Risk-Based or Random: How to Determine the …

1 Risk-Based or random : How to Determine the Scope of your Audit Peggy Stilley, CPC, CPMA, CPC-I, COBGC, ACS-OB Deann Tate, MHA, CPC, CPMA, CCC, CEMC Risk-Based or random : How to Determine the Scope of your Audit This course was current at the time it was published. This course was prepared as a tool to assist the participant in understanding how to perform a successful internal audit to protect your medical practice. Although every reasonable effort has been made to assure the accuracy of the information within these pages the ultimate responsibility all of the information has does not accept responsibility or liability with regard to errors, omissions, misuse and misinterpretation. Please keep in mind that every insurance company has processing and reimbursing procedures that are individual to each particular company. Instructions and recommendations given in this booklet should not be interpreted as applying specifically to every insurance carrier.

2 Please confirm with your carriers coding practices that are applicable to each carrier. The American Academy of Professional Coders (AAPC) employees, agents, and staff make no representation, warranty or guarantee that this compilation of information is error-free and will bear no responsibility, or liability for the results or consequences of the use of this course. NOTICES Current Procedural Terminology (CPT ) is copyright 2013 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association (AMA). Disclaimer 2 Risk-Based or random : How to Determine the Scope of your Audit Risk-Based or random Audits Benchmarking Data CERT, RAC, OIG, MIC, etc. EMR Audit Results for Physicians Agenda 3 Risk-Based or random : How to Determine the Scope of your Audit Discover need for coding education Find areas for improvement in documentation Prepare for potential payer audits Identify areas in which provider/practice is outlier Discover revenue opportunities Uncover reimbursement deficiencies Reasons for an Audit 4 Risk-Based or random : How to Determine the Scope of your Audit random Focused Prospective (pre-claims submission) Retrospective (post-payment or post-denial) Types of Audits 5 Risk-Based or random : How to Determine the Scope of your Audit Sample should be representative of provider s typical case mix Identify potential overcoding and/or undercoding May be performed prospectively or retrospectively Gives unbiased results Discover previously unknown areas for improvement random Audits 6 Risk-Based or random .

3 How to Determine the Scope of your Audit RAT-STATS Statistical software program created by OIG Primary statistical tool for OIG Office of Audit Services Download and use to select your sample Can also use for estimating overpayments Used by many payers to fulfill requirements of CIA (corporate integrity agreement) Selecting random Sample 7 Risk-Based or random : How to Determine the Scope of your Audit 8 Risk-Based or random : How to Determine the Scope of your Audit 9 Risk-Based or random : How to Determine the Scope of your Audit 10 Risk-Based or random : How to Determine the Scope of your Audit Risk Based Auditors can use online E/M utilization data as a comparison for practice data Use online tools/charts AAPC E/M Utilization Benchmarking Tool Medicare MGMA Be aware that there are differences in patient mix between providers of same specialty Focused Audits 11 Risk-Based or random : How to Determine the Scope of your Audit AAPC Benchmarking Tool 12 Risk-Based or random : How to Determine the Scope of your Audit 13 Risk-Based or random : How to Determine the Scope of your Audit Sample includes charges from a pre-identified area or potential deficiency May be performed as a result of findings from a random audit Usually done on prospective basis Focused Audits 14 Risk-Based or random .

4 How to Determine the Scope of your Audit Determining the scope of your audit CERT (Comprehensive Error Rate Testing) RAC (Recovery Audit Contractors) OIG (Office of Inspector General) Work Plan Previous billing by your provider/practice Level 4 and 5 E/M services Codes that prompted a previous letter from payer Focused Audits 15 Risk-Based or random : How to Determine the Scope of your Audit CERT - RAC - OIG MAC 16 Risk-Based or random : How to Determine the Scope of your Audit Comprehensive Error Rate Testing Select random samples of paid claims Request records Compared to Medicare guidelines Calculates error rates based on charts reviewed Reports these errors, not assigned as fraudulent In 2009 sampled approximately 100,000 claims Failure to respond results in auto overpayment error 17 Risk-Based or random : How to Determine the Scope of your Audit Zone Program Integrity Contractors Medicare FFS Advantage programs Targeted reviews Pre and post payment Automated and Complex Identified potential Fraud 18 Risk-Based or random : How to Determine the Scope of your Audit Recovery Audit Contractors CMS has budgeted for hiring personnel Get a percentage of what is recovered 1 billion identified for overpayments Use medical personnel, coders, nurses Providers have chosen to appeal < 25% of determinations 19 Risk-Based or random : How to Determine the Scope of your Audit Recovery Audit Regions 20 A Diversified Collection Services B CGI C Connolly D Health Data Insights Risk-Based or random .

5 How to Determine the Scope of your Audit Medicaid Integrity Audits Complete compliance overview Services billed properly, paid according to policies Adherence to state Medicaid regulations Review, Audit, Education 21 Risk-Based or random : How to Determine the Scope of your Audit 22 Whereas provider s conduct which is subject to this agreement involves any and all claims submitted between XXX and XXX (4 year period) that the OAG believes were medically unnecessary and/or failed to meet professional recognized standards of practice and the provider maintains they services were medically necessary, met the recognized standards of practice, and had not intent to violate any statutes or administrative the provider shall pay a total sum of $XXXXX in restitution and $5000 in investigation costs to the OAG. Risk-Based or random : How to Determine the Scope of your Audit May 2012, Coding Trends of Medicare Evaluation and Management Services Part B payments increased by 43 % $77 billion to $110 billion E/M increased 48% $ billion to $ billion OIG Report 23 Risk-Based or random : How to Determine the Scope of your Audit 24 Risk-Based or random : How to Determine the Scope of your Audit 25 Risk-Based or random : How to Determine the Scope of your Audit 26 Risk-Based or random : How to Determine the Scope of your Audit Physicians identified as consistently billing higher Physicians identified by state Physicians identified by specialty Internal Med, Family Med, Emergency Med Most common ICD-9 codes reported Higher Levels E/M Codes 27 Risk-Based or random : How to Determine the Scope of your Audit 28 Risk-Based or random .

6 How to Determine the Scope of your Audit Cloned documentation Contradictory statements Volume of documentation vs. Medical Necessity Non-specific documentation Missing signature MUE Common Issues Identified 29 Risk-Based or random : How to Determine the Scope of your Audit Good, Bad, and Ugly Electronic Medical Record 30 Risk-Based or random : How to Determine the Scope of your Audit EMR/EHR The copy and paste Over-documentation Missing documentation Auto-coding E/M Author of documentation Signature authentication Incomplete notes Likely Culprits 31 Risk-Based or random : How to Determine the Scope of your Audit Voice recognition software Accents, illness Use of normal templates for transcription Physicians utilizing free text within EMR Likely Culprits 32 Risk-Based or random : How to Determine the Scope of your Audit Audit Results 33 Risk-Based or random .

7 How to Determine the Scope of your Audit Communication of audit results is vital Translate coding concepts into layman terms No coder-speak Use non-confrontational manner Refer to specific examples Ask questions Suggest future education and follow-up audit Presenting Audit Findings 34 Risk-Based or random : How to Determine the Scope of your Audit Performed baseline audit for 30 providers Overall E/M accuracy 59% 7 of the providers had over 80% Documentation lacking for procedures Case Study #1 Group Practice 35 Risk-Based or random : How to Determine the Scope of your Audit Common Issues Consultations did not meet criteria Documentation of time was lacking EMR functions Trigger point, immunizations, office procedures lacked documentation Preventive services billed as Acute visits Medicare AWV, G and Q codes Case Study #1 (cont) 36 Risk-Based or random : How to Determine the Scope of your Audit Recommendations One-on-one training for providers 80% and under Work with IT and providers for EMR output Outcome IT and EMR worked together Templates updated Case Study #1 (cont) 37 Risk-Based or random .

8 How to Determine the Scope of your Audit 2nd round of audits for same group of physicians Overall E/M accuracy increased to 78% Eleven providers with accuracy of 80% or above Education with physicians showed improvement Revealed incident-to issues (tracking) Case Study #1 (cont) 38 Risk-Based or random : How to Determine the Scope of your Audit Most recent Audit Improvements Improvement in Incident To billing History and Exam Deficiencies MDM based on new carrier rules Issues with documentation of office procedures Incorrect ICD-9 codes Counseling/coordination of care still need improvement Case Study #1 (cont) 39 Risk-Based or random : How to Determine the Scope of your Audit Performed baseline audit of a new provider Audit scope: random sample of office E/M codes (10) Overall E/M accuracy 70% 7 out of 10 E/M services coded correctly 2 E/M services overcoded, 1 undercoded Meeting with Dr.

9 Smith to discuss results & provide education Plan to reaudit in 2 months Case Study #2 Dr. Smith 40 Risk-Based or random : How to Determine the Scope of your Audit Re-audit Audit scope: Risk-Based sample of office E/M codes 20 encounters were selected for re-audit, comprised only of E/M codes that were incorrect on baseline Overall E/M accuracy 90% 18 out of 20 E/M services coded correctly 2 E/M services undercoded Meeting with Dr. Smith to discuss results Next audit according to compliance plan schedule (1 year) Case Study #2 Dr. Smith (cont.) 41 Risk-Based or random : How to Determine the Scope of your Audit Annual (scheduled) audit Dr. Smith now sees patients in hospital as well as office Audit scope: random sample of office & hospital E/M codes (10) Overall E/M accuracy 60% 6 out of 10 E/M services coded correctly 3 E/M services overcoded and 1 was incorrectly reported as a consult for Medicare patient (overcoded services lacked D exam but had High MDM) Meeting with Dr.

10 Smith to discuss results & provide education Re-audit in 2 months Case Study #2 Dr. Smith (cont.) 42 Risk-Based or random : How to Determine the Scope of your Audit Re-audit: Risk-Based sample of hospital E/M codes (20) Overall E/M accuracy 70% 16 out of 20 E/M services coded correctly 4 E/M services overcoded (MDM supports only) Meeting with Dr. Smith to discuss results One-on-one E/M coding class scheduled for following week Dr. Smith does not appear for scheduled session but does attend 2 weeks later Re-audit in 1 month Case Study #2 Dr. Smith (cont.) 43 Risk-Based or random : How to Determine the Scope of your Audit Re-audit: Risk-Based sample of hospital E/M codes (20) Overall E/M accuracy 90% 18 out of 20 E/M services coded correctly 2 E/M services undercoded (billed 99232 to pass audit) Meeting with Dr. Smith to discuss results Re-audit in 6 months Will review hospital and office E/M codes Case Study #2 Dr.