Don’t Land in Hot Water-Audit Proof your Coding and Documentation

1. Don’t Land in Hot Water Don’t Land in Hot Water Audit Proof your Coding and Audit Proof your Coding and Documentation Documentation Presented by: Presented by: Nikki Taylor, MBA, COC,CPC, CPMA Nikki Taylor, MBA, COC,CPC, CPMA Auditor Auditor- -The Coding Institute The Coding Institute

2. Learning Objectives Learning Objectives • Government Audits • How they work • Areas of Concern • How self-audits and external audits can: • Identify areas for improvements in documentation • Point out corrections that need to be made • Review diagnosis coding to ensure specificity and accuracy • Crack-down on insufficient provider documentation • Avoid undercoding, overcoding, and bad coding habits • Identify great resources and tools • EM Auditor • CCI Edits Checker • TCI Consulting & Revenue Cycle Solutions 2

3. Why Audits are Important Why Audits are Important • Good Practice • Audits ensure regular check-ups • Boost up compliance • Reel in reimbursement • Increased payer scrutiny=increased risk • Includes: • Internal/In-house • External/Third Party 3

4. Why Audits are Important, cont. Why Audits are Important, cont. • Audits help: • Ensure proper billing and coding • Correct reimbursement • New reimbursement opportunities • Fight back against government audits • Payer medical record requests and denials • Ensure provider education • Documentation requirements • Quality patient care • Malpractice litigation 4

5. Documentation Issues Documentation Issues • Not just for coding! • Documentation equally important! • Clinical staff • Providers • Enter documentation at time of service • Shortly thereafter • Timelines for compliance • Good patient care 5

6. Documentation Issues, cont. Documentation Issues, cont. • Signature requirements • CMS guidelines • Legible-hand written • Signature stamps-NOT appropriate • Electronic-often require physician code or login • Signatures = provider reviewed and agree • Dates and Time • All entries • Allow medical treatment to be reconstructed at a later time • If time of service and time of entry are different -document why 6

7. Documentation Issues, cont. Documentation Issues, cont. • Types: • Handwritten • Dictation • Templates • Electronic • Handwritten: • Often illegible • Dictation: • Clear and thorough • Timing-transcription • Summaries • Signatures 7

8. Documentation Issues, cont. Documentation Issues, cont. • Templates: • Cloning • Information lacking key details • Not thorough • Electronic • Cloning • Built-in templates • Over documenting/medical necessity 8

9. RAC Audits RAC Audits •Recovery Audit Program (RAC) • Mission: • Identify and correct improper payments • Overpayment detection and collection • Identifying underpayments • Prevent future improper payments https://www.cms.gov 9

10. RAC Audits, cont. RAC Audits, cont. • National Recovery Audit program • Demo program- utilized Recovery Auditors • Medicare overpayments and underpayments • Between 2005 and 2008 • Resulted in > $900 million being returned to the Medicare Trust Fund • Nearly $38 million in underpayments to health care providers. • Secretary of the Department of Health and Human Services • Instituted permanent and national Recovery Audit program https://www.cms.gov 10

11. RAC Audits, cont. RAC Audits, cont. • Post-payment basis • Follows Medicare policies • Carriers, FIs and MACs: NCDs, LCDs and CMS Manuals • Two types of reviews: • Automated (no medical record needed) • Complex (medical record required) • No claims paid prior to October 1, 2007 • Can go back three years • Date of payment • Staff consists of nurses, therapists, certified coders, and a physician CMD https://www.cms.gov 11

12. RAC Audits, cont. RAC Audits, cont. •Demand letter is issued by RAC •Opportunity for provider • Discuss the determination with the RAC • Not part of the normal appeal process •Issues reviewed by RAC - approved by CMS •Issues approved are posted to website before widespread review https://www.cms.gov 12

13. RAC Audits, cont. RAC Audits, cont. • RAC contractors are paid a contingency fee • % of every dollar in overpayments collected • Lose the appeal-must pay fee back • Focus--organizations with billings higher than the majority • Other providers/suppliers • Medicare services only • Nearly ANY inconsistency is grounds recovery demand https://www.cms.gov 13

14. RAC Audits, cont. RAC Audits, cont. • Top issues for 1stQuarter: • Non-covered services • Duplicate claims • Incorrectly coded services • Incorrect payment amounts • Prolonged services • Physician-referring/ordering info • Insufficient documentation https://www.cms.gov 14

15. RAC Audits, cont. RAC Audits, cont. • Check the RAC website • www.cms.hhs.gov/RAC • Check CERT reports • www.cms.hhs.gov/cert • OIG reports • www.oig.hhs.gov/reports.html • Locate the types of improper payments found in the reviews https://www.cms.gov 15