risk-based or random: how to determine the scope of your...

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. 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

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• Risk-Based or Random Audits

• Benchmarking Data

• CERT, RAC, OIG, MIC, etc.

• EMR

• Audit Results for Physicians

Agenda

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• 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

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• Random

• Focused

• Prospective (pre-claims submission)

• Retrospective (post-payment or post-denial)

Types of Audits

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• 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

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• 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

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Risk-Based or Random: How to Determine the Scope of Your Audit 8


• 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

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AAPC Benchmarking Tool

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• 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

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• 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

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CERT - RAC - OIG – MAC

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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

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Zone Program Integrity Contractors

• Medicare FFS – Advantage programs

• Targeted reviews

• Pre and post payment

• Automated and Complex

• Identified potential Fraud

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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

http://www.cms.hhs.gov/RAC/downloads

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Recovery Audit Regions

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A Diversified Collection Services B CGI C Connolly D Health Data Insights


Medicaid Integrity Audits

• Complete compliance overview

• Services billed properly, paid according to policies

• Adherence to state Medicaid regulations

• Review, Audit, Education

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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 regulations…….. the provider shall pay a total sum of $XXXXX in restitution and $5000 in investigation costs to the OAG.


• 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%

– $22.7 billion to $33.5 billion

https://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf

OIG Report

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• 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

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• Cloned documentation

• Contradictory statements

• Volume of documentation vs. Medical Necessity

• Non-specific documentation

• Missing signature

• MUE

Common Issues Identified

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Good, Bad, and Ugly

Electronic Medical Record

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• EMR/EHR

– The “copy and paste”

– Over-documentation

– Missing documentation

– Auto-coding E/M

– Author of documentation

– Signature authentication

– Incomplete notes

Likely Culprits

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• Voice recognition software

– Accents, illness

• Use of “normal” templates for

transcription

• Physicians utilizing “free text”

within EMR

Likely Culprits

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Audit Results

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• 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

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• 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

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• 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)

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• 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


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• 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)


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• 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


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• Performed baseline audit of a new provider

– Audit scope: Random sample of office E/M codes (10)


– 7 out of 10 E/M services coded correctly

– 2 E/M services overcoded, 1 undercoded

• Meeting with Dr. Smith to discuss results & provide education

• Plan to reaudit in 2 months

Case Study #2 – Dr. Smith

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• 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



– 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.)

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• 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)



– 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. Smith to discuss results & provide education

• Re-audit in 2 months


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• Re-audit: Risk-based sample of hospital E/M codes (20)



– 4 E/M services overcoded (MDM supports only)


• 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


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• Re-audit: Risk-based sample of hospital E/M codes (20)



– 2 E/M services undercoded (billed 99232 to pass audit)


• Re-audit in 6 months

– Will review hospital and office E/M codes


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• Performed yearly scheduled audit of a provider

– Audit scope: Random sample of office and hospital E/M codes (10)



– 3 E/M services overcoded (lacking ROS, FH) Undercoded (99212)

• Mtg with Dr. Jones to discuss results & provide education


Case Study #3 – Dr. Jones

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• Re-audit

– Audit scope: Risk based sample of office and hospital E/M codes

(20)



– 1 E/M services wrong category (reported initial hospital visit instead

of initial observation service)

• Mtg with Dr. Jones to discuss results

• Plan to reaudit in 1 year


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• Scheduled yearly audit

– Audit scope: Random sample of office and hospital E/M codes (10)



– 1 E/M overcoded (-FH) & 1 undercoded (99231)

• Mtg with Dr. Jones to discuss results & provide education



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• Re-audit

– Audit scope: Risk-based sample of office & hospital E/M codes (20)



• Mtg with Dr. Jones to discuss resuls

• Regularly scheduled audit in 1 year


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CEU ORL333

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