Auditing for Optimal Reimbursement and Compliance

1. Auditing for Optimal Reimbursementand Compliance Presented by Dawne Beckley, RHIT, CPC The Rybar Group, Inc. September 19, 2008

2. The Revenue Cycle Audit • The Revenue Cycle Audit is an excellent Operational Analysis tool. ©The Rybar Group, Inc. 2008

3. Why a Revenue Cycle Audit? • Substantiates that each service provided by the clinician was reasonable and medically necessary. ©The Rybar Group, Inc. 2008

4. Why a Revenue Cycle Audit? • Validates that payment for services was accurately and completely processed. ©The Rybar Group, Inc. 2008

5. Components of the Revenue Cycle The Front End • Patient Scheduling/Registration • Appointment scheduling • Verification of insurance eligibility • Prior authorization for care • Financial responsibility ©The Rybar Group, Inc. 2008

6. Components of the Revenue CycleThe Core • Charge Capture/Billing • Pricing and fee screens • Documentation • Coding • Charge entry ©The Rybar Group, Inc. 2008

7. Components of the Revenue CycleThe Back End • Claims Management • Submission • Follow-up • Denials/Rejections • Appeals ©The Rybar Group, Inc. 2008

8. Mistakes Mistakes at the Front End, the Core, or the Back End will result in Denials, Delays, or Reduced Payments. Nearly every process in operations has the potential of impacting the receipt of revenue! ©The Rybar Group, Inc. 2008

9. Components of the Revenue Cycle • The Internal Revenue Cycle: controlling the front end, the core and the back end of the Revenue Cycle is the most important improvement a facility can make to increase its financial position. ©The Rybar Group, Inc. 2008

10. The Internal Revenue Cycle • Assess operational processes • Analyze contractual agreements and payment policies • Perform a revenue cycle audit • Perform benchmark comparisons • Create a work plan and implement! ©The Rybar Group, Inc. 2008

11. Charge Capture:Identify Areas of Pitfalls/Opportunities • Begin by looking at Appointment Scheduling through to Payment Resolution for ALL services rendered. ©The Rybar Group, Inc. 2008

12. The Auditing Process • Types • Steps • Issues Found • Coding/Modifiers • Medical Necessity • OIG • Claims Management ©The Rybar Group, Inc. 2008

13. Three Types of Audits • Prospective Audit • Review of claims before they are submitted to payors • Retrospective Audit • Review of claims after they are paid ©The Rybar Group, Inc. 2008

14. Three Types of Audits • Significant Event Audit • Review of a specified service or coding pattern All three types of audits are necessary. ©The Rybar Group, Inc. 2008

15. Steps in An Audit • Define the purpose of the audit • Baseline compliance audit • Follow-up review • Assess revenue cycle processes • Select the type of audit • Prospective, retrospective or event ©The Rybar Group, Inc. 2008

16. Steps in An Audit • Define the sampling methodology • Random • Systematic • All payors/single payor • Select the audit tools • Compare documentation against data ©The Rybar Group, Inc. 2008

17. Steps in An Audit • Analyze findings • Benchmark/Peer comparison • Implement change Note: The OIG recommends auditing 5 or more medical records per payor or 5 to 10 records per physician. ©The Rybar Group, Inc. 2008

18. Issues Found During An Audit • Scheduling/Registration/Check-in • Scheduled incorrect type of service • Inaccurate insurance information/eligibility not validated • Pre-certification/authorizations not obtained prior to service • Collecting co-pays and outstanding balances ©The Rybar Group, Inc. 2008

19. Issues Found During an Audit • Billing/Charge Capture • Pricing • Updating charges • Billing slips • Updated codes • ABN process • Non-covered services ©The Rybar Group, Inc. 2008

20. Issues Found During an Audit • Documentation! • Coding! • Medical necessity! • Charge entry! ©The Rybar Group, Inc. 2008

21. Issues Found During an Audit • No documentation to support billed services • No authentication of documentation • Missed codes and charges • Invalid codes due to outdated charge tools ©The Rybar Group, Inc. 2008

22. Issues Found During an Audit • Unbundling of procedure codes • Inappropriate or no modifier used when required • CCI Edit issues (internal) ©The Rybar Group, Inc. 2008

23. Coding • Has everything been billed that can be billed? • Are modifiers used appropriately? • Are diagnoses linked correctly to corresponding procedures? • Does documentation support the codes assigned? ©The Rybar Group, Inc. 2008

24. Coding • Validate ICD-9-CM and CPT code assignments • Is documentation in the operative report supportive of codes assigned? • Are all codes assigned on the claim form? ©The Rybar Group, Inc. 2008

25. Coding - Has everything been billed that can be billed? • Use the CCI edits to look for bundling edits • Column 1 Column 2 coding edits • Mutually exclusive edits http://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEHOPPS/list.asp#TopOfPage • Use the CMS Addendum B to look at Medicare’s procedure status indicators ©The Rybar Group, Inc. 2008

26. Coding - Has everything been billed that can be billed? For example: CPT code 49560 - Repair initial incisional or ventral hernia; reducible • When mesh implantation is utilized during repair, should assign code 49568 in addition to hernia repair code. ©The Rybar Group, Inc. 2008

27. Excision of Lesions • Commonly seen during an audit: An excision of a lesion is performed and is coded as an excision of a Benign Lesion. The pathology report confirms a Malignant Lesion. Coding should be held for pathology report. ©The Rybar Group, Inc. 2008

28. Laceration Repairs • Common errors noted: • The size of the repair is not documented • Wound cleaning or removal of matter is not documented • The depth of the wound is not documented ©The Rybar Group, Inc. 2008

29. Laceration Repairs The documentation of the size of the laceration and the depth of the lesion will decide which to code: an intermediate repair or a simple repair. Documentation should be in the body of the operative report - not just the header. ©The Rybar Group, Inc. 2008

30. Colonoscopies • Were biopsies performed and what type? • Other procedures separately performed? • Terminated or reduced service? • Screening versus Diagnostic ©The Rybar Group, Inc. 2008

31. Coding • Ensure that procedure (code) is on Medicare’s approved list of procedures for Ambulatory Surgery Centers. • Intraocular Lens, drugs and biologicals, OPPS pass-through devices, brachytherapy sources, and radiology procedures reported separately? ©The Rybar Group, Inc. 2008

32. Coding • If the ancillary services or devices are not initially reported on the same claim as the primary procedure, an additional claim can be submitted; Medicare will perform a claims history to locate the original claim with the same date of service - when the claim is identified, Medicare will reimburse the second claim! ©The Rybar Group, Inc. 2008

33. Modifiers • Modifier 22 – Unusual procedural services (professional claim) When a procedure is complicated or requires more time than usual. Example: If a patient has extensive abdominal adhesions that require a lot of time and effort to remove. ©The Rybar Group, Inc. 2008

34. Modifiers • Modifier 52 – Reduced Services Example: When a colonoscopy can only be performed partially because of poor prep. Medicare will apply a 50% payment reduction for these procedures. ©The Rybar Group, Inc. 2008

35. Modifiers • Modifier 73 - Discontinued outpatient procedure prior to anesthesia administration Medicare will apply a 50% payment reduction for a procedure that is terminated due to complications after the patient has been prepared for surgery and taken to the OR, but before anesthesia has been induced or the procedure initiated. ©The Rybar Group, Inc. 2008

36. Modifiers • Modifier 74 - Discontinued outpatient procedure after anesthesia administration Medicare will make full payment for surgical procedures that are terminated due to complications after anesthesia has been induced or the procedure initiated. ©The Rybar Group, Inc. 2008

37. Modifiers • Modifier 59 – Distinct Procedural Service • Need to indicate that a procedure or service was distinct or independent from other services performed on the same session. • Known as the modifier of last resort. • Overrides CCI edits when a modifier is allowed. ©The Rybar Group, Inc. 2008

38. Modifiers • HCPCS Level II Modifiers • LT, RT • FA, F1-F9 • TA-T9 • E1- E4 ©The Rybar Group, Inc. 2008

39. Medical Necessity Lack of medical necessity is one of the most common reasons for payment denial. • If the signs and symptoms support the service requested…… • Medical Necessity exists • If the signs and symptoms are not recognized as a standard for the services requested…… • Medical Necessity does not exist ©The Rybar Group, Inc. 2008

40. Medical Necessity • Patient signs and symptoms prompt the physician to order services. • Coders translate signs and symptoms into ICD-9 diagnostic codes and services into HCPCS or CPT codes. • Payor edits match ICD-9 with HCPCS to determine if a service is necessary for the diagnosis submitted. ©The Rybar Group, Inc. 2008

41. Medical Necessity • Commonly seen as denied: • Mammograms • Bone Density Scans • Prostate Cancer Screening • Colorectal Cancer Screening • Cervical or Vaginal Cancer Screening Note: Coverage determined by age, frequency, risk factors, absence or presence of signs/symptoms. ©The Rybar Group, Inc. 2008

42. Medical Necessity • Review National Coverage Determinations and Local Coverage Determinations for coverage information. • Diagnosis supporting medical necessity? • Is ABN process in place? ©The Rybar Group, Inc. 2008

44. OIG Work Plan • Identify OIG Work Plan targets. • For Example: 2008 work plan includes review of ASC payments due to APC transitioning. ©The Rybar Group, Inc. 2008

45. OIG Work Plan • Modifiers with CCI Edits • In 2001, $565 million paid with a modifier included on an edit pair. • Although not on 2008 work plan, it is a common target. ©The Rybar Group, Inc. 2008

46. Issues Found During an Audit • Claims Management • Clean, timely claim • Get it right the first time • Work the remittance advice • Denied/Rejected claims • Coding Eligibility • Registration Referral/pre-authorization • Appeal ©The Rybar Group, Inc. 2008

47. Claims Management • Loss of claim dollars are due to: • Inaccurate coding • Dirty or untimely claim • Code to claim issues • “Un-worked” remittance advices • Failure to resubmit denied claims (write-offs) • No appeals process ©The Rybar Group, Inc. 2008

48. Major Reasons for Claim Denials • Errors made during the patient registration process • Verification of information not obtained • Referral or pre-authorization not obtained • Invalid codes (HCPCS and ICD-9-CM) • Service not medically necessary • Service not supported by documentation • Modifier use ©The Rybar Group, Inc. 2008

49. The Revenue Cycle Audit • Compliance Plan • Post Audit • Results ©The Rybar Group, Inc. 2008

50. Performing a Revenue Cycle Audit • Facilities should implement an internal auditing policy as part of their compliance plan. • Internal audits should be performed on a routine basis to stay proactive in preventing potential billing cycle issues. • An external audit should also be performed every 1-3 years. ©The Rybar Group, Inc. 2008