Don’t Land in Hot Water Audit Proof your Coding and Documentation Presented by: Nikki Taylor, MBA, COC,CPC, CPMA Auditor-The Coding Institute
Learning Objectives • Government Audits • How they work • Areas of Concern
• How self-audits and external audits can: • • • • •
Identify areas for improvements in documentation Point out corrections that need to be made Review diagnosis coding to ensure specificity and accuracy Crack-down on insufficient provider documentation Avoid undercoding, overcoding, and bad coding habits
• Identify great resources and tools
• EM Auditor • CCI Edits Checker • TCI Consulting & Revenue Cycle Solutions
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Why Audits are Important • Good Practice • Audits ensure regular check-ups
• Boost up compliance • Reel in reimbursement • Increased payer scrutiny=increased risk • Includes: • Internal/In-house • External/Third Party
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Why Audits are Important, cont. • Audits help: • Ensure proper billing and coding • Correct reimbursement • New reimbursement opportunities
• Fight back against government audits • Payer medical record requests and denials
• Ensure provider education • Documentation requirements
• Quality patient care • Malpractice litigation
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Documentation Issues • Not just for coding! • Documentation equally important! • Clinical staff • Providers
• Enter documentation at time of service • Shortly thereafter • Timelines for compliance • Good patient care
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Documentation Issues, cont. • Signature requirements • • • • •
CMS guidelines Legible-hand written Signature stamps-NOT appropriate Electronic-often require physician code or login Signatures = provider reviewed and agree
• Dates and Time • All entries • Allow medical treatment to be reconstructed at a later time • If time of service and time of entry are different -document why
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Documentation Issues, cont. • Types: • • • •
Handwritten Dictation Templates Electronic
• Handwritten: • Often illegible
• Dictation: • • • •
Clear and thorough Timing-transcription Summaries Signatures
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Documentation Issues, cont. • Templates: • Cloning • Information lacking key details • Not thorough
• Electronic • Cloning • Built-in templates • Over documenting/medical necessity
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RAC Audits • Recovery Audit Program (RAC) • Mission: • Identify and correct improper payments • Overpayment detection and collection • Identifying underpayments • Prevent future improper payments
https://www.cms.gov
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RAC Audits, cont. • National Recovery Audit program • • • • • • •
Demo program- utilized Recovery Auditors Medicare overpayments and underpayments Between 2005 and 2008 Resulted in > $900 million being returned to the Medicare Trust Fund Nearly $38 million in underpayments to health care providers. Secretary of the Department of Health and Human Services Instituted permanent and national Recovery Audit program https://www.cms.gov
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RAC Audits, cont. • Post-payment basis • Follows Medicare policies • Carriers, FIs and MACs: NCDs, LCDs and CMS Manuals
• Two types of reviews: • Automated (no medical record needed) • Complex (medical record required)
• No claims paid prior to October 1, 2007 • Can go back three years • Date of payment
• Staff consists of nurses, therapists, certified coders, and a physician CMD https://www.cms.gov
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RAC Audits, cont. • Demand letter is issued by RAC • Opportunity for provider • Discuss the determination with the RAC • Not part of the normal appeal process
• Issues reviewed by RAC - approved by CMS • Issues approved are posted to website before widespread review https://www.cms.gov
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RAC Audits, cont. • RAC contractors are paid a contingency fee • % of every dollar in overpayments collected • Lose the appeal-must pay fee back
• Focus--organizations with billings higher than the majority • Other providers/suppliers • Medicare services only
• Nearly ANY inconsistency is grounds recovery demand https://www.cms.gov
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RAC Audits, cont. • Top issues for 1st Quarter: • • • • • • •
Non-covered services Duplicate claims Incorrectly coded services Incorrect payment amounts Prolonged services Physician-referring/ordering info Insufficient documentation
https://www.cms.gov
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RAC Audits, cont. • Check the RAC website • www.cms.hhs.gov/RAC
• Check CERT reports • www.cms.hhs.gov/cert
• OIG reports • www.oig.hhs.gov/reports.html
• Locate the types of improper payments found in the reviews https://www.cms.gov
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