleep study and the hypoventilation was shown to be a possibility but not noted as such on discharge

o Remove G629 (S21) the neuropathy is documented as due to diabetes

o Remove K529 colitis noted on HP as possible but not further noted or confirmed at discharge

Procedure CodingFinding Procedures were sometimes coded incorrectly

Recommendation The entire medical record should be reviewed and all procedures coded as documented Coding procedures incorrectly or assigning incorrect CPT codes may result in lost revenue

bull Incorrect root operation

o Revise principal procedure to 0DQ68ZZ for clipping of the ulcer per OP report clipping is root operation repair

bull Biopsy versus Excision

o Procedure 0DBA0ZX (biopsy of jejunum) should change to 0DBA0ZZ (excision of jejunum) per op note this was not a biopsy procedure

bull Coding Guideline error

o Remove 0RG10K0 for allograft due to being inclusive in principal procedure

o Remove codes for adhesiolysis 0DN80ZZ 0UN10ZZ and 0UN90ZZ due to no significance noted per OP report

bull Incorrect approach

o Revise 0TF63ZZ (fragmentation percutaneous approach) to 0TF68ZZ (fragmentation endoscopic) for procedure performed via scope per the operative report

bull Procedure coded without provider documentation

o Remove secondary procedure of excisional debridement (0JB90ZZ) due to lack of documentation of excisional debridement per operative report The header in the operative report documents IampD and debridement but the body of the operative report only documents an IampD

bull Incorrect CPT code assignment

o Post-op note supports the nerve block injections of four nerves therefore code 64421 (multiple nerve block) should replace 64420 (injection of one intercostal nerve)

Queries Finding Conflicting incomplete and vague documentation is found within provider chart notes

Recommendation Prior to code assignment if the coder finds ambiguous or conflicting documentation the provider should be queried

Reference AHA Coding Clinic 2002 2nd Quarter pages 17-18

bull Query for acute blood loss anemia since hgb has dropped and patient is being transfused PRBC

bull Recommend query to clarify if cardiorenal syndrome is current as it is documented per 627 nephrology consult but unclear if current

bull Documentation does not support SIRS noninfectious without organ failure It is conflicting since patient has respiratory failure Query should be initiated for clarification with or without organ failure or infectious or non-infectious Patient has pneumonia per query as well as last progress note therefore if SIRS is not further specified per query PNA should be sequenced as principal diagnosis and SIRS should be removed

bull Recommend provider query necrotizing lung consolidation noted on DS as principal diagnosis-unclear does the patient have lobar pneumonia Secondary dx states necrotic pneumonia which is coded as principal diagnosis-this diagnosis is clear but consolidation portion is unclear

bull Recommend query for preterm labor delivery at 301 weeks

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull Query the provider regarding pathology report notation of endometriosis andor possible re-sequence of stenosis as principal diagnosis as it also meets principal diagnosis guidelines This would result in an MS-DRG change to 742 and APR-DRG change to 513

bull QUERY secondary diagnosis MCC and ROM 4 code T3166 (60 TBSA of which 60 are third degree burns) Chart notes do not specify how much of TBSA was actually third degree If after query TBSA is found to be less than 50 (T3164) then ROM will change from 4 to 3 but no change to overall APR-DRG or weight

Auditor Quality amp Productivity

Audit Productivity Standards

It takes twice as long to audit a chart as it does to code it a statistic that takes into account the time to document an explanation of any coding decision the auditor is not in agreement with o For example in an emergency department audit with a productivity of 12

charts per hour for a coder our auditors would probably be able to review six per hour

o If there are multiple services to audit on each encounter the productivity may only be 4 per hour

o The amount of detail you put into your audit report will also be a factorndash Are you using an automated audit softwarendash Are you using a spreadsheet to auditndash How many Systems are needed to complete the audit

Coder Quality Audits

Quality Audits (QA) should be done on your coders and auditors regularly Frequent reviews with smaller sample size will allow more consistent

review and feedbacko Example 10 charts per month per coder if the coder passes 2-3 months

consecutively with 95 or better score move them to quarterly reviewso Some QA programs review a percentage of the coders work This

methodology requires more time and resources

Auditor QA should also score and comment on the accuracy of the audit comments and recommendations

Presenting the Audit Results

Presenting the Audit Results

Communicating the Audit FindingsoWho requested the AuditoWho are you reporting the finding to

ndash CEOndash CFOndash Physicianndash Revenue Cycle Managerndash HIM Directorndash Billing Managerndash Coding Manager

ReportsAudit Resultspptx

Post Audit Education

Provider Education

Provider Education is best received when it is specific to the provider(s) 11 sessions going over the audit result Look at their notes with them

oHighlight areas for documentation improvementoReinforce Coding Guidelines that are specific to themoAsk them to share how they establish their LOS for E amp M serviceso Integrate their EMR system into the training

Provider Education

Group Training SessionsoUse the audit results to identify common issues within a specialty group

ndash Refer to the Executive Summary reportoVery effective for identifying system issues

ndash Teaching Attestationsndash Templatesndash Copy and Pastendash Cloned notes

o Everyone hears the same messagesoAn Issue may not appear on the individual audit but is still a concern for the

group

Education Delivery

In person or remote sessionso Factors to consider

ndash Providers scheduleavailabilityndash Location(s)ndash Personality of the providerndash Budget

Coder Education

Coders do well in group training so they can learn from each other 11 training allows the coder to get feedback on their coding

Handling Audit Disputes

Handling Audit Disputes

Be open to all points of viewo Let the documentation tell the story

Refer to the guidelines Ask

oCan we defend the reported service with the current documentation

Self Disclosures Refunds and Corrected Billing

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

General Recommendations and CommentsFinding Pertinent secondary diagnoses are not coded and diagnoses are code which are not supported in provider documentation Code only those diagnoses which are documented by the provider on the current chart Not all codes are coded to the highest degree of specificity and combination codes were sometimes missed

Recommendation It is important to assign codes for all conditions which meet the definition of a reportable diagnosis Documentation from all providers should be used including but not limited to radiologists pathologists anesthesiologists CRNAs and FNPs

Reference Coding Clinic Official Coding Guidelines

bull Report all secondary diagnoses which meet the definition of a secondary diagnosis which is defined as all conditions that coexist at the time of admission that develop subsequently or that affect the treatment received andor the length of stay Codes which enhance the overall picture of the patientrsquos visit should be added

o Add T45515A to report adverse effect of Coumadin which caused the GI bleed

o Add I2690 for septic pulmonary emboli (MCCSOI4ROM4)

o Add N179 for acute kidney failure (S3M2CC) per the nephrology consult and the 628 progress note

o Add code I429 cardiomyopathy per HampP

o Add B964 to report proteus in a UTI per the 620 hospitalist progress note

o Code for D649 anemia and I701 stenosis of renal artery should be added as secondary diagnoses per the HampP

bull Only report diagnoses which are substantiated by provider documentation in the current chart notes If a suspected condition is not verified at discharge on an inpatient account it cannot be coded

o Remove G4734 (idiopathic sleep related non-obstructive alveolar hypoventilation) as patient was noted to have the sleep study and the hypoventilation was shown to be a possibility but not noted as such on discharge

o Remove G629 (S21) the neuropathy is documented as due to diabetes

o Remove K529 colitis noted on HP as possible but not further noted or confirmed at discharge

Procedure CodingFinding Procedures were sometimes coded incorrectly

Recommendation The entire medical record should be reviewed and all procedures coded as documented Coding procedures incorrectly or assigning incorrect CPT codes may result in lost revenue

bull Incorrect root operation

o Revise principal procedure to 0DQ68ZZ for clipping of the ulcer per OP report clipping is root operation repair

bull Biopsy versus Excision

o Procedure 0DBA0ZX (biopsy of jejunum) should change to 0DBA0ZZ (excision of jejunum) per op note this was not a biopsy procedure

bull Coding Guideline error

o Remove 0RG10K0 for allograft due to being inclusive in principal procedure

o Remove codes for adhesiolysis 0DN80ZZ 0UN10ZZ and 0UN90ZZ due to no significance noted per OP report

bull Incorrect approach

o Revise 0TF63ZZ (fragmentation percutaneous approach) to 0TF68ZZ (fragmentation endoscopic) for procedure performed via scope per the operative report

bull Procedure coded without provider documentation

o Remove secondary procedure of excisional debridement (0JB90ZZ) due to lack of documentation of excisional debridement per operative report The header in the operative report documents IampD and debridement but the body of the operative report only documents an IampD

bull Incorrect CPT code assignment

o Post-op note supports the nerve block injections of four nerves therefore code 64421 (multiple nerve block) should replace 64420 (injection of one intercostal nerve)

Queries Finding Conflicting incomplete and vague documentation is found within provider chart notes

Recommendation Prior to code assignment if the coder finds ambiguous or conflicting documentation the provider should be queried

Reference AHA Coding Clinic 2002 2nd Quarter pages 17-18

bull Query for acute blood loss anemia since hgb has dropped and patient is being transfused PRBC

bull Recommend query to clarify if cardiorenal syndrome is current as it is documented per 627 nephrology consult but unclear if current

bull Documentation does not support SIRS noninfectious without organ failure It is conflicting since patient has respiratory failure Query should be initiated for clarification with or without organ failure or infectious or non-infectious Patient has pneumonia per query as well as last progress note therefore if SIRS is not further specified per query PNA should be sequenced as principal diagnosis and SIRS should be removed

bull Recommend provider query necrotizing lung consolidation noted on DS as principal diagnosis-unclear does the patient have lobar pneumonia Secondary dx states necrotic pneumonia which is coded as principal diagnosis-this diagnosis is clear but consolidation portion is unclear

bull Recommend query for preterm labor delivery at 301 weeks

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull Query the provider regarding pathology report notation of endometriosis andor possible re-sequence of stenosis as principal diagnosis as it also meets principal diagnosis guidelines This would result in an MS-DRG change to 742 and APR-DRG change to 513

bull QUERY secondary diagnosis MCC and ROM 4 code T3166 (60 TBSA of which 60 are third degree burns) Chart notes do not specify how much of TBSA was actually third degree If after query TBSA is found to be less than 50 (T3164) then ROM will change from 4 to 3 but no change to overall APR-DRG or weight

Auditor Quality amp Productivity

Audit Productivity Standards

It takes twice as long to audit a chart as it does to code it a statistic that takes into account the time to document an explanation of any coding decision the auditor is not in agreement with o For example in an emergency department audit with a productivity of 12

charts per hour for a coder our auditors would probably be able to review six per hour

o If there are multiple services to audit on each encounter the productivity may only be 4 per hour

o The amount of detail you put into your audit report will also be a factorndash Are you using an automated audit softwarendash Are you using a spreadsheet to auditndash How many Systems are needed to complete the audit

Coder Quality Audits

Quality Audits (QA) should be done on your coders and auditors regularly Frequent reviews with smaller sample size will allow more consistent

review and feedbacko Example 10 charts per month per coder if the coder passes 2-3 months

consecutively with 95 or better score move them to quarterly reviewso Some QA programs review a percentage of the coders work This

methodology requires more time and resources

Auditor QA should also score and comment on the accuracy of the audit comments and recommendations

Presenting the Audit Results

Presenting the Audit Results

Communicating the Audit FindingsoWho requested the AuditoWho are you reporting the finding to

ndash CEOndash CFOndash Physicianndash Revenue Cycle Managerndash HIM Directorndash Billing Managerndash Coding Manager

ReportsAudit Resultspptx

Post Audit Education

Provider Education

Provider Education is best received when it is specific to the provider(s) 11 sessions going over the audit result Look at their notes with them

oHighlight areas for documentation improvementoReinforce Coding Guidelines that are specific to themoAsk them to share how they establish their LOS for E amp M serviceso Integrate their EMR system into the training

Provider Education

Group Training SessionsoUse the audit results to identify common issues within a specialty group

ndash Refer to the Executive Summary reportoVery effective for identifying system issues

ndash Teaching Attestationsndash Templatesndash Copy and Pastendash Cloned notes

o Everyone hears the same messagesoAn Issue may not appear on the individual audit but is still a concern for the

group

Education Delivery

In person or remote sessionso Factors to consider

ndash Providers scheduleavailabilityndash Location(s)ndash Personality of the providerndash Budget

Coder Education

Coders do well in group training so they can learn from each other 11 training allows the coder to get feedback on their coding

Handling Audit Disputes

Handling Audit Disputes

Be open to all points of viewo Let the documentation tell the story

Refer to the guidelines Ask

oCan we defend the reported service with the current documentation

Self Disclosures Refunds and Corrected Billing

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Procedure CodingFinding Procedures were sometimes coded incorrectly

Recommendation The entire medical record should be reviewed and all procedures coded as documented Coding procedures incorrectly or assigning incorrect CPT codes may result in lost revenue

bull Incorrect root operation

o Revise principal procedure to 0DQ68ZZ for clipping of the ulcer per OP report clipping is root operation repair

bull Biopsy versus Excision

o Procedure 0DBA0ZX (biopsy of jejunum) should change to 0DBA0ZZ (excision of jejunum) per op note this was not a biopsy procedure

bull Coding Guideline error

o Remove 0RG10K0 for allograft due to being inclusive in principal procedure

o Remove codes for adhesiolysis 0DN80ZZ 0UN10ZZ and 0UN90ZZ due to no significance noted per OP report

bull Incorrect approach

o Revise 0TF63ZZ (fragmentation percutaneous approach) to 0TF68ZZ (fragmentation endoscopic) for procedure performed via scope per the operative report

bull Procedure coded without provider documentation

o Remove secondary procedure of excisional debridement (0JB90ZZ) due to lack of documentation of excisional debridement per operative report The header in the operative report documents IampD and debridement but the body of the operative report only documents an IampD

bull Incorrect CPT code assignment

o Post-op note supports the nerve block injections of four nerves therefore code 64421 (multiple nerve block) should replace 64420 (injection of one intercostal nerve)

Queries Finding Conflicting incomplete and vague documentation is found within provider chart notes

Recommendation Prior to code assignment if the coder finds ambiguous or conflicting documentation the provider should be queried

Reference AHA Coding Clinic 2002 2nd Quarter pages 17-18

bull Query for acute blood loss anemia since hgb has dropped and patient is being transfused PRBC

bull Recommend query to clarify if cardiorenal syndrome is current as it is documented per 627 nephrology consult but unclear if current

bull Documentation does not support SIRS noninfectious without organ failure It is conflicting since patient has respiratory failure Query should be initiated for clarification with or without organ failure or infectious or non-infectious Patient has pneumonia per query as well as last progress note therefore if SIRS is not further specified per query PNA should be sequenced as principal diagnosis and SIRS should be removed

bull Recommend provider query necrotizing lung consolidation noted on DS as principal diagnosis-unclear does the patient have lobar pneumonia Secondary dx states necrotic pneumonia which is coded as principal diagnosis-this diagnosis is clear but consolidation portion is unclear

bull Recommend query for preterm labor delivery at 301 weeks

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull Query the provider regarding pathology report notation of endometriosis andor possible re-sequence of stenosis as principal diagnosis as it also meets principal diagnosis guidelines This would result in an MS-DRG change to 742 and APR-DRG change to 513

bull QUERY secondary diagnosis MCC and ROM 4 code T3166 (60 TBSA of which 60 are third degree burns) Chart notes do not specify how much of TBSA was actually third degree If after query TBSA is found to be less than 50 (T3164) then ROM will change from 4 to 3 but no change to overall APR-DRG or weight

Auditor Quality amp Productivity

Audit Productivity Standards

It takes twice as long to audit a chart as it does to code it a statistic that takes into account the time to document an explanation of any coding decision the auditor is not in agreement with o For example in an emergency department audit with a productivity of 12

charts per hour for a coder our auditors would probably be able to review six per hour

o If there are multiple services to audit on each encounter the productivity may only be 4 per hour

o The amount of detail you put into your audit report will also be a factorndash Are you using an automated audit softwarendash Are you using a spreadsheet to auditndash How many Systems are needed to complete the audit

Coder Quality Audits

Quality Audits (QA) should be done on your coders and auditors regularly Frequent reviews with smaller sample size will allow more consistent

review and feedbacko Example 10 charts per month per coder if the coder passes 2-3 months

consecutively with 95 or better score move them to quarterly reviewso Some QA programs review a percentage of the coders work This

methodology requires more time and resources

Auditor QA should also score and comment on the accuracy of the audit comments and recommendations

Presenting the Audit Results

Presenting the Audit Results

Communicating the Audit FindingsoWho requested the AuditoWho are you reporting the finding to

ndash CEOndash CFOndash Physicianndash Revenue Cycle Managerndash HIM Directorndash Billing Managerndash Coding Manager

ReportsAudit Resultspptx

Post Audit Education

Provider Education

Provider Education is best received when it is specific to the provider(s) 11 sessions going over the audit result Look at their notes with them

oHighlight areas for documentation improvementoReinforce Coding Guidelines that are specific to themoAsk them to share how they establish their LOS for E amp M serviceso Integrate their EMR system into the training

Provider Education

Group Training SessionsoUse the audit results to identify common issues within a specialty group

ndash Refer to the Executive Summary reportoVery effective for identifying system issues

ndash Teaching Attestationsndash Templatesndash Copy and Pastendash Cloned notes

o Everyone hears the same messagesoAn Issue may not appear on the individual audit but is still a concern for the

group

Education Delivery

In person or remote sessionso Factors to consider

ndash Providers scheduleavailabilityndash Location(s)ndash Personality of the providerndash Budget

Coder Education

Coders do well in group training so they can learn from each other 11 training allows the coder to get feedback on their coding

Handling Audit Disputes

Handling Audit Disputes

Be open to all points of viewo Let the documentation tell the story

Refer to the guidelines Ask

oCan we defend the reported service with the current documentation

Self Disclosures Refunds and Corrected Billing

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Queries Finding Conflicting incomplete and vague documentation is found within provider chart notes

Recommendation Prior to code assignment if the coder finds ambiguous or conflicting documentation the provider should be queried

Reference AHA Coding Clinic 2002 2nd Quarter pages 17-18

bull Query for acute blood loss anemia since hgb has dropped and patient is being transfused PRBC

bull Recommend query to clarify if cardiorenal syndrome is current as it is documented per 627 nephrology consult but unclear if current

bull Documentation does not support SIRS noninfectious without organ failure It is conflicting since patient has respiratory failure Query should be initiated for clarification with or without organ failure or infectious or non-infectious Patient has pneumonia per query as well as last progress note therefore if SIRS is not further specified per query PNA should be sequenced as principal diagnosis and SIRS should be removed

bull Recommend provider query necrotizing lung consolidation noted on DS as principal diagnosis-unclear does the patient have lobar pneumonia Secondary dx states necrotic pneumonia which is coded as principal diagnosis-this diagnosis is clear but consolidation portion is unclear

bull Recommend query for preterm labor delivery at 301 weeks

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull RECOMMEND QUERY no chest pain on admit per ER and HP cardiology provider states no CP with ER stating chest pressure the day prior to admit Appears patient was admitted due to elevated troponins which cardiology says are likely due to hypotension and AKI DS states chest pain but also says bradycardia and hypotension were the reason for admit

bull Query the provider regarding pathology report notation of endometriosis andor possible re-sequence of stenosis as principal diagnosis as it also meets principal diagnosis guidelines This would result in an MS-DRG change to 742 and APR-DRG change to 513

bull QUERY secondary diagnosis MCC and ROM 4 code T3166 (60 TBSA of which 60 are third degree burns) Chart notes do not specify how much of TBSA was actually third degree If after query TBSA is found to be less than 50 (T3164) then ROM will change from 4 to 3 but no change to overall APR-DRG or weight

Auditor Quality amp Productivity

Audit Productivity Standards

It takes twice as long to audit a chart as it does to code it a statistic that takes into account the time to document an explanation of any coding decision the auditor is not in agreement with o For example in an emergency department audit with a productivity of 12

charts per hour for a coder our auditors would probably be able to review six per hour

o If there are multiple services to audit on each encounter the productivity may only be 4 per hour

o The amount of detail you put into your audit report will also be a factorndash Are you using an automated audit softwarendash Are you using a spreadsheet to auditndash How many Systems are needed to complete the audit

Coder Quality Audits

Quality Audits (QA) should be done on your coders and auditors regularly Frequent reviews with smaller sample size will allow more consistent

review and feedbacko Example 10 charts per month per coder if the coder passes 2-3 months

consecutively with 95 or better score move them to quarterly reviewso Some QA programs review a percentage of the coders work This

methodology requires more time and resources

Auditor QA should also score and comment on the accuracy of the audit comments and recommendations

Presenting the Audit Results

Presenting the Audit Results

Communicating the Audit FindingsoWho requested the AuditoWho are you reporting the finding to

ndash CEOndash CFOndash Physicianndash Revenue Cycle Managerndash HIM Directorndash Billing Managerndash Coding Manager

ReportsAudit Resultspptx

Post Audit Education

Provider Education

Provider Education is best received when it is specific to the provider(s) 11 sessions going over the audit result Look at their notes with them

oHighlight areas for documentation improvementoReinforce Coding Guidelines that are specific to themoAsk them to share how they establish their LOS for E amp M serviceso Integrate their EMR system into the training

Provider Education

Group Training SessionsoUse the audit results to identify common issues within a specialty group

ndash Refer to the Executive Summary reportoVery effective for identifying system issues

ndash Teaching Attestationsndash Templatesndash Copy and Pastendash Cloned notes

o Everyone hears the same messagesoAn Issue may not appear on the individual audit but is still a concern for the

group

Education Delivery

In person or remote sessionso Factors to consider

ndash Providers scheduleavailabilityndash Location(s)ndash Personality of the providerndash Budget

Coder Education

Coders do well in group training so they can learn from each other 11 training allows the coder to get feedback on their coding

Handling Audit Disputes

Handling Audit Disputes

Be open to all points of viewo Let the documentation tell the story

Refer to the guidelines Ask

oCan we defend the reported service with the current documentation

Self Disclosures Refunds and Corrected Billing

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Auditor Quality amp Productivity

Audit Productivity Standards

It takes twice as long to audit a chart as it does to code it a statistic that takes into account the time to document an explanation of any coding decision the auditor is not in agreement with o For example in an emergency department audit with a productivity of 12

charts per hour for a coder our auditors would probably be able to review six per hour

o If there are multiple services to audit on each encounter the productivity may only be 4 per hour

o The amount of detail you put into your audit report will also be a factorndash Are you using an automated audit softwarendash Are you using a spreadsheet to auditndash How many Systems are needed to complete the audit

Coder Quality Audits

Quality Audits (QA) should be done on your coders and auditors regularly Frequent reviews with smaller sample size will allow more consistent

review and feedbacko Example 10 charts per month per coder if the coder passes 2-3 months

consecutively with 95 or better score move them to quarterly reviewso Some QA programs review a percentage of the coders work This

methodology requires more time and resources

Auditor QA should also score and comment on the accuracy of the audit comments and recommendations

Presenting the Audit Results

Presenting the Audit Results

Communicating the Audit FindingsoWho requested the AuditoWho are you reporting the finding to

ndash CEOndash CFOndash Physicianndash Revenue Cycle Managerndash HIM Directorndash Billing Managerndash Coding Manager

ReportsAudit Resultspptx

Post Audit Education

Provider Education

Provider Education is best received when it is specific to the provider(s) 11 sessions going over the audit result Look at their notes with them

oHighlight areas for documentation improvementoReinforce Coding Guidelines that are specific to themoAsk them to share how they establish their LOS for E amp M serviceso Integrate their EMR system into the training

Provider Education

Group Training SessionsoUse the audit results to identify common issues within a specialty group

ndash Refer to the Executive Summary reportoVery effective for identifying system issues

ndash Teaching Attestationsndash Templatesndash Copy and Pastendash Cloned notes

o Everyone hears the same messagesoAn Issue may not appear on the individual audit but is still a concern for the

group

Education Delivery

In person or remote sessionso Factors to consider

ndash Providers scheduleavailabilityndash Location(s)ndash Personality of the providerndash Budget

Coder Education

Coders do well in group training so they can learn from each other 11 training allows the coder to get feedback on their coding

Handling Audit Disputes

Handling Audit Disputes

Be open to all points of viewo Let the documentation tell the story

Refer to the guidelines Ask

oCan we defend the reported service with the current documentation

Self Disclosures Refunds and Corrected Billing

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Audit Productivity Standards

It takes twice as long to audit a chart as it does to code it a statistic that takes into account the time to document an explanation of any coding decision the auditor is not in agreement with o For example in an emergency department audit with a productivity of 12

charts per hour for a coder our auditors would probably be able to review six per hour

o If there are multiple services to audit on each encounter the productivity may only be 4 per hour

o The amount of detail you put into your audit report will also be a factorndash Are you using an automated audit softwarendash Are you using a spreadsheet to auditndash How many Systems are needed to complete the audit

Coder Quality Audits

Quality Audits (QA) should be done on your coders and auditors regularly Frequent reviews with smaller sample size will allow more consistent

review and feedbacko Example 10 charts per month per coder if the coder passes 2-3 months

consecutively with 95 or better score move them to quarterly reviewso Some QA programs review a percentage of the coders work This

methodology requires more time and resources

Auditor QA should also score and comment on the accuracy of the audit comments and recommendations

Presenting the Audit Results

Presenting the Audit Results

Communicating the Audit FindingsoWho requested the AuditoWho are you reporting the finding to

ndash CEOndash CFOndash Physicianndash Revenue Cycle Managerndash HIM Directorndash Billing Managerndash Coding Manager

ReportsAudit Resultspptx

Post Audit Education

Provider Education

Provider Education is best received when it is specific to the provider(s) 11 sessions going over the audit result Look at their notes with them

oHighlight areas for documentation improvementoReinforce Coding Guidelines that are specific to themoAsk them to share how they establish their LOS for E amp M serviceso Integrate their EMR system into the training

Provider Education

Group Training SessionsoUse the audit results to identify common issues within a specialty group

ndash Refer to the Executive Summary reportoVery effective for identifying system issues

ndash Teaching Attestationsndash Templatesndash Copy and Pastendash Cloned notes

o Everyone hears the same messagesoAn Issue may not appear on the individual audit but is still a concern for the

group

Education Delivery

In person or remote sessionso Factors to consider

ndash Providers scheduleavailabilityndash Location(s)ndash Personality of the providerndash Budget

Coder Education

Coders do well in group training so they can learn from each other 11 training allows the coder to get feedback on their coding

Handling Audit Disputes

Handling Audit Disputes

Be open to all points of viewo Let the documentation tell the story

Refer to the guidelines Ask

oCan we defend the reported service with the current documentation

Self Disclosures Refunds and Corrected Billing

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Coder Quality Audits

Quality Audits (QA) should be done on your coders and auditors regularly Frequent reviews with smaller sample size will allow more consistent

review and feedbacko Example 10 charts per month per coder if the coder passes 2-3 months

consecutively with 95 or better score move them to quarterly reviewso Some QA programs review a percentage of the coders work This

methodology requires more time and resources

Auditor QA should also score and comment on the accuracy of the audit comments and recommendations

Presenting the Audit Results

Presenting the Audit Results

Communicating the Audit FindingsoWho requested the AuditoWho are you reporting the finding to

ndash CEOndash CFOndash Physicianndash Revenue Cycle Managerndash HIM Directorndash Billing Managerndash Coding Manager

ReportsAudit Resultspptx

Post Audit Education

Provider Education

Provider Education is best received when it is specific to the provider(s) 11 sessions going over the audit result Look at their notes with them

oHighlight areas for documentation improvementoReinforce Coding Guidelines that are specific to themoAsk them to share how they establish their LOS for E amp M serviceso Integrate their EMR system into the training

Provider Education

Group Training SessionsoUse the audit results to identify common issues within a specialty group

ndash Refer to the Executive Summary reportoVery effective for identifying system issues

ndash Teaching Attestationsndash Templatesndash Copy and Pastendash Cloned notes

o Everyone hears the same messagesoAn Issue may not appear on the individual audit but is still a concern for the

group

Education Delivery

In person or remote sessionso Factors to consider

ndash Providers scheduleavailabilityndash Location(s)ndash Personality of the providerndash Budget

Coder Education

Coders do well in group training so they can learn from each other 11 training allows the coder to get feedback on their coding

Handling Audit Disputes

Handling Audit Disputes

Be open to all points of viewo Let the documentation tell the story

Refer to the guidelines Ask

oCan we defend the reported service with the current documentation

Self Disclosures Refunds and Corrected Billing

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Presenting the Audit Results

Presenting the Audit Results

Communicating the Audit FindingsoWho requested the AuditoWho are you reporting the finding to

ndash CEOndash CFOndash Physicianndash Revenue Cycle Managerndash HIM Directorndash Billing Managerndash Coding Manager

ReportsAudit Resultspptx

Post Audit Education

Provider Education

Provider Education is best received when it is specific to the provider(s) 11 sessions going over the audit result Look at their notes with them

oHighlight areas for documentation improvementoReinforce Coding Guidelines that are specific to themoAsk them to share how they establish their LOS for E amp M serviceso Integrate their EMR system into the training

Provider Education

Group Training SessionsoUse the audit results to identify common issues within a specialty group

ndash Refer to the Executive Summary reportoVery effective for identifying system issues

ndash Teaching Attestationsndash Templatesndash Copy and Pastendash Cloned notes

o Everyone hears the same messagesoAn Issue may not appear on the individual audit but is still a concern for the

group

Education Delivery

In person or remote sessionso Factors to consider

ndash Providers scheduleavailabilityndash Location(s)ndash Personality of the providerndash Budget

Coder Education

Coders do well in group training so they can learn from each other 11 training allows the coder to get feedback on their coding

Handling Audit Disputes

Handling Audit Disputes

Be open to all points of viewo Let the documentation tell the story

Refer to the guidelines Ask

oCan we defend the reported service with the current documentation

Self Disclosures Refunds and Corrected Billing

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Presenting the Audit Results

Communicating the Audit FindingsoWho requested the AuditoWho are you reporting the finding to

ndash CEOndash CFOndash Physicianndash Revenue Cycle Managerndash HIM Directorndash Billing Managerndash Coding Manager

ReportsAudit Resultspptx

Post Audit Education

Provider Education

Provider Education is best received when it is specific to the provider(s) 11 sessions going over the audit result Look at their notes with them

oHighlight areas for documentation improvementoReinforce Coding Guidelines that are specific to themoAsk them to share how they establish their LOS for E amp M serviceso Integrate their EMR system into the training

Provider Education

Group Training SessionsoUse the audit results to identify common issues within a specialty group

ndash Refer to the Executive Summary reportoVery effective for identifying system issues

ndash Teaching Attestationsndash Templatesndash Copy and Pastendash Cloned notes

o Everyone hears the same messagesoAn Issue may not appear on the individual audit but is still a concern for the

group

Education Delivery

In person or remote sessionso Factors to consider

ndash Providers scheduleavailabilityndash Location(s)ndash Personality of the providerndash Budget

Coder Education

Coders do well in group training so they can learn from each other 11 training allows the coder to get feedback on their coding

Handling Audit Disputes

Handling Audit Disputes

Be open to all points of viewo Let the documentation tell the story

Refer to the guidelines Ask

oCan we defend the reported service with the current documentation

Self Disclosures Refunds and Corrected Billing

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Post Audit Education

Provider Education

Provider Education is best received when it is specific to the provider(s) 11 sessions going over the audit result Look at their notes with them

oHighlight areas for documentation improvementoReinforce Coding Guidelines that are specific to themoAsk them to share how they establish their LOS for E amp M serviceso Integrate their EMR system into the training

Provider Education

Group Training SessionsoUse the audit results to identify common issues within a specialty group

ndash Refer to the Executive Summary reportoVery effective for identifying system issues

ndash Teaching Attestationsndash Templatesndash Copy and Pastendash Cloned notes

o Everyone hears the same messagesoAn Issue may not appear on the individual audit but is still a concern for the

group

Education Delivery

In person or remote sessionso Factors to consider

ndash Providers scheduleavailabilityndash Location(s)ndash Personality of the providerndash Budget

Coder Education

Coders do well in group training so they can learn from each other 11 training allows the coder to get feedback on their coding

Handling Audit Disputes

Handling Audit Disputes

Be open to all points of viewo Let the documentation tell the story

Refer to the guidelines Ask

oCan we defend the reported service with the current documentation

Self Disclosures Refunds and Corrected Billing

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Provider Education

Provider Education is best received when it is specific to the provider(s) 11 sessions going over the audit result Look at their notes with them

oHighlight areas for documentation improvementoReinforce Coding Guidelines that are specific to themoAsk them to share how they establish their LOS for E amp M serviceso Integrate their EMR system into the training

Provider Education

Group Training SessionsoUse the audit results to identify common issues within a specialty group

ndash Refer to the Executive Summary reportoVery effective for identifying system issues

ndash Teaching Attestationsndash Templatesndash Copy and Pastendash Cloned notes

o Everyone hears the same messagesoAn Issue may not appear on the individual audit but is still a concern for the

group

Education Delivery

In person or remote sessionso Factors to consider

ndash Providers scheduleavailabilityndash Location(s)ndash Personality of the providerndash Budget

Coder Education

Coders do well in group training so they can learn from each other 11 training allows the coder to get feedback on their coding

Handling Audit Disputes

Handling Audit Disputes

Be open to all points of viewo Let the documentation tell the story

Refer to the guidelines Ask

oCan we defend the reported service with the current documentation

Self Disclosures Refunds and Corrected Billing

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Provider Education

Group Training SessionsoUse the audit results to identify common issues within a specialty group

ndash Refer to the Executive Summary reportoVery effective for identifying system issues

ndash Teaching Attestationsndash Templatesndash Copy and Pastendash Cloned notes

o Everyone hears the same messagesoAn Issue may not appear on the individual audit but is still a concern for the

group

Education Delivery

In person or remote sessionso Factors to consider

ndash Providers scheduleavailabilityndash Location(s)ndash Personality of the providerndash Budget

Coder Education

Coders do well in group training so they can learn from each other 11 training allows the coder to get feedback on their coding

Handling Audit Disputes

Handling Audit Disputes

Be open to all points of viewo Let the documentation tell the story

Refer to the guidelines Ask

oCan we defend the reported service with the current documentation

Self Disclosures Refunds and Corrected Billing

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Education Delivery

In person or remote sessionso Factors to consider

ndash Providers scheduleavailabilityndash Location(s)ndash Personality of the providerndash Budget

Coder Education

Coders do well in group training so they can learn from each other 11 training allows the coder to get feedback on their coding

Handling Audit Disputes

Handling Audit Disputes

Be open to all points of viewo Let the documentation tell the story

Refer to the guidelines Ask

oCan we defend the reported service with the current documentation

Self Disclosures Refunds and Corrected Billing

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Coder Education

Coders do well in group training so they can learn from each other 11 training allows the coder to get feedback on their coding

Handling Audit Disputes

Handling Audit Disputes

Be open to all points of viewo Let the documentation tell the story

Refer to the guidelines Ask

oCan we defend the reported service with the current documentation

Self Disclosures Refunds and Corrected Billing

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Handling Audit Disputes

Handling Audit Disputes

Be open to all points of viewo Let the documentation tell the story

Refer to the guidelines Ask

oCan we defend the reported service with the current documentation

Self Disclosures Refunds and Corrected Billing

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Handling Audit Disputes

Be open to all points of viewo Let the documentation tell the story

Refer to the guidelines Ask

oCan we defend the reported service with the current documentation

Self Disclosures Refunds and Corrected Billing

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Self Disclosures Refunds and Corrected Billing

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Overpayment

In general If a person has received an overpayment the person shallo report and return the overpayment to the Secretary the State an

intermediary a carrier or a contractor as appropriate at the correct address and ndash notify the Secretary State intermediary carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment

What is an ldquoOverpaymentrdquo ndash The term ldquooverpaymentrdquo means any funds that a person receives or retains under subchapter XVIII or XIX of this chapter to which the person after applicable reconciliation is not entitled under such subchapter

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Self Disclosure

The Office of Inspector General (OIG) has several self-disclosure processes that can be used to report potential fraud in Department of Health and Human Services (HHS) programs Choose the one that applies to you from the following descriptions to learn moreo Health Care Provider Self-Disclosures

ndash Health care providers suppliers or other individuals or entities subject to Civil Monetary Penalties can use the Provider Self-Disclosure Protocol which was created in 1998 to voluntarily disclose self-discovered evidence of potential fraud Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation Visit the Provider Self-Disclosure Protocol webpage for more information

o HHS Contractor Self-Disclosuresndash Contractors are individuals businesses or other legal entities that are awarded Government contracts or

subcontracts to provide services to the Department of Health and Human Services (HHS) OIGs contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud conflict of interest bribery or gratuity This self-disclosure process is available for those entities with a Federal Acquisition Regulation-based contract Visit the Contractor Self-Disclosure webpage for more information

o HHS Grantee Self-Disclosuresndash HHS grantees or subrecipients may voluntarily disclose evidence of potential violations of Federal criminal law

involving fraud bribery or gratuity violations potentially affecting the Federal award 45 CFR 75113 notes mandatory disclosures of criminal offenses that non-Federal entities must make with respect to HHS grants Recipients submitting disclosures in connection with this requirement should include the subject reference line Mandatory Grant Disclosure Recipients choosing to disclose conduct that may not fit squarely within the scope of offenses described in 45 CFR 75113 should include the following subject reference line in the submission Voluntary Grant Disclosure

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Medicare 60 day rule

The 60 Day Rule (Medicare Parts A amp B) o The 60 day time period for reportingreturning begins when either

ndash The reasonable diligence is completed orndash On the day the provider received credible information of a potential overpayment (if the

provider fails to conduct reasonable diligence) o For an investigation to be conducted in a ldquotimelyrdquo manner providers typically

must complete the investigation within 6 months from receipt of credible information indicating there may be an overpayment

ndash ndash 6-month timeframe may potentially be extended under ldquoextraordinary circumstancesrdquo ndash 8 months generally the maximum total time to return overpayments The government recommends that providers maintain records documenting ldquoreasonable diligencerdquo

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Medicare 60 Day Rule

Six-year lookback period ndash Sometimes possible to use a shorter period depending on the facts at issue Amount to be repaid ndash May vary depending on the method used to

reportreturn eg Medicare administrative contractor (ldquoMACrdquo) v self-disclosure Overpayment notification ndash After receiving an overpayment

notification from the government you should investigate for related overpayments eg other time periods

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Medicare 60 Day Rule

Self-disclosure protocols ndashoA submission to the OIG or CMS protocols suspends the 60 day requirement

for returning overpayments until a settlement agreement is executed ndash ndash OIGrsquos Self-Disclosure Protocol (SDP) ndash ndash CMS Voluntary Self-Referral Disclosure Protocol (SRDP) ndash

o Self-disclosures to other agencies do not suspend the repayment deadlinendash ndash Eg Department of Justice local US Attorneyrsquos Office Medicaid Fraud Control Unit

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Medicare 60 Day Rule

Facilitating Compliance With the 60 Day Rule Compliance programs should include o ndash Appropriate policies and procedures o ndash Periodic billing and coding audits to proactively identify overpaymentso ndash Focus on high-risk areas o ndash Utilization of publicly available government resources to guide audit efforts o ndash Investigating any suspected incidents of non-compliance with federal health

care program requirements

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Self Disclosure

Choice of AgencyoOIG ndash Self-Disclosure Protocol

ndash ndash Conduct involving false billingndash ndash Conduct involving excluded personsndash ndash Conduct involving the Anti-Kickback Statute (including conduct thatndash violates both the AKS and Stark Law)

oCMS ndash Self-Referral Disclosure Protocolndash ndash Conduct involving only violations of the Stark Law

oDOJndash ndash May be appropriate when provider believes a FCA release is necessary

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Summary

The Cost of a Well-Executed Coding Audit ProcessThe costs associated with an auditing program are worth it in the long run Ideally your organization is performing audits on a regular basis across all service types locations and payers Weve all seen claims that have been denied resulting in additional work that may be preventable with a proper audit program The goal is to use the audit feedback to improve coding quality and lower potential risk and cost to the organization Organizations should be investing in an effective coding audit program to make your coders and providers better and enhance documentation improvement from the providers

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom

Questions

Thank you for your attentionLynn Handy

Vice President of Coding amp Audit ServicesLynnhandymanagedresourcesinccom