physician e/m audit problems and effective...
TRANSCRIPT
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Physician E/M Audit Problems and Effective SolutionsLamon Willis
Director of Business Development | Healthicity
CPCO, CPC-I, COC, CPC
Agenda
1. Setting Up Your Audits
2. Audit Resources
3. Auditing Methodology
4. Auditing Education and Reporting
5. Case Studies and Challenges of Medical Auditing
6. Common Areas of Risk2
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Setting Up Your Audits
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Good Leadership
The Audit Director has an active role within the organization's compliance committee, coding leadership, billing leadership and other revenue cycle related leaders in the organization's decision making structure and process.
The Audit Director participates in established meetings of the organization's compliance program.
The Audit Director directs: The implementation of an effective program to measure and monitor the quality of the auditors and auditing activities being performed.
The Audit Director approves audit related policies, standards and guidelines for the organization before they are implemented.
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Utilizing Audit Guidelines
Do you have written internal practice guidelines for your audits?
• Consistency
• Accuracy
• Increased productivity
• Fortifies your audits
Identifying / understanding unintended consequences of your guidelines. For example, requiring MDM can lower provider scores. Does this impact RVU bonus or other things?
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Utilizing Audit Guidelines
• Type of E/M guideline (1995 or 1997 guidelines) to use
• If using the 1995 E/M guidelines, define what equals a detailed exam
• If the chief complaint can be inferred
• Define what prescription drug management includes
• Define what additional work up includes
• Is MDM required for 2 of the 3 key components
• Provider and staff signature logs
• Define acceptable abbreviations and/or acronyms
• Define timely authentication time line
• List approved coding tools and resources 6
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Utilizing Audit Guidelines
Educate coders and providers on your audit guidelines
Incorporate into your coding and documentation training for new staff as well as for your annual trainings
Include your audit guidelines in your audit worksheet, reports, etc.
Review your MAC carrier and commercial payer website and/or emails for changes, and attend local payer workshops to ensure you aware of any changes and incorporate into your guidelines
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Audit Resources
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Common Resourcing Issues
•Not allocating the necessary resources to conduct audit and post audit education activities.
•Audits being conducted by qualified and competent staff.
• Failure to monitor quality.
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Invest in Compliance
Access to current coding books and reference materials.
Auditors are appropriately trained and proficient in the use of any audit tools and software programs.
Appropriate staffing ratios.
The recommended auditor to provider ratio should not exceed 100 providers per auditor. This ratio may vary depending on the scope and frequency outlined within the organizations audit / compliance program requirements
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Working with Limited Resources
Outsource audits and keep education internal
Staggering audit projects
Don’t compromise compliance standards
Leverage technology to improve efficiency
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Working with Limited Resources
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Auditor Qualifications
Audit staff have demonstrated their competency by obtaining applicable certifications.
Auditors are subject to a skills tests to evaluate their auditing skill levels before being allowed to perform audits.
Audits are assigned to auditors matching the experience and expertise to the medical specialty being reviewed.
Auditors are checked against all required State and Federal regulatory exclusion databases annually.
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Resources to Monitor Quality
Quality Audit Committee or appointed designee(s)
Developed audit quality standards, guidelines and corrective actions which are clearly outlined
Oversees corrective actions of audit staff
Quality performance reviews are conducted regularly
Conduct periodic external review to audit your auditors
Quality reviews include meaningful elements
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Quality Metrics
• E/M coding accuracy
• CPT coding accuracy
• Modifier coding accuracy
• Diagnosis coding accuracy
• HCPCS coding accuracy
• Data entry accuracy
• Key findings accuracy
• Recommendations accuracy
• Reference citation accuracy 15
Auditing Methodology
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Written Policies
• Key objectives or focus of the audit
• Sampling parameters
• Type of audit (e.g. prepayment vs. retrospective)
• Frequency requirements for audits to be performed
• Minimum scope (e.g. CPT, E/M, HCPCS, Documentation elements)
• Establish minimum audit pass rate requirements
• Establish audit scoring and accuracy rate calculation methodologies
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Written Policies
• Approved reference materials (e.g. CPT Assistant, Coding Clinic, etc.)
• Define post-audit training or education requirements
• Define remedial training or auditing requirements for individuals who do not meet the minimum audit pass rate requirements
• Establish appropriate guidelines for incentives or punitive actions associated with audit results or performance
• Auditing standards are maintained by the organization, reviewed regularly, acted on, and updated as needed
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Selecting Your Sample Size
Federal Register / Vol. 65, No. 194
“Optimally, a randomly selected number of medical records could be reviewed to ensure that the coding was performed accurately.
Although there is no set formula to how many medical records should be reviewed, a basic guide is five or more medical records per Federal payor (i.e., Medicare, Medicaid), or five to ten medical records per physician.”
https://oig.hhs.gov/authorities/docs/physician.pdf
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Selecting Your Sample Size
What are payers and the OIG using to evaluate you?
• Risk scoring and predictive modeling
• Cross payer analytics
• Special Investigation Units
• Detection Analytics
• Provider profiling
• Multi-variant modeling
VsIs your sampling methodology outdated?
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Example of Utilization Review
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Example of Utilization Review
0
5
10
15
20
25
30
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0 10000 20000 30000 40000 50000 60000
17003 (Lesion Destruction 2-15 Lesions) Per PatientCalifornia Dermatology Providers
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Scoring Audit Results/Pass Rates
• Equal weight - total errors / total possible
• Under-coded not counted as an error
• Weighted averages
• Fee schedule overpayment
• Type of scoring should be based on the type of audit performed
• OIG uses 95% of dollars from the claim as an acceptable passing rate….set your passing threshold to match
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Auditing & Monitoring Frequency
•Baseline
•Ongoing monitoring
• Focused
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Auditing Education and Reporting
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Post-Audit Education
Perform the audit, provide feedback, monitor, and then re-audit.
Requirements for providing results
Structure in place to monitor feedback and training of providers
Ensure trainers are giving correct and accurate feedback
Feedback is shared with compliance / administration
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Documenting Your Results
• What type of reports should you use?
• What type of information should be included on an audit report?
• How long should you keep your reports?
• Signature page
• When is attorney client privilege appropriate?
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What To Include In Reports
• Patient identification, DOS
• Comparison of audited and reported codes
• Key documentation or coding issues
• Observation of findings for each encounter reviewed
• Recommendations for improvement and to correct problems
• Results are reported in an organized format that allows the viewer to easily draw conclusions
• Audit results are maintained by the organization and easily accessible
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What To Include In Reports
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What To Include In Reports
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What To Include In Reports
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Providing Feedback – Best Practice
• An audit is not an accusation. An auditor’s role is to be an advocate to the coder and/or provider.
• Providing the feedback can be done several different ways; one/one training, group training, shadowing, or written report.
• Best practice is to use the method of education based on the audit results and your provider’s needs.
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Dealing with Difficult Providers
What do you do if the provider does not like the result and requests a change?
• Listen
• Try understand from a clinical perspective
• Educate using approved reference
• Agree to resolution – revise or leave as is
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Proactive Versus Reactive Training
• The organization has appointed a designated individual(s) responsible for monitoring and managing coding and billing updates.
• Auditors receive training and are aware of applicable coding and billing updates and amendments.
• Providers receive training and are aware of applicable coding and billing updates and amendments.
• Coders receive training and are aware of applicable coding and billing updates and amendments.
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Proactive Versus Reactive Training
• The organization has appointed a designated individual(s) responsible for monitoring and managing coding and billing updates.
• Auditors receive training and are aware of applicable coding and billing updates and amendments.
• Providers receive training and are aware of applicable coding and billing updates and amendments.
• Coders receive training and are aware of applicable coding and billing updates and amendments.
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Case Studies and Challenges of Medical Auditing
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Complexity of Coding
Medical Specialty Correct Overcoded Undercoded
CPT
coded correct
CPT coded
incorrect
CPT codes
added
"Anesthesiology" 84% 12% 5% 89.5% 6.1% 4.3%
"Cardiology" 74% 19% 7% 72.1% 25.3% 2.6%
"Critical Care" 87% 7% 7% 60.0% 40.0% 0.0%
"Dermatology" 79% 13% 8% 83.5% 11.4% 5.1%
"Emergency Medicine" 74% 21% 5% 86.7% 5.6% 7.7%
"Family Medicine" 77% 17% 5% 70.2% 25.0% 4.8%
"Otorhinolaryngology (ENT)" 77% 19% 5% 61.8% 30.3% 7.8%
"Gastroenterology" 63% 32% 5% 91.1% 5.7% 3.3%
"Internal Medicine" 78% 15% 6% 67.9% 26.6% 5.5%
"Obstetrics and Gynecology" 77% 17% 5% 68.7% 26.0% 5.3%
"Orthopedic" 76% 20% 4% 79.9% 16.6% 3.5%
"Pediatrics" 79% 17% 4% 68.4% 24.8% 6.8%
"Surgery, General" 69% 25% 7% 76.9% 17.7% 5.3%
Averages 73% 21% 6% 79% 16% 5%
E/M coding results CPT coding results
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Complexity of Coding
Financial Impact To A Practice: Primary Care
Average Number of Patient Visits / Year = 4,000
RVU weighted conversion factor / RVU = $35.82
Average RVU variance for undercoding = .80
Average RVU variance for overcoding = 1.05
4,000 x 21% = 840 claims x $37.00 (overcoded value) = $31,000 / year
4,000 x 6% = 240 claims x $29.00 (undercoded value) = $7,000 / year 38
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Case Study
Audit Results Correct Over Coding(Compliance Risk)
Under coded(Revenue Loss)
Baseline Review 65% 25% 10%
Impact Baseline
Compliance Risk $26M
Missed Revenue $5.8M
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Client Challenges
Understaffing key resources
Failure to leverage technology
Poorly structured audit reports
Failure to provide feedback and close the loop
Battle between Revenue Cycle vs. Compliance
Utilizing auditors with the wrong skill set
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Case Study
Period Correct Over Coding Under coded
Baseline Review 65% 25% 10%
Q2 Review 80% 15% 5%
Q3 Review 87% 7% 6%
Q4 Review 91% 5% 4%
Impact Baseline Q4
Compliance Risk $26M $3.7M
Missed Revenue $5.8M $2.3M
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How They Made Improvements
Interim step – outsourced audits
Worked to re-build improve internal audit abilities
Revised their audit reports
Instituted remedial training program and re-audit standards based on defined accuracy rates
Required all providers receive audit results
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Common Risk Areas
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EMR Impacts
•Over documentation for follow up visits or based on the nature of the presenting problem.
•Missing documentation of procedures. This is caused by providers not reviewing the final note prior to authentication.
•Misuse of templates.
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Common E/M Errors
• Documenting “non-contributory” for family history.
• Documenting “see HPI” for review of systems when there are no associated signs / symptoms or a ROS documented in the HPI.
• Not documenting the chief complaint for subsequent hospital visits.
• Coding MDM based on the point system alone rather than the nature of the presenting problem and the medical necessity of the service.
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Common E/M Errors
• Documenting “non-contributory” for family history.
• Documenting “see HPI” for review of systems when there are no associated signs / symptoms or a ROS documented in the HPI.
• Not documenting the chief complaint for subsequent hospital visits.
• Coding MDM based on the point system alone rather than the nature of the presenting problem and the medical necessity of the service.
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Questions?
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Contact Info
•Lamon Willis
•http://www.healthicity.com
•800-626-2633, Ext. 318
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