2015 User Conference

Surviving an Insurance AuditApril 24, 2015 (PM-290)

Presented by:

Susan J. Kressly, MD, FAAPMedical Director

PM Session

2015 Office Practicum User Conference

Learning Objectives

▪Review who gets audited

▪Understand the implications of an insurance audit

▪ Identify 3 ways you can use best practices to decrease audit vulnerability

▪Outline important steps to take in response to an insurance audit

2015 Office Practicum User Conference

Who gets audited?

▪Coding “outliers”

▪Higher use of 99214 or 99215 compared to peers

▪Higher use of modifiers

▪Higher use of other CPTs

▪Random selection

▪Some payers have mandatory random audit quotas

▪Allegations of fraud

▪ANYONE can be audited at ANY time

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Why do audits happen?

▪Public insurance companies (Medicare/Medicaid) have oversight mandates

▪Attempts to identify/eliminate fraud▪All payers attempting to

decrease/eliminate overpayment ▪The bottom line▪Technically under-coding is also subject

to corrective action (have never seen it happen)

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What are the implications of an audit?

▪Commonly ask for a review of a finite number of charts (example 40)

▪Example: if they believe you inappropriately coded ten 99214s they feel should have been 99213s (25%) and…

▪The difference in payment for your practice is $35 for this payer…..

▪And your practice submitted claims using 99214 a total of 3,000 times over past 2 years

▪They assume they overpaid you $26,250 and want the $$$ back

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Take-backs

▪Length of time they can pursue for take-backs depends on state regulations

▪Can ask for check immediately or take from claims submitted going forward

▪Can be subject to additional interest/penalties

▪Many payers use third-party companies which get to keep a % of monies collected

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Who is ultimately responsible?

▪The owners▪The billing providers

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E/M coding distribution

▪ Is not a bell shaped curve▪ In Pediatrics most providers should be

billing >30% 99214s or you are likely leaving $$$ on the table

▪Some pediatricians bill > 50% 99214s▪99215 is underutilized▪Few pediatricians bill a large # of

99212s ▪Exception is well/sick at the same time

▪99211 should not be used for vaccine only appointments unless additional separately identifiable reason for visit

E/M coding distribution

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Procedures

▪Make sure you are using the appropriate CPT code for commonly used codes such as:▪Hearing/Vision▪In house lab tests▪Wart treatments▪Burn/wound care▪Chemical cautery of skin lesions▪Frenulotomy▪Urinary bladder catheterization

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Best Practices to Limit Vulnerability

▪Coding education▪Providers▪Billing staff

▪Periodic internal coding surveillance audits▪Internal if have expertise▪Hire outside consultant if internal expertise lacking

▪Track E/M coding distribution by provider

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Cardinal Rules of Coding

▪Do what is indicated by the patient’s presenting complaint(s) and conditions

▪Document what you do (including thought processes in medical-decision-making)

▪Code appropriately as supported by your documentation

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OP Coding Decision Support

▪ Is based on the 1997 CMS coding guidelines

▪While the 1995 guidelines may be more “pediatric friendly” they do not lend themselves to “bullet counting” by a computer

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Keys to Coding Success in OP

▪Understand how “suggested” coding occurs

▪Use the coding calculator to make sure your documentation supports your coding choice

▪Medical-decision-making is a manual process

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Help, I’m being audited! What now?

▪BREATHE……..▪ If you have documented and coded appropriately, you have nothing to fear▪Look at your time line▪Read the request for ‘gotchas’

▪May state only the first response will be used for the audit, supporting documents will not be counted

▪Details about how far back they may extrapolate▪Consider response that you want the opportunity to do more extensive review/submission with more charts

▪Review all documentation before you send!

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New OP 14 Audit Notes

▪Available from the chart itself ▪Encounter notes and Well Visits▪OP 14 upon finalization of note:

▪automatically builds and saves a note summary based on practice report rules

▪automatically builds and saves an audit report note (criteria not customizable)

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Audit Note Contents

▪Confidential disclaimer with all notes

▪MU Information

▪Location

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Audit Note Contents (continued)

Plan and Patient Instructions (if available) included

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Audit Note Contents (continued)

▪New section for coding/audit support

▪Contains summary on what was used to calculate code

▪Note started time: first time any user opened note (nurse/MA/provider)

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Medical Decision Making

▪Computer cannot compute what provider is thinking (nor can billing staff)

▪Provider must go to coding decision tab and select appropriate levels

▪MDM must have documentation within the body of the note to support choosing level

▪Must check box for Coding Count Override to be included in audit note

MDM Audit Note

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MDM Information in Audit Note

▪MDM only appears if user checks “coding override” box

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Overriding Suggested Code

▪May put PMH or SH in HPI or other section

▪May feel ROS/exam elements not counted correctly by OP (would document why you think this somewhere in note)

▪Must pay attention to MDM section if choose to override as these details will be included in audit note

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Coding Based on Time

▪Best practice is to insert wording: “spent x minutes face to face with patient/parent” discussing/counseling on concerns and diagnosis”

▪Can be put in plan section, counseling/care coordination section or both

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Time Coding Decision Support

▪Key component: time

▪Record total visit length

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Audit Note for Time Based Coding

▪Total visit time included in visit information

▪Counseling duration included (with confidential information withheld)

▪Audit support reinforces counseling is key factor

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What about my old notes?

▪Can reconstruct using new audit note rules▪Go to alternate note tab▪Choose summary report criteria: Audit

Report Note▪Use edit pencil to enter comments/purpose▪Click on Rebuild Summary

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Review Before Releasing Documentation

▪Have internal/external expert review notes to do an assessment whether documentation fits coding level put on claim

▪ Include additional print outs of surveys, etc.

▪ If you feel there is missing information, call OP before you send!

▪there may be additional information that can be added to your documentation to support your claim

▪OP may be able to provide a letter regarding how reports are constructed or changes in versions

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Looking for more education/consulting?

▪AAP coding resources▪E/M University has coding

videos, pediatric specific learning modules, and auditing tools *

▪The Verden Group*▪Pediatric Management Instit

ute*

* Office Practicum does not specifically endorse this product/group

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Questions?

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We want your feedback!