Don’t Land in Hot WaterAudit Proof your Coding and

Documentation

Presented by:Nikki Taylor, MBA, COC,CPC, CPMA

Auditor-The Coding Institute

Learning Objectives• Government Audits

• How they work• Areas of Concern

• How self-audits and external audits can:• Identify areas for improvements in documentation• Point out corrections that need to be made• Review diagnosis coding to ensure specificity and accuracy• Crack-down on insufficient provider documentation• Avoid undercoding, overcoding, and bad coding habits

• Identify great resources and tools • EM Auditor• CCI Edits Checker• TCI Consulting & Revenue Cycle Solutions

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Why Audits are Important

• Good Practice• Audits ensure regular check-ups

• Boost up compliance

• Reel in reimbursement

• Increased payer scrutiny=increased risk

• Includes:• Internal/In-house

• External/Third Party

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Why Audits are Important, cont.

• Audits help:• Ensure proper billing and coding

• Correct reimbursement

• New reimbursement opportunities

• Fight back against government audits• Payer medical record requests and denials

• Ensure provider education • Documentation requirements

• Quality patient care• Malpractice litigation

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Documentation Issues

• Not just for coding!

• Documentation equally important!• Clinical staff

• Providers

• Enter documentation at time of service• Shortly thereafter

• Timelines for compliance

• Good patient care

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Documentation Issues, cont.

• Signature requirements• CMS guidelines

• Legible-hand written

• Signature stamps-NOT appropriate

• Electronic-often require physician code or login

• Signatures = provider reviewed and agree

• Dates and Time• All entries

• Allow medical treatment to be reconstructed at a later time

• If time of service and time of entry are different -document why

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Documentation Issues, cont.• Types:

• Handwritten• Dictation• Templates• Electronic

• Handwritten:• Often illegible

• Dictation:• Clear and thorough• Timing-transcription• Summaries• Signatures

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Documentation Issues, cont.

• Templates:• Cloning

• Information lacking key details

• Not thorough

• Electronic• Cloning

• Built-in templates

• Over documenting/medical necessity

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RAC Audits

•Recovery Audit Program (RAC)• Mission:

• Identify and correct improper payments

• Overpayment detection and collection

• Identifying underpayments

• Prevent future improper payments

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https://www.cms.gov

RAC Audits, cont.

• National Recovery Audit program • Demo program- utilized Recovery Auditors

• Medicare overpayments and underpayments

• Between 2005 and 2008

• Resulted in > $900 million being returned to the Medicare Trust Fund

• Nearly $38 million in underpayments to health care providers.

• Secretary of the Department of Health and Human Services

• Instituted permanent and national Recovery Audit program

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https://www.cms.gov

RAC Audits, cont.

• Post-payment basis

• Follows Medicare policies • Carriers, FIs and MACs: NCDs, LCDs and CMS Manuals

• Two types of reviews: • Automated (no medical record needed)

• Complex (medical record required)

• No claims paid prior to October 1, 2007

• Can go back three years • Date of payment

• Staff consists of nurses, therapists, certified coders, and a physician CMD

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https://www.cms.gov

RAC Audits, cont.•Demand letter is issued by RAC

•Opportunity for provider • Discuss the determination with the RAC

• Not part of the normal appeal process

• Issues reviewed by RAC - approved by CMS

• Issues approved are posted to website before widespread review

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https://www.cms.gov

RAC Audits, cont.

• RAC contractors are paid a contingency fee• % of every dollar in overpayments collected

• Lose the appeal-must pay fee back

• Focus--organizations with billings higher than the majority • Other providers/suppliers

• Medicare services only

• Nearly ANY inconsistency is grounds recovery demand

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https://www.cms.gov

RAC Audits, cont.

• Top issues for 1st Quarter: • Non-covered services

• Duplicate claims

• Incorrectly coded services

• Incorrect payment amounts

• Prolonged services

• Physician-referring/ordering info

• Insufficient documentation

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https://www.cms.gov

RAC Audits, cont.

• Check the RAC website• www.cms.hhs.gov/RAC

• Check CERT reports• www.cms.hhs.gov/cert

• OIG reports• www.oig.hhs.gov/reports.html

• Locate the types of improper payments found in the reviews

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https://www.cms.gov