Presenting Audit Results Shannon DeConda, CPC, CPC I, CEMC, CMSCS, CPMA, CPMN, CMPM How are your results received? Are you the Cop or the Educator? Are your recommendations put into a plan of action and executed? During today s session, we will take findings from audits and put you into groups who you will work together with to deliver your best results. 1
BEFORE WE BEGIN Let s just talk about some of the basics: Reports Presentation Style Tools and Take Aways Reports There are many different topics related to reports that should be considered: Electronic vs. Paper Findings Records Audited Support/Guidelines Disclaimer Acknowledgement of Findings Presentation Style Also, presentation styles could be a full day s topic, but considerations for this session include: Onsite versus Remote Phone versus Web Authoritarian or Educator Medical Care versus Medical Documentation 2
Tools & Take Aways Tell me the purpose of a proactive audit. Ethical contributions toward compliance. What tools, cheat sheets, or take aways can you provide for success? Rules of This Session Take this seriously Don t laugh Act like you have been treated in practice settings NOW LET S HAVE FUN!! 3
Medical Assistant (who is scribing) Practice Manager Compliance Manager Auditor Scenario #1 10 Physician Practice Ortho and Pain Management You are providing results to an employed physician Proactive Retrospective Audit Ancillary services provided at this practice include x ray and PT Scenario #1, cont. Details: Medical Assistant has only been with the practice for 6 months and is scribing for the Provider, but has never scribed at any prior jobs. The MA has 10 years of experience and seems somewhat overly confident. The Practice Manager has been with this group since it was a solo practice, and has watched the baby grow. The PM, self proclaimedly, has a team of providers that is working at full capacity, and would bet they all pass their audits with flying colors. Uponhearingthe findingsoftheaudit audit, thepmisdoubtfulthe auditor s findingsare valid. The Compliance Officer is young and new to the practice. The CO was previously an auditor with BCBS and has only been in healthcare for 5 years. Although not as experienced, the CO is very astute and knows her stuff. She is not surprised by the miserable findings of the other providers and certainly does not think that this provider will have findings any different than the others. All of the Auditing Team work for a third party consulting firm. They have been engaged to perform the audit in an effort to ensure OIG compliance. They were told that there were not red flags that the practice knew of for any of the staff or providers. Scenario #1, cont. The audit was conducted and included an audit of 20 charts per provider. The charts included a mix of E&M services (new and established), office visit services with procedures, and surgical cases. The precision rating of the provider was 70%. The findings indicated the following deficiencies: The bell curve of this provider indicated a high rate of 99214 encounters be used. Upon review, it was noted that most services for this provider were documented to include the components needed for a 99214, but that the medical necessity did not always support the higher level service. The records were identified to not include an appropriate chief complaint, most of the time, only stating the following: CC: As per noted in the HPI. The records included multiple areas that were carried over from visit to visit as noted by sections indicating: Reviewed on 1 1 2111 by Shannon DeConda and updated. The records are not all being locked and; therefore, lack the electronic signatures needed. 4
Nurse Practitioner Supervising MD CEO CFO Coder Scenario #2 This is a FQHC organization and they have 2 locations (both rural). The NP works at Location A alone on Monday and Wednesday while the MD works at Location B, Tuesday and Thursday they work together at Location B and then Fridays the NP works alone at Location B while the MD is off. Performing a proactive audit because the CEO attended a seminar by Sean Weiss and got scared. Scenario #2, cont. Details: The NP and MD are the only providers. The CEO and CFO know nothing about coding, but have heard many troubling stories and are worried for the well being of their practice. They know there are probably some short tfallings, and just want to do their best tfor their community. The coder is performing check in/out duties, billing, and truly does not do much coding work for the practice, but is a CPC. The auditors are from a third party consulting firm hired to analyze the documentation. Scenario #2, cont. Findings of the Audit: All of the NP s services are being performed and billed to Medicare and Medicaid under the supervising MD s billing number. Overall, both providers are down coding their services. They are billing mostly 99212 services for the MD and 99211 for the NP s services. Services are handwritten and often difficult to read. Hint for presentation: If you are not familiar with FQHC services, you will still be ok presenting this. The key to remember, is they code E&M levels of service the same as any other provider don t be swayed on this point. They are paid at a flat fee regardless of the level of service, but that DOES NOT mean they should not still choose their codes according to the guidelines. 5
Attorney Physician (Opthalmologist) Physician Assistant Scribe Scenario #3 Attorney contracted the Auditor to review the findings of a recent audit for office visits with intravitreal injections. CMS audited 50 charts that were billed with E&M services with same day minor procedure with a 25 modifier. Scenario #3, cont. Findings of Auditor s Review: Office visits were evaluation of bilateral eyes for any noted improvement since prior injection and re evaluation for another injection today. Therefore, theauditor agreeswiththecmsaudit the audit that these E&M services are not billable. CMS noted that the HPI was documented by the scribe, but that was not signed and noted as such. The PA s services are dictated to indicate that the PA is dictating on behalf of the physician. Scenario #4 Physician (Dermatologist) Billing Company (3 rd Party) Manger Billing Company Practice Biller Retrospective audit performed at the request of a single provider, solo practice. Audit included a sampling of 20 encounters with varieties of level and type of service including in office procedures. 6
Scenario #4, cont. Audit Findings: Inappropriate use of the 59 modifier. The 59 was applied to every procedural code. Examples: 99213 25, 17000 59, 17000 59 Office visits were under billed based on medical necessity and documentation guidelines. The physician is billing nurse visit code for serviced he provided. Scenario #5 Provider Coder ComplianceOfficer from Hospital Pre bill, pro active audit. Hospital owned, multi specialty practice. Review included all services for 2 weeks. Scenario #5, cont. The audit you are assigned to is for an ENT provider. Upon auditing the records, you note that while the content for documentation guidelines is well documented, the medical necessity to support the higher levels of service is not as clear. When presenting the findings to the provider, he insists that anyone familiar with ENT services should be able to connect the medical complexities of his patients and know why certain procedures are performed. 7
Scenario #6 Physician A Physician B Physician C Retrospective, pro active audit. 10 charts per provider. No attorney client privilege Scenario #6, cont. The audit results identify the providers in this practice would better benefit in their documentation by utilizing 1995 guidelines. While discussing these results, the providers are completely ignorant of documentation guidelines not event realizing there are 2 different sets of guidelines. Questions? Shannon DeConda, CPC, CPC I, CEMC, CMSCS, CPMA, CPMN, CMPM sdeconda@drsmgmt.com 8