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Advanced E/M Auditing and How to Initiate a Self-Audit

Paul Chandler, BS-HRM, AA-C,

CPC, CPC-I, CPC-H, CPMA, CPCO, CPPM, CPB,

CANPC, CCC, CEDC, CEMC, CGSC, CIMC, COBGC, COSC, CRHC

Healthcon 2014

Monday, April 14, 2014

This presentation is for education purposes only. The information presented is not intended to be legal advice. The information presented was current at the time presented and when applicable, based upon guidelines published by the AMA, CMS, and NCCI.

The presenter indemnify and hold harmless AAPC and its employees from any liability of any nature or kind, including costs and expenses for, or on account of, any copyrighted or trademarked material used in the performance of this agreement.

Disclaimer

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Comprehend and apply the following information while coding:

SOAP note

CMS Guidelines

Audit Sheets

Components of E/M

Self-Audits 101

Today’s Objectives:

Subjective (history)

Objective (exam)

Assessment (MDM)

Plan (MDM)

SOAP note

MDM = Medical Decision Making

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1995 CMS Guidelines

15 pages

Examinations are based on the organ systems and body areas.

1997 CMS Guidelines

53 pages

Examinations are based on bullets outlined through specific system examinations.

CMS Guidelines

Audit Sheets

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Based on the documentation provided, E/M services are provided with a score based on 3 necessary components.

History

Examination

Medical Decision Making

Factors used to decide level: time spent with patient, coordination of care provided, the presenting problem of the patient, and counseling provided by the doctor(s).

Components of E/M services

Four areas of documentation needed to decide correct level of history:

Chief Complaint (CC)

History of Present Illness (HPI)

Review of Systems (ROS)

Past, Family, and Social History (PFSH)

HISTORY

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The Chief Complaint provides the medical necessity requirement of the E/M service provided.

“The medical record should clearly reflect the chief complaint”, CMS Guidelines.

The doctor is required to write, type, or dictate a chief complaint for the medical record.

Example: patient has headache

HPI: patient presents with chronic non-progressive headache in the frontal lobe

HISTORY: Chief Complaint

Location

Severity

Timing

Modifying Factors

Quality

Duration

Context

Associated Signs and Symptoms

HISTORY: History of Present Illness

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HISTORY: History of Present Illness

1995 Guidelines

Brief History

1-3 elements

Extended History

4+ elements

1997 Guidelines Brief History 1-3 elements

Extended History 4+ elements OR 3+ chronic/inactive conditions

Allergy / Immunology

Cardiovascular

Constitutional

Ears, Nose, Throat (ENT)

Endocrine

Eyes

GI

GU

Hematologic / Lymphatic

Integumentary

Musculoskeletal

Neurologic

Psychiatric

Respiratory

HISTORY: Review of Systems

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ROS documentation must contribute to the CC

Verify with your MAC if ‘double dipping’ is permitted

All ROS must meet medical necessity

If a positive finding is documented, it must be specified (not just ‘yes’)

Following the positive finding documentations, doctor may say “all remaining # ROS were reviewed and all # were negative” is acceptable

HISTORY: Review of Systems

Available options:

None

Pertinent to 1 system

Extended to 2-9 systems

Complete 10 systems or “all other # negative”

HISTORY: Review of Systems

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Past Medical, Family, & Social History Past History Current medications, past surgeries, past illnesses Family History Parents, siblings, children, aunts and uncles (by blood),

grandparents Social History Smoking, alcohol usage, marital status, sexual history, employment

status, education information

HISTORY: PFSH

Established patient:

Detailed = 1 history area

Comprehensive = 2-3 history areas

New patient:

Detailed = 1-2 history areas

Comprehensive = 3 history areas

HISTORY: PFSH

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Level of history is determined by the column that is marked farthest to the left.

2 detailed + 1 comprehensive = 1 detailed

HISTORY

Problem Focused: a limited examination of the affected body area or organ system.

Expanded Problem Focused: a limited examination of the affected body area or organ system and other symptomatic or related organ system(s).

Detailed: an extended examination of the affected body area(s) and other symptomatic or related organ system(s).

Comprehensive: a general multi-system examination or complete examination of a single organ system.

Examination – 95 guidelines

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Problem Focused: 1-5 elements identified by a bullet

Exp. Problem Focused: 6+ elements identified by a bullet

Detailed: 2+ elements identified by a bullet from each 6 areas/systems OR at least 12 elements identified by a bullet in 2+ areas/systems

Comprehensive: Performed all elements identified by a bullet and document at least 2 elements by a bullet from each of the 9 areas/systems

Examination – 97 guidelines

Three areas of documentation:

Diagnosis (based on points)

Complexity (based on points)

Risk (based on elements)

Cannot get credit for mentioning a diagnosis that may be not applicable to the day’s visit.

Minimum of one diagnosis treated with a developed plan of care.

Diagnosis should have relevance to the treatment.

Mentioning diagnosis may be a secondary issue.

Medical Decision Making

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MDM: Diagnosis

MDM: Complexity

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MDM: Risk

Level with 2 components or 1 in the middle

MDM Scoring

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Depending on the CPT code, either 2 of 3 or 3 of 3 components are required.

2 of 3 = middle or level of 2 components

Established patient, office visit

3 of 3 = the lowest component of all 3

New patient, office visit

Level of Service

Place of Service = Office

New/Est. = Established

Code ranges: 99211-99215

2/3 or 3/3? 2 out of 3 components

1995 Guidelines

Detailed History

Detailed Exam

Moderate MDM

CPT 99214

1997 Guidelines

Detailed History

Expanded Problem Focused Exam

Moderate MDM

CPT 99214

Level of Service example

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Medical necessity is the key to avoiding fraud/abuse

Key

Steps: 1. Audit Preparation 2. Identify Audit Objective 3. Determine the Sample 4. Develop/Select Audit Tools 5. What to Look For 6. Complete Review Analysis & Summary Report 7. Meet with Providers 8. Develop an Education Plan 9. Develop a Monitoring Process

How to Initiate a Self-Audit

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Decide who will perform the audit (self-audit, internal, external)

Decide where the audit will be performed

Decide focus of audit (documentation, CPT, ICD-9, HCPCS, or combination)

Will the audit be done pre-payment or post-payment?

1) Audit Preparation

Educate

Benchmark

Investigate a suspicious pattern

Government mandate under CIA

Determine provider bonus

Identify missed charges

Detect unbundling

Global periods

2) Identify Audit Objective

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For a routine audit, review of 10 records per provider is recommended

No fewer than 5 records is recommended

For a probe review of an identified problem, 20-40 records should be reviewed

For a follow-up audit, 5-10 records (90% score)

Recommended time period is the most recent 3-6 months of service

3) Determine the Sample

Audit Tool

Service specific tool (office, hospital)

Specialty specific tool (ENT, Neurology)

Surgery audit tool

Electronic audit tool and software

Other Tools

Frequency report by physician

Benchmarking utilization based on specialty

4) Develop/Select Audit Tools

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Proper recording of time

Special guidelines followed (incident to, academic practice, global period)

Documentation is legible

Doctor’s orders are present for all tests documents

All diagnosis billed are on record

Correct provider

Correct DOS

5) What to Look For

Analyze raw data

Research guidelines as necessary

Include source documents as needed

Calculate an error rate, accuracy rate, compliance rate

Prepare a report listing each encounter reviewed, correct and incorrect coding, comments, recommendations

6) Complete Review Analysis & Summary Report

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Review the provider’s individual results and recommendations for improvement, preferably one-on-one

Provide feedback, ask questions, educate, answer questions, review source documents (back-up your facts!)

Make any agreed upon changes to the final report based on insight form the provider

7) Meet with Providers

Should be based on problem areas identified in the audits Develop tools to assist in correct coding Cheat sheets Templates Coding tool

Shadowing

Develop a training program

8) Develop an Education Plan

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Frequency: quarterly, semiannually, or annual

Annually for an external audit of internal auditor to insure that his/her findings are objective

Based on achievement of a set accuracy score

Immediately upon discovery of a serious coding issue providing a compliance risk

9) Develop a Monitoring Process

Paul Chandler, BS-HRM, AA-C

CPC, CPC-I, CPC-H, CPMA, CPCO, CPPM, CPB, CANPC, CCC, CEDC, CEMC, CGSC, CIMC, COBGC, COSC, CRHC

Ohana Coding LLC 134 Enchanted Parkway Suite 204C Manchester, MO 63021

Office: 855.OHANA.66 (855.642.6266) paul@ohanacoding.com www.ohanacoding.com

Questions?