3/28/2016 1 Physician E/M Audit Problems and Effective Solutions Lamon 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 Risk 2
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3/28/2016
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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
• 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.”