advanced e/m auditing: secrets to...
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Advanced E/M Auditing: Secrets to Success
Advanced E/M Auditing: Secrets to
Success
Presented by
Carrie Severson CPC, CPC-H, CPMA, CPC-I
Senior Auditor, AAPC Client Services
Advanced E/M Auditing: Secrets to Success
• OIG Report (OEI-04-10-00180)
• Coding Trends of Medicare Evaluation and
Management Services - May 2012
Why We Are Here
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Advanced E/M Auditing: Secrets to Success 4
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Advanced E/M Auditing: Secrets to Success
• Compare your practice to your peers
• 20 most common coding and documentation errors
& how to avoid them
• The “Grey Areas”
• EHR pitfalls and what to look for in your audit
• Strategies for improving documentation and coding
• How to conduct an effective audit
Objectives
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Advanced E/M Auditing: Secrets to Success
Where does your practice fit?
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Advanced E/M Auditing: Secrets to Success
Where does your practice fit?
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Advanced E/M Auditing: Secrets to Success
Room for improvement
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Advanced E/M Auditing: Secrets to Success
The 20 most common coding and
documentation errors
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Advanced E/M Auditing: Secrets to Success
• Chief Complaint
• History of Present Illness
• Chronic Conditions
• Review of Systems
• Language
History Common Mistakes
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Advanced E/M Auditing: Secrets to Success
• Documentation
• Mixing
• Check boxes
• Understanding
Exam Common Mistakes
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Advanced E/M Auditing: Secrets to Success
• Severity and number
• Time based
• Orders
• Diagnosis
Assessment and Plan (MDM) Common Mistakes
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Advanced E/M Auditing: Secrets to Success
• Inconsistent documentation
• Abbreviations
• Counting elements
• Office procedures
• Misunderstanding of preventive services
• Authentication
• Timely
General Documentation Mistakes
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Advanced E/M Auditing: Secrets to Success
• Modifier misuse
• NCCI and LCD edits
• Diagnosis coding
• Chronic conditions
Coding & Data Entry Mistakes
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Advanced E/M Auditing: Secrets to Success
The “Grey Areas”
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Advanced E/M Auditing: Secrets to Success
• Fact or Fiction – The CC can be pulled from the
HPI.
Chief Complaint in HPI
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Advanced E/M Auditing: Secrets to Success
• Fact or Fiction – Status of 3 chronic conditions can
be used to support an extended level of history with
the ‘95 guidelines
Status of 3 Chronic Conditions
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Advanced E/M Auditing: Secrets to Success
• Fact or Fiction – If the history is unobtainable or non
contributory you can automatically bill a
comprehensive history
Unobtainable History
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Advanced E/M Auditing: Secrets to Success
• Fact or Fiction - If the nurse takes the HPI the
physician can then state, "HPI as above by the
nurse" or “Have read and agree with the HPI”
HPI Taken By Nurse
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Advanced E/M Auditing: Secrets to Success
• Fact or Fiction – A provider can count a single
history item in both the HPI and ROS
Double Dipping
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Advanced E/M Auditing: Secrets to Success
• Fact or Fiction – It’s acceptable to use the ‘97
Specialty specific exams for the comprehensive
exam of a single organ system in ‘95
Single Organ System Exam
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Advanced E/M Auditing: Secrets to Success
• Fact or Fiction – CMS defined the requirements of
the Detailed Exam for the ‘95 Guidelines
Detailed Exam
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Advanced E/M Auditing: Secrets to Success
EHR - Good or Bad
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Advanced E/M Auditing: Secrets to Success
• The copy and paste
EHR Issue #1
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Advanced E/M Auditing: Secrets to Success
• Over documentation
EHR Issue #2
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Advanced E/M Auditing: Secrets to Success
• Missing documentation
EHR Issue #3
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Advanced E/M Auditing: Secrets to Success
• Auto coding E/M
EHR Issue #4
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Advanced E/M Auditing: Secrets to Success
• Favorites lists
EHR Issue #5
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Advanced E/M Auditing: Secrets to Success
• Updates
EHR Issue #6
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Advanced E/M Auditing: Secrets to Success
• Who did it
EHR Issue #7
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Advanced E/M Auditing: Secrets to Success
• Signature authentication
EHR Issue #8
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Advanced E/M Auditing: Secrets to Success
• Incomplete notes
EHR Issue #9
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Advanced E/M Auditing: Secrets to Success
• Coding edits
EHR Issue #10
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Advanced E/M Auditing: Secrets to Success
• Educate providers
• Coders involvement with template design
• Perform gap assessment of new templates/EHR
• Coders shadow providers
• Perform regular audits
• Re-educate providers
Strategies for improving documentation &
coding
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Advanced E/M Auditing: Secrets to Success
• Knowledge of
– Carrier interpretations of E/M Guidelines
– Carrier policies for CPT®, ICD-9 and HCPCS
– OIG Work Plan
– RAC, CERT and other audit focus areas
– Internal documentation and coding policies
– How to effectively and professionally communicate
and educate
How to Conduct an Effective Audit
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Advanced E/M Auditing: Secrets to Success
Tips and Tools
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Conducting an Internal Audit
Advanced E/M Auditing: Secrets to Success
• Coding accuracy goal
• Reduction in billing/claim errors
• 100% participation
• Turnaround time to complete audits
• Staff certification and education
Coding Compliance Program
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Advanced E/M Auditing: Secrets to Success
• What is the focus of the audit?
– Focused
– New employment
– Chronic problem
– Targeted code(s)
Focus
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Advanced E/M Auditing: Secrets to Success
• No surprises
• Focus
• Timeline
Be Prepared
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Advanced E/M Auditing: Secrets to Success
• Specialized auditors
• Specialty credentials
• How do you ensure the quality of the audit?
Auditors
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Advanced E/M Auditing: Secrets to Success
• Advocate
– To the provider
– To the coder
• Attitude
– Educator
– Trainer
– Enforcer
Auditor’s Role
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Advanced E/M Auditing: Secrets to Success
• Define grey areas
– ‘95 or ‘97 guidelines?
– “HEENT: negative”
– Prescription drug management
– Additional work up
– Medical necessity
Standards
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Advanced E/M Auditing: Secrets to Success
Medical Record
Lab
X-ray
Outside orders
Medication lists
History forms
Documentation
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Advanced E/M Auditing: Secrets to Success
• Know your MAC carrier guidelines
• Review website often and attend trainings
MAC
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Advanced E/M Auditing: Secrets to Success
• Provider signature logs
• Supervising physicians
• Abbreviations
• Tools
Gather
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Advanced E/M Auditing: Secrets to Success
• Individual?
• Group?
• Provider?
• Coder?
• Provider and coder?
• Follow-up
Training
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Advanced E/M Auditing: Secrets to Success
• Summary
• Action Plan
• Follow-up
Report and Follow-up
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Advanced E/M Auditing: Secrets to Success
• Current ICD-9-CM code book
• Current CPT® code book
• Current HCPCS Level II Coding Procedures code
book
• Specialty specific coding
reference from a credible source
Recommended Resources
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Advanced E/M Auditing: Secrets to Success
“Any fool can know. The point is to understand.”
~ Albert Einstein
Knowledge
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Advanced E/M Auditing: Secrets to Success
• Coding and documentation audits
• ICD-10-CM assessment readiness audits
• Compliance risk assessments
• Compliance program implementation
• Training and education
Visit us at: www.aapcps.com or Call: 888.200.4157
AAPC Client Services can assist you with:
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Advanced E/M Auditing: Secrets to Success
Questions?
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Advanced E/M Auditing: Secrets to Success
Senior Auditor
AAPC Client Services
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