HCA. Coding, Billing, and Documentation Regarding Inpatient, Outpatient, Ambulatory Surgery, and Physician Patient Accounts 3/17/2015

Transcription

1 Coding, Billing, and Documentation Regarding Inpatient, Outpatient, Ambulatory Surgery, and Physician Patient Accounts Mark J. Eddy, CPA Vice President HCA Internal Audit 1 HCA Headquarters: Nashville, TN 2014 Net Revenue: $36.9 billion Hospitals: 166 in 20 states and London, England Freestanding Outpatient Surgery Centers: 113 Employed Physicians: 3,500 Admissions: 1,795,300 Inpatient Surgeries: 518,900 Outpatient Surgeries 891,600 ER Visits: 7,450,700 Employees: 214,000 Internal Audit Employees:

2 Understand Your Structure Internal Audit Internal Control Process 3 Audit Purpose 1. Testing Control(s) Overall Focused areas 2. Testing payment accuracy 3. Define an error 4. Define population 4 2

3 Sample Selection Approach 1. Haphazard 2. Targeted 3. Statistical sampling Attribute sampling (rate of occurrence of given condition) Variable unrestricted dollar appraisals (measure quantitative characteristics) 5 Inpatient Random 6 3

4 Inpatient Random 7 Inpatient Random 8 4

5 Inpatient Random 9 Inpatient Random 10 5

6 Inpatient Random 11 Inpatient Random 12 6

7 Inpatient Random 13 Inpatient Focused 14 7

8 Inpatient Focused 15 Inpatient Focused 16 8

9 Inpatient Focused 17 Inpatient Focused 18 9

10 Inpatient Focused 19 Inpatient Focused 20 10

11 Clinical Documentation Improvement (CDI) 21 Clinical Documentation Improvement (CDI) 22 11

12 Clinical Documentation Improvement (CDI) 23 Clinical Documentation Improvement (CDI) 24 12

13 Clinical Documentation Improvement (CDI) 25 Clinical Documentation Improvement (CDI) 26 13

14 Clinical Documentation Improvement (CDI) 27 Clinical Documentation Improvement (CDI) 28 14

15 Clinical Documentation Improvement (CDI) 29 Clinical Documentation Improvement (CDI) 30 15

16 Outpatient PPS 31 Outpatient PPS 32 16

17 Outpatient PPS 33 Outpatient PPS 34 17

18 Physicians and Mid Levels Coding and Billing Compliance 1. Audit team members should be evaluated to ensure their objectivity and independence is not impaired (in fact or appearance). Items to consider include: Family relationships Specific operations for which they were previously responsible Previous accounting assistance assignments If impairment exists, consult with the applicable Vice President to consider reassigning the auditor or implementing compensating controls (I.e. additional scrutiny, etc.). Document the objectivity evaluation, conclusions, and any compensating controls. 35 Physicians and Mid Levels Coding and Billing Compliance 2. Obtain a download of Government Payor (Medicare, Medicaid and Tricare) paid patient account data from the HCAPS data warehouse or other relative source for claims data not maintained within the HCAPS data warehouse. The time period for testing should be the most recently closed three month period in which claims have been paid. 3. Select a sample of Governmental Payor paid claims. All services provided that day, and billed by that provider, should be audited. Claims are selected 20% random, 20% top volume, and 20% risk. The number of claims is dependent upon claims volume for the practice

19 Physicians and Mid Levels Coding and Billing Compliance 4. For each office where claims have been selected for testing, determine where the coding and billing functions occur for Governmental Payors. Contact the Physician Office Practice Manager and the Billing Service Center Director to inform them that claims for their office have been selected for audit and that an engagement letter will be sent detailing items needed. Based upon the sample of claims selected, work with the Internal Audit AVP to determine if the claims volume for the physician offices being audited warrants a field visit or if the review can be done as a desk review. Consider use of a control log. 37 Physicians and Mid Levels Coding and Billing Compliance 5. If the facility is not on an HCA system, work with the Practice or Facility staff to obtain the required information for the audit. 6. Send Engagement Letter and Internal Control Questionnaire (ICQ) for the Billing Director at the Physician Practice and/or the Billing Service Center. Request the Billing/Coding ICQ be returned completed within two weeks. Request medical records be prepared and submitted timely based on number of records facility needs to prepare

20 Physicians and Mid Levels Coding and Billing Compliance 7. Gain an understanding of the Physician practice billing and coding process and controls by review of the completed ICQ. 8. For the claims selected for review, obtain the final bill submitted, the related Medical Record documentation, and the Remittance Advice from the Governmental Payor. 9. Compare the codes submitted and paid to the Medical Record documentation to ensure the accuracy of the coding and billing using the MD Audit. Compare the codes submitted and paid to the Medical Record documentation to ensure the accuracy of the coding and billing using MD Audit. Validate the accuracy of the HCPCS/CPT codes to the medical 39 Physicians and Mid Levels Coding and Billing Compliance record resulting in payment(s) according to official coding guidelines and any applicable unique payer requirements. Validate the accuracy of modifiers appended to HCPCS/CPT codes that impacts payment. Validate the accuracy of ICD- 9-CM diagnosis codes to the medical record for services performed according to official coding guidelines. Compare ICD-9-CM codes to Local Carrier Determination (LCD) policies for validation. 10. List discrepancies on audit worksheets. 11. Use Regulatory Guidance to support statements made on audit worksheets

21 Physicians and Mid Levels Coding and Billing Compliance 12. Communicate the results of the record review with the facility personnel. Provide the opportunity to produce any missing documentation. 13. Prepare an Interim Summary Summarize results from audit work. Identify and quantify items impacting reimbursement. Prepare an overall report summarizing results. 14. Submit Interim Summary to AVP/VP for review which will become the Executive Summary/Report upon approval of report. 41 Physicians and Mid Levels Coding and Billing Compliance 15. Subsequent to VP/Director review of the Executive Summary/Report, as applicable, document (in note format) significant changes (e.g., major issues dropped to memoonly, issue dropped, etc.) on the Interim Summary and the individual section memos. Wording or format changes do not need to be documented. 16. Issue Final Reports to appropriate corporate, division and facility management. Include a copy of final report in the work papers

22 2014 Ambulatory Surgery Division Risk Assessment Center Criteria 1. New Center 2. Request from ASD senior leadership 3. Length of time since last audit 4. New Coder Case Criteria 1. Five Medicare cases for SOX testing randomly selected from sample population 2. Five focused Medicare cases representing the highest case volume procedures 3. Ten focused Medicare cases representing high level of coding complexityrefer to focused selection criteria document 4. Five focused non government cases representing the highest case volume procedures 43 Ambulatory Surgery Division Coding and Billing Compliance 1. Audit team members should be evaluated to ensure their objectivity and independence is not impaired (in fact or appearance). Items to consider include: Family relationships Specific operations for which they were previously responsible Previous accounting assistance assignments If impairment exists, consult with the applicable Vice President to consider reassigning the auditor or implementing compensating controls (I.e. additional scrutiny, etc.). Document the objectivity evaluation, conclusions, and any compensating controls

23 Ambulatory Surgery Division Coding and Billing Compliance 2. Consider the use of a control log. 3. Create reports of high level account data for the center with Medicare and non government paid claims from the previous three month period to select 5 random cases, 15 focused cases and 5 random or focused non government cases from the payer specific population. In addition to the sample, additional cases will be selected for alternates as needed. Use Business Objects to generate reports with detailed account data elements for populating review worksheets. Create the Excel file containing sample selection with alternates. 45 Ambulatory Surgery Division Coding and Billing Compliance 4. Send Engagement Letter and Internal Control Questionnaire (ICQ) to the center requesting information necessary to perform review. Request ICQ to be returned completed with records submitted for review. Request records be prepared timely based on number of records center has to prepare. 5. Gain an understanding of center s billing and coding process and controls by review of the completed ICQ. Summarize the results in the work papers

24 Ambulatory Surgery Division Coding and Billing Compliance 6. Perform detailed case review by performing the following: Validate the accuracy of the HCPCS/CPT codes to the medical record resulting in RA payment(s) according to official coding guidelines and any applicable unique payer requirements. Validate the accuracy of modifiers appended to HCPCS/CPT codes that impacts RA payment. Validate the accuracy of ICD 9 CM diagnosis codes to the medical record for services performed according to official coding guidelines. 47 Ambulatory Surgery Division Coding and Billing Compliance Compare ICD 9 CM codes to Local Carrier Determination (LCD) policies to validate medical necessity requirements met. Compare the paid services submitted on claim to the RA payment received. Identify claim denials. Determine if a root cause can be identified

25 Ambulatory Surgery Division Coding and Billing Compliance 7. Communicate the results of the record review with the facility personnel. Provide the opportunity to produce any missing documentation. 8. Prepare an Interim Summary. Summarize results from the audit work. Identify and quantify items impacting Reimbursement. Prepare an overall report summarizing the results. 9. Submit Interim Summary to AVP/VP for review which will become the Executive Summary/Report upon approval of report. 49 Ambulatory Surgery Division Coding and Billing Compliance 10. Subsequent to VP/Director review of the Executive Summary/Report, as applicable, document (in note format) significant changes (e.g. major issue dropped to memo only, issue dropped, etc.) on the Interim Summary and the individual section memos. Wording and format changes do not need to be documented. 11. Issue final reports to appropriate corporate, division and facility management and include a copy of final report in the work papers

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