What To Look For In A Coding Audit

Don’t Leave Money On The Table

Wiks Moffat

Laurie Zabel, CHC, CHPC, CPC

Agenda

Regulatory Compliance

7 Elements/4 Challenges of Compliance

Looking Forward

Audit Types

Process

Who Conducts the Audit

Common Pitfalls/Concerns

Corrective Action Plan

Helpful Hints

Compliance Program

HIPAA – HITECH

Corporate Compliance

OSHA

Corporate Compliance

Code of Conduct

Anti-Kickback & Stark Self-Referral

Fraud & Abuse Laws

Reporting Structure & Disciplinary Actions

Whistle Blowers

Documentation

Training

Monitoring & Auditing

Achieving Compliance Best Practice Methodology

7 Elements

4 Challenges

Seven Fundamental Elements

IMPLEMENTING written policies, procedures and standards of conduct.

Designating a COMPLIANCE officer and compliance committee

Conducting effective training and EDUCATION

RESPONDING promptly to detected offenses and undertaking corrective action

AUDITING and conducting internal monitoring .

Developing effective lines of COMMUNICATION

ENFORCING standards through well-publicized disciplinary guidelines

Four Challenges Paperwork, Record Keeping

Manuals, compliance forms, P & P’s

Employee Training

Document it, Continuously, Annually

Mechanism to Maintain Compliance

Continuous Readiness

New Hires

New Regulations

Compliance Issue Remediation

Things To Look Forward To

ICD-10

ACA

PQRS

CMS Chart Audits

What Audits Are Being Conducted

RAC – Recovery Audit Program (Contractor)

Mission - The Recovery Audit Program’s mission is to identify and correct Medicare improper payments through the efficient detection and collection of overpayments made on claims of health care services provided to Medicare beneficiaries, and the identification of underpayments to providers so that the CMS can implement actions that will prevent future improper payments in all 50 states.

Types of Audits Being Conducted

MIC – Medicaid Integrity Audit (Contractor)

Ensure that paid claims were: For services provided and properly documented; For services billed properly, using correct and

appropriate procedure codes; For covered services; and Paid according to Federal and State laws,

regulations, and policies. 5

OIG OIG – The Office of Inspector General provides a list

yearly that outlines all audits that they will be conducting for each specific year. This OIG “work plan” may be found at:

http://oig.hhs.gov/reports-and-publications/archives/workplan/2015/FY15-Work-Plan.pdf

Evaluation and Management (E & M) services have been an area that the OIG has been auditing for many years.

Audit Selection Process

Targeted in the OIG Workplan

Criteria based on Medicare rules and regulations

Accepted clinical practice

Coding and billing policies

Data mining

CMS Audit Process

Letter requesting chart note copies

30 days to produce

Respond

Recie

Who Will Conduct the Audit

Certified Coders Professional Clinicians Physicians Medical Directors Nurses Therapists

Common Pitfalls/Concerns of Documentation and Coding

Undercoding – 99213 to 99214 99214 = 4 HPI, 2 ROS, 1 PSFH, Moderate MDM

Overcoding – 99204 to 99203 or 99223 to 99222 99204 & 99223 = 4 HPI, 10 ROS, 3 PFSH, 8 Organ System Exam, Moderate MDM

(99204), High MDM (99223)

Additionally billable services – E & M service with a Well Visit/Physical

Cloning/copying and pasting/templates – Copied HPI, HPI/ROS mismatch

Corrective Action Plan

Auditing plan must include Corrective Action Plan

Ensure that re-audits are part of plan

Document all steps of CAP

Educate, Educate, Educate

Helpful Hints Establish a budget

Too big to do alone. Enlist internal resources to help and external resources when necessary

Remember…..you are never done. Apply the continuous readiness strategy

If you step up to the 4 challenges and the 7 elements, you will be fine!!

THANK YOU

Wiks Moffat

Laurie Zabel CHC, CHPC, CPC