Advanced E/M Auditing: Secrets to Successstatic.aapc.com/.../d7019ac5-bdec-48c5-b761-cd8a3589b8f7.pdf · 2014-01-17 · 8 Advanced E/M Auditing: Secrets to Success •Fact or Fiction

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Advanced E/M Auditing: Secrets to Success

Advanced E/M Auditing: Secrets to

Success

Presented by

Carrie Severson CPC, CPC-H, CPMA, CPC-I

Senior Auditor, AAPC Client Services


• OIG Report (OEI-04-10-00180)

• Coding Trends of Medicare Evaluation and

Management Services - May 2012

Why We Are Here

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Advanced E/M Auditing: Secrets to Success 3

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• Compare your practice to your peers

• 20 most common coding and documentation errors

& how to avoid them

• The “Grey Areas”

• EHR pitfalls and what to look for in your audit

• Strategies for improving documentation and coding

• How to conduct an effective audit

Objectives

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Where does your practice fit?

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Where does your practice fit?

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Room for improvement

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The 20 most common coding and

documentation errors

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• Chief Complaint

• History of Present Illness

• Chronic Conditions

• Review of Systems

• Language

History Common Mistakes

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• Documentation

• Mixing

• Check boxes

• Understanding

Exam Common Mistakes

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• Severity and number

• Time based

• Orders

• Diagnosis

Assessment and Plan (MDM) Common Mistakes

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• Inconsistent documentation

• Abbreviations

• Counting elements

• Office procedures

• Misunderstanding of preventive services

• Authentication

• Timely

General Documentation Mistakes

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• Modifier misuse

• NCCI and LCD edits

• Diagnosis coding

• Chronic conditions

Coding & Data Entry Mistakes

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The “Grey Areas”

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• Fact or Fiction – The CC can be pulled from the

HPI.

Chief Complaint in HPI

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• Fact or Fiction – Status of 3 chronic conditions can

be used to support an extended level of history with

the ‘95 guidelines

Status of 3 Chronic Conditions

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• Fact or Fiction – If the history is unobtainable or non

contributory you can automatically bill a

comprehensive history

Unobtainable History

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• Fact or Fiction - If the nurse takes the HPI the

physician can then state, "HPI as above by the

nurse" or “Have read and agree with the HPI”

HPI Taken By Nurse

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• Fact or Fiction – A provider can count a single

history item in both the HPI and ROS

Double Dipping

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• Fact or Fiction – It’s acceptable to use the ‘97

Specialty specific exams for the comprehensive

exam of a single organ system in ‘95

Single Organ System Exam

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• Fact or Fiction – CMS defined the requirements of

the Detailed Exam for the ‘95 Guidelines

Detailed Exam

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EHR - Good or Bad

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• The copy and paste

EHR Issue #1

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• Over documentation

EHR Issue #2

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• Missing documentation

EHR Issue #3

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• Auto coding E/M

EHR Issue #4

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• Favorites lists

EHR Issue #5

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• Updates

EHR Issue #6

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• Who did it

EHR Issue #7

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• Signature authentication

EHR Issue #8

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• Incomplete notes

EHR Issue #9

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• Coding edits

EHR Issue #10

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• Educate providers

• Coders involvement with template design

• Perform gap assessment of new templates/EHR

• Coders shadow providers

• Perform regular audits

• Re-educate providers

Strategies for improving documentation &

coding

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• Knowledge of

– Carrier interpretations of E/M Guidelines

– Carrier policies for CPT®, ICD-9 and HCPCS

– OIG Work Plan

– RAC, CERT and other audit focus areas

– Internal documentation and coding policies

– How to effectively and professionally communicate

and educate

How to Conduct an Effective Audit

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Tips and Tools

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Conducting an Internal Audit


• Coding accuracy goal

• Reduction in billing/claim errors

• 100% participation

• Turnaround time to complete audits

• Staff certification and education

Coding Compliance Program

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• What is the focus of the audit?

– Focused

– New employment

– Chronic problem

– Targeted code(s)

Focus

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• No surprises

• Focus

• Timeline

Be Prepared

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• Specialized auditors

• Specialty credentials

• How do you ensure the quality of the audit?

Auditors

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• Advocate

– To the provider

– To the coder

• Attitude

– Educator

– Trainer

– Enforcer

Auditor’s Role

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• Define grey areas

– ‘95 or ‘97 guidelines?

– “HEENT: negative”

– Prescription drug management

– Additional work up

– Medical necessity

Standards

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Medical Record

Lab

X-ray

Outside orders

Medication lists

History forms

Documentation

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• Know your MAC carrier guidelines

• Review website often and attend trainings

MAC

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• Provider signature logs

• Supervising physicians

• Abbreviations

• Tools

Gather

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• Individual?

• Group?

• Provider?

• Coder?

• Provider and coder?

• Follow-up

Training

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• Summary

• Action Plan

• Follow-up

Report and Follow-up

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• Current ICD-9-CM code book

• Current CPT® code book

• Current HCPCS Level II Coding Procedures code

book

• Specialty specific coding

reference from a credible source

Recommended Resources

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“Any fool can know. The point is to understand.”

~ Albert Einstein

Knowledge

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• Coding and documentation audits

• ICD-10-CM assessment readiness audits

• Compliance risk assessments

• Compliance program implementation

• Training and education

Visit us at: www.aapcps.com or Call: 888.200.4157

AAPC Client Services can assist you with:

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http://www.aapcps.com/

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Questions?

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[email protected]

Senior Auditor

AAPC Client Services

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mailto:[email protected]

Documents

Advanced E/M Auditing: Secrets to Successstatic.aapc.com/.../d7019ac5-bdec-48c5-b761-cd8a3589b8f7.pdf · 2014-01-17 · 8 Advanced E/M Auditing: Secrets to Success •Fact or Fiction