the practice performance audit -...
TRANSCRIPT
The Practice Performance Audit:
Its More Than Just About Coding
Presented By:
Marsha S. Diamond, CPC, CPC-H, CCS
AAPC National Conference
04/17/13
All rights reserved, 2013 National AAPC
What IS a Practice Performance
Audit?
An audit of the overall effectiveness of the practice through a series of evaluative and investigative reviews of documentation, charge entry, coding, charge capturing and other areas of the practice affecting reimbursement and the overall success of the practice
…But Isn’t It Just About Coding?
Coder may assign the appropriate
code(s), however, errors may occur
that prevent the claim from proper
reimbursement
….It’s an Entire Process…Not Just Coding!!
The Reimbursement Cycle
• Appointment Scheduling
• Pre-Certification/Authorization
• Registration
• Front Desk/Check in
• Clinical
• Data Entry/Charge Capturing
• Coding
• Billing/Collections
All areas are co-dependent on others for
successful reimbursement/practice
Appointments/Registration The Beginning (Or End) Of It All
Process begins with first contact with patient via phone or office
Appointment/Registration staff must be educated in capturing billing and other needed information
Patient informed of payment at time of service
Appropriate insurance participation information captured
Pre-authorization/certification performed prior to first visit and routinely on a scheduled basis
Copies made of insurance cards/identification
Insurance updates performed on a scheduled basis
Valid contact information for future contact for collections
if necessary
Front Desk/Check In
• First personal contact with patient
• Staff must be informative, knowledgeable in insurance participation and payment policies of all plans
(HMO, PPO, Authorizations Needed, Co-Payments)
Collect appropriate co-insurance/co-payment
Collect appropriate insurance information
Collect appropriate authorizations
Obtain copies of insurance cards and identification
Request scheduled routine updates of insurance information
Registration in billing system on new patients/updates to established patients
Effects of Ineffective Appt/Regis/Front Desk Processes
• Non-payment of services (no co-payment)
• Denial of insurance benefits (not pre-authorized or inappropriate services authorized
AUDITING TECHNIQUES:
• Monitor denials and categorize where the errors/lack of documentation occurred
(Claims Review Process Worksheet)
• Determine whether covered services are listed correctly on Managed Care Worksheets
Clinical/Documentation
• Providers and clinical staff must be knowledgeable where services may be provided
• Providers and clinical staff must be knowledgeable what services require pre-authorization
Document services performed
Document medical necessity of services performed
Document medical necessity of services ordered
Ensure all services performed are marked on charge documents
Direct patients to appropriate facilities by insurance type
Request authorization when appropriate for inter-office testing or ancillary requests
Effects of Ineffective Clinical Documentation
• Lack of medical necessity
• Denial of services
AUDITING TECHNIQUES: • Monitor whether practice guidelines are followed
• Monitor denials and categorize those services denied based on insufficient documentation
(Claims Review Process Worksheet)
Charge Capturing Process • Gathering of charge documents from all departments that “capture” all
services performed in the practice/facility
• Captured via charge document and other mechanisms
Charge capturing mechanism in billing system
Log sheets for ancillary services
Log out sheets for medicines/supplies
“Macros” for combined services
Pre-Cert Services marked in System, link to Auth #
Non-Covered Services marked in System
Data Entry Process
• Data entry staff must be knowledgeable of services requiring authorization numbers
• Data entry staff must be accurate in their entry of ICD-9, CPT and appropriate modifier codes
• Turnaround time should be no more than 3 calendar days
Routine audit of services marked on charge document vs items entered by operator for:
- Missed items
- Incorrectly keyed items
Maintain log of turnaround times
Charge ticket enhancements/billing system enhancements to capture missed charges in future
(Utilize Data Entry Review Worksheet)
DATA ENTRY REVIEW WORKSHEET
Date: Data Entry Date 01/12 DATA ENTRY REVIEW WORKSHEET
X 52 wks
Entry # Cht# Line Item Line Item EXPLANATION
Operator DOS Date Days Provider Patient Name Pt# Submitted Keyed Illegible Incomplete Typo Other +/-
1 01/11 01/12 1 2 Patient #1 99213 99212 X -20
1 01/11 01/12 1 2 Patient #2 99213 99212 X -20.00
1 01/10 01/12 2 2 Patient #3 99213 99212 X -20.00
1 01/11 01/12 1 2 Patient #4 99213 99214 X 50.00
1 01/11 01/12 1 2 Patient #5 99212 99213 X 25.00
2 01/11 01/12 1 2 Patient #6 99213 99214 X 50.00
2 01/10 01/12 2 2 Patient #7 99214 99213 X -50.00
2 01/09 01/12 3 2 Patient #8 99214 99213 X -50.00
2 01/08 01/12 4 2 Patient #9 99213 99212 X -20.00
2 01/11 01/12 1 3 Patient #10 99214 99213 X -50.00
2 01/10 01/12 2 3 Patient #11 99213 99212 X -20.00
3 01/10 01/12 2 3 Patient #12 99214 99213 X -50.00
3 01/10 01/12 2 3 Patient #13 99213 99212 X -20.00
3 01/09 01/12 3 1 Patient #14 99213 99212 X -20.00
3 01/07 01/12 5 1 Patient #15 99214 99213 X -50.00
3 01/02 01/12 10 1 Patient #16 99213 99212 X -20.00
3 01/03 01/12 9 1 Patient #17 99214 99213 X -50.00
3
01/07/ 01/12 5 1 Patient #18 99213 99212 X -20.00
3 01/08 01/12 4 1 Patient #19 99214 99213 X -50.00
TOTAL -405.00
Copyright 1999 - 2013 MD Consultative Services Annualized Total -21060.00
All rights reserved
Page _____ of _____
Illustration 22-1
CLAIMS REVIEW WORKSHEET (Part 1)
CLAIMS REVIEW WORKSHEET
Review Dates: 1 week of claims X 52 weeks (annualized)
TYPE OF ERROR ID# Incorr Ins Pre-Auth Other(Spec) Other (Spec) COMMENTS $ Amt
REGISTRATION/APPTS
Pt Name/Acct #
Patient #1 X 115.00
Patient #2 X Non-Part Carrier 125.00
Patient #3 X 100.00
Patient #4 X No Pre Auth 75.00
Patient #5 X 125.00
Patient #6 X 100.00
Patient #7 X 95.00
Patient #8 X 125.00
Patient #9 X No Pre Auth 125.00
Patient #10 X 100.00
Patient #11 X 225.00
Patient #12 X X 175.00
Patient #13 X 155.00
Patient #14 X 125.00
Patient #15 X 110.00
Patient #16 150.00
TOTALS 2025.00
Annualized TOTALS 105300.00
CLAIMS REVIEW WORKSHEET (Part 2)
TYPE OF ERROR Ref Phy Auth # Code(s) Coding Mismatch Other Spec COMMENTS $ Amt CHARGE DOCUMENT/ CHARGE CAPTURING Pt Name/Acct # Patient #1 X No Ref for Consultation 175.00
Patient #2 X Dx/CPT Med Necess 100.00
Patient #3 X Dx/CPT Med Necess 75.00
Patient #4 X Missing CPT Code 150.00
Patient #5 X Missing CPT Code 125.00
Patient #6 X No Ref for Consultation 275.00
Patient #7 X Dx/CPT Med Necess 155.00
Patient #8 X Dx/CPT Med Necess 100.00
Patient #9 X Dx/CPT Med Necess 255.00
TOTALS 1410.00
Annualized TOTALS 73320.00
CLAIMS REVIEW WORKSHEET (Part 3) TYPE OF ERROR Dx CPT POS Modifier Other Spec COMMENTS $ Amt
CODING
Pt Name/Acct #
Patient #1 X Invalid Dx 175.00
Patient #2 X CPT Not Covered 150.00
Patient #3 X Dx NC 110.00
Patient #4 X POS Conflict w/Hosp 350.00
Patient #5 X Lacking Approp Modifier 125.00
Patient #6 X Invalid Dx 125.00
Patient #7 X Invalid CPT 150.00
Patient #8 X CPT Not Covered 125.00
Patient #9 X Invalid Dx 225.00
Patient #10 X Dx NC 125.00
Patient #11 X Dx NC 120.00
TOTALS 1780.00
Annualized TOTALS 92560.00
GRAND TOTALS 271180.00
Completed by: _________________________________ Date: _______________________
Copyright 1999-2013 MD Consultative Services
All rights reserved
Coding Process
• Coding staff must be knowledgeable of services performed versus appropriate CPT codes
• Coding staff/management must ensure that non-coded services are reviewed routinely for accuracy
Routine, semi-annual review of services to include:
Evaluation and Management Services
Hospital services
Medical Necessity/ICD-9
Coder accuracy should be reviewed regularly
Audit of coder assignment, data entry code and code received on the Explanation of Benefits to identify code issues
(Utilize Chart Audit Worksheet)
Sample Completed Chart Audit Worksheet
GREATER ORLANDO MEDICAL GROUP
Practice Assignment Reviewer Assignment Diff Annual Annual Annual
Chart # Code Charge Code Charge +/- Volume % Error # Error Impact COMMENTS
1 99284 200 99283 120 -80 6240 50% 3120 -$249,600 no detailed hx/exam
2 99281 50 99285 250 200 18000 100% 18000 $3,600,000 L5 does not req hx/exam pt cond
3 99223 300 99221 200 -100 2880 100% 2880 -$288,000 no comp hx/exam
4 99284 200 99284 200 0 $0
5 99213 100 99213 100 0 57600 0% 0 $0
6 99222 250 99221 200 -50 1920 100% 1920 -$96,000 no comp hx/exam
7 99231 50 99231 50 0 9600 0% 0 $0
8 99232 75 99231 50 -25 2880 100% 2880 -$72,000 stable/improving overaching crit
9 99212 75 99213 100 25 4800 100% 4800 $120,000 EPF Hx/Exam, Mod MDM
10 99214 125 99213 100 -25 2880 100% 2880 -$72,000 no detailed hx/exam
11 19301-RT 1500 19301-58-RT 1800 300 384 100% 384 $115,200 Bx/Def Surg Allowed per NCCI
19101-RT $0
12 11446/15120 600 11646/15120 800 200 1152 100% 1152 $230,400 Lesion malign
13 29827/29826 3000 23410/29826 3500 500 768 100% 768 $384,000 RTC open
14 25608 1700 25415 2000 300 96 100% 96 $28,800 Nonunion not ORIF
15 29823 2000 29823 2000 0 720 0% 0 $0
16 28290 1450 28296 1650 200 576 100% 576 $115,200 Metatarsal Osteotomy
17 30520/21325 3500 30520 2500 -1000 384 100% 384 -$384,000 Other proc bundled
18 69436-50 2500 69436-50 2500 0 1536 0% 0 $0
19 36561 1250 36561 1250 0 1536 0% 0 $0
20 45385/45383 1200 45385/45383 1450 250 480 100% 480 $120,000 + colonoscopy
45380 43239 -biopsy/same site
ANNUAL IMPACT $3,552,000
Billing/Payment Processes • Billing staff must be code knowledgeable
• Payment posting staff must be code knowledgeable to determine whether codes submitted were appropriate
• Billing staff should perform pre-bill/claim audits
Calculate days to billing (Date of Service to Billing Date)
Turnaround time should average no more than 2-3 days
Calculate accuracy rate (Error rate)
Identify area of errors, % errors, Calculate Practice Impact
Identify billing system errors
Identify monies not collected at time of service
Identify errors that can be corrected with billing system edits
Collections/AR • Collections staff should be code knowledgeable to identify coding errors
that resulting in non-payment, incorrect payment or denial
• Collections staff should be billing knowledgeable to identify when/where errors occurred to report back to appropriate individuals
Identify patient monies that should have been collected at the time of service
Identify monies in patient responsibility that should have been collected from insurance carrier
Identify coding/billing errors that resulted from billing system errors/inadequacies
Determine Days in A/R and Collection Rates and identify areas that resulting in increases/decreases
What To Do With the Information
• Correct billing systems issues that result in incorrect/unpaid claims
• Identify areas of the practice that result in decrease in days to billing/collections
• Identify areas that need additional education in order for practice to efficiently collect and gather billing information
• Identify areas/individuals that result in non-payment at the time of service
• Correct billing/coding errors before they leave the practice
• Initiate a methodology for capturing all lost charges
• Track accounts receivable/collections to immediately identify practice issues that affect monies
HOW to Use the Information
• Track New Patient Registrations - Printout of new patients registered daily reviewed for
errors, omissions and provide additional education
- Track new employees during training period and periodically all employees registering/updating patient information
- Design practice-specific insurance information sheet with information to include:
Insurance Carriers (HMO/PPO/POS)
Services Needing Authorization
Services Which Can Be Provided in Office
vs Referred Out
Participating Labs/Ancillaries
30% of practice errors relate directly back to incorrect/incomplete
insurance/registration information
HOW to Use the Information (continued)
• Track Charge Capturing - Identify Areas Not Being Captured
- Implement Mechanisms for Capturing Charges
Charge Capturing Logs
Billing System Macros
Bar Codes/Sticker Mechanisms
Room/Individual to Maintain Supplies/Items
Revisions to Charge Documents
Average of 20-33% missed charge in average practice
HOW to Use the Information (continued)
• Improve Clinical Documentation
- Identify areas of insufficient documentation
(Evaluation and Management, Medical Necessity)
- Implement Training for Clinical Staff/Providers to improve documentation as needed
- Perform ongoing audits to document improvements or lack thereof in documentation requirements
- Provide information from tracking mechanism to providers for their use
Publish Monthly/Quarterly updates for providers
Provide monetary gains/losses from documentation changes
HOW to Use the Information (continued)
• Improve Billing/Collections
- Increase Collections from Correct Coding
- Decrease Days to Charge Entry
- Decrease Days in A/R, Collection Days
Develop Mechanism for Preventing Coding Errors
Develop Scheduled Coding Review Mechanism
Track monetary gains/losses and publish
According to CMS CERT information, average 18-22% coding errors in E & M levels
alone
According to insurance industry statistics, approximately 30-35% of all claims initially denied will not be resubmitted for payment consideration on a timely basis
What is the Price of NOT Using this Information?
• Calculations based on 3 physician practice seeing an average of 30 patients per day (General Practice/FM/IM)
Average charges per patient $115.00
Average annual charges $2,732,400
Additional Revenue Projections From Implementation:
• 30% Patient Registrations $819,720/yr
• 20% Charge Capturing $546,480/yr
• 25% Coding Improvements $683,200/yr
Additional Revenue $2,049,400
TOTAL REVENUE $4,781,800
42% INCREASE IN PRACTICE REVENUE
Monitoring Tools For Performing Practice
Performance Audits
Tools for Practice Performance may be downloaded at the following website
Log onto:
www.coeh.com/tools
