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Presented by Caroline Rader Znaniec
Associate Director of CDM and Charge Capture Integrity
May 7, 2009
Outpatient Auditing Techniques
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Table of Contents
Section 1 » Introduction
Section 2 » “Audit” is not a dirty word
Section 3 » Information is everywhere
Section 4 » To Audit or Not to Audit
Section 5 » Some working examples
Section 6 » Your Speaker
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Introduction
Section 1
2
Page 4
Introduction
» Understand why and when to audit
» Understand sources and resources to perform audit
» Understand what steps to take and how to perform audit
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“Audit” is not a dirty word
Section 2
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“Audit” is not a dirty word
» To audit is to examine and verify against a resource
» Not necessarily prompted by intentional wrong doing (i.e. fraud and abuse)
» Can be beneficial to the facility clinically and financially and the same for the patients served
To audit is to have an opportunity to improve!
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Information is everywhere
Section 3
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Information is everywhere
» To compare yourself to resources (“to audit”) you must know first what internal sources are available and what information they can provide
» Internal sources
› Charge Description Master
› Usage Statistics
› Denials Data
› Audit Reports
› Department Feedback
» External resources
› CMS Contractors (e.g. FI, MAC, RAC)
› OIG/HHS
› Trade publications and associations
› National and local papers
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To Audit or Not to Audit
Section 4
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To Audit or Not to Audit
» Reasons to audit› Financial
‒ Unexpected increase/decrease in captured revenue
‒ Unexpected increase/decrease in reimbursement
› Clinical
‒ Unexpected increase/decrease in casemix
‒ Unexpected increase/decrease in patient volumes
› Compliance
‒ Change in regulations/guidance
‒ “Hot Spots” seen in publications, regulatory bulletins, etc.
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Some working examples
Section 5
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Some working examples
Scenario 1
The Director of Patient Financial Services has indicated a sudden increase in Medicare denials for lack of medical necessity related to CTAs of the thorax. She has provided a listing of accounts for review and assistance in resolving.
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Some working examples
Scenario 2
The Director of Emergency Medicine for a regional medical centerhas been closely reviewing his budget each month. His revenue isless than expected. In reviewing the distribution of ED levels, he finds the distribution to be different from what was anticipatedbased on prior years.
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Some working examples
Scenario 3
The Director of Health Information Management has indicated thatthe staff is seeing an increase of accounts where the encoder isprompting the review and use of modifier -59. The accounts primarily represent services from Radiology where the departmentis responsible for CPT assignment.
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Some working examples
Scenario 4
http://www.highmarkmedicareservices.com/cert/index.html
A review of published CERT common errors show regional facilities are not providing services under a physician order.
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Some working examples
Scenario 5
The Director of Finance believes there is an issue in the Electrophysiology Laboratory regarding the capture of high dollar implants. Costs have increased while procedural revenue has remained neutral. She has provided usage statistics for the top 5 procedures and supplies to assist with the audit.
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Some working examples
Procedures
Supplies
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Some working examples
http://www.cms.hhs.gov/HospitalOutpatientPPS/02_device_procedure.asp#TopOfPage
Medicare Device to Procedure Code Edits – AICD EXAMPLE
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Some working examples
Scenario 6
The Director of Finance believes there is an issue in Nuclear Medicine regarding the capture of radiopharmaceuticals. Costs have increased while procedural revenue has remained neutral. She hasprovided usage statistics for the top 5 procedures and radiopharmaceuticals to assist with the audit.
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Some working examples
Procedures
Radiopharmaceuticals
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Some working examples
Scenario 7
The Compliance Committee wants to prepare the facility for the upcoming RAC. The Committee wants to ensure that those areas reviewed in the demonstration project are addressed at the facility. These include the following:
- Reporting of units for Speech Therapy “per treatment” services
- Reporting of units for Neulasta
- Use of modifier -59
- Reporting bilateral services as two line items with LT and RT modifier
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Some working examples
Scenario 8
The Director of Reimbursement is concerned that the outpatient casemix has decreased in the last quarter under the CPV.
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Your Speaker
Section 6
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Your Speaker
Caroline Rader ZnaniecAssociate Director of CDM and Charge Capture Integrity
Email [email protected]
Cell/office 410-463-9867
Secure fax 866-861-0084
Caroline Rader Znaniec is an Associate Director in Navigant Consulting’s healthcare practice. She has close to 15 years of related experience, which includes all aspects of billing compliance and revenue cycle management. Her expertise is in charge description master creation and maintenance, as well as outpatient billing compliance. She has been a local and national speaker for AHIMA, HCCA and MdHIMA on similar issues. Ms. Znaniec also works closely with the Maryland Regulatory practice on HSCRC reimbursement issues. Ms. Znaniec’s local client base includes large academic hospital systems as well as community hospitals. She is a Maryland native having been raised on the Eastern Shore where she continues to live today with her husband and two sons. Her other interests include boating, camping, ATVs and motorcycles.
