On the topic: Auditing Essentials for Compliant · 2016-11-21 · Welcome to PMI’s Webinar...

Welcome to PMI’sWebinar Presentation

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On the topic:

Auditing Essentials for Compliant Billing Practices

Meet the Presenter…

Audrey E. Coaxum, CHC, CEMC, CPC, CMC,

CMIS, CMOM, CMCO

Welcome to Practice Management Institute’s Webinar and Audio

Conference Training. We hope that the information contained herein will

give you valuable tips that you can use to improve your skills and

performance on the job. Each year, more than 40,000 physicians and office

staff are trained by Practice Management Institute. For 30 years, physicians

have relied on PMI to provide up-to-date coding, reimbursement,

compliance and office management training. Instructor-led classes are

presented in 400 of the nation’s leading hospitals, healthcare systems,

colleges and medical societies.

PMI provides a number of other training resources for your practice,

including national conferences for medical office professionals, self-paced

certification preparatory courses, online training, educational audio

downloads, and practice reference materials. For more information, visit

PMI’s web site at www.pmiMD.com

Please be advised that all information in this program is provided for

informational purposes only. While PMI makes all reasonable efforts to

verify the credentials of instructors and the information provided, it is not

intended to serve as legal advice. The opinions expressed are those of the

individual presenter and do not necessarily reflect the viewpoint of Practice

Management Institute. The information provided is general in nature.

Depending on the particular facts at issue, it may or may not apply to your

situation. Participants requiring specific guidance should contact their legal

counsel.

CPT® is a registered trademark of the American Medical Association.

Practice Management Institute®

8242 Vicar | San Antonio, Texas 78218-1566

tel: 1-800-259-5562 | fax: (210) 691-8972

[email protected]

Auditing Essentials for Compliant Billing Practices

Developed & Presented by:

Audrey E. Coaxum, CHC, CPC, CEMC, CMC, CMIS, CMOM, CMCO

Agenda

Overview

Why Audit?

Who Audits?

How to Audit?

What to Audit?

Sample Audit Process

Sample Audit Worksheets

Sample Audit

Audit Tips

Audit Discussion Cases

CPT® is a trademark of the American Medical AssociationCurrent Procedural Terminology© 2015 American Medical Association. All Rights Reserved.

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Practice Management Institutewww.pmiMD.com

Webinar/Audio Conference November 22, 2016

1

Overview

Billing Audits

– Evaluate performance

– Assess compliance

– Identify areas of risk

– Serve as educational tools

3

Why Audit?

Purpose of Billing Audits

– Supports compliance efforts

– Identifies potential for lost revenue

– Assures appropriate reimbursement

– Ensures billing & coding guidelines are being followed

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• Medicare Administrative Contractors (MACS)

• Comprehensive Error Rate Testing Program (CERT)

Pre-payment Reviews

• Zone Program Integrity Contractors (ZPICs)

• Program Safeguard Contractor (PSC)

• Recovery Auditors

Additional Documentation Requests (ADRs) • Medicaid Integrity

Contractors (MICs)

• Peer Review Organizations (PROs)

• Internal Reviews

Post-payment Reviews

Who Audits?

5

Preparing for a Payer Audit– Organize your team and assign responsibilities.

– Take all correspondence seriously, especially subpoenas and requests from FBI or OIG agents.

– Read audit letters carefully.

– Provide all information requested in a timely manner.

– Document all communication.

– Follow up telephone communication in writing.

– Evaluate patterns of current denials and any “vulnerabilities” identified internally through audits.

– Identify and assess target areas.

– Consult a healthcare attorney if necessary.

Who Audits?

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How to Audit?Identify

Purpose of Audit

Who Will Conduct

Identify Sample

Determine Collection

Tool

Analyze Results

Communicate Results

Follow-up &/or

Corrective Action

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Documentation Errors

• Incomplete progress notes

• Unauthenticated medical records

•Inconsistent documentation

•Cloning

Procedure Code Usage

• Billing for items/services not rendered

• Procedures

• Level/Type of Service

• Modifier Use

• Unbundling

Documentation for Medical Necessity

• ICD-10-CM assignment

• Certification of plan of care

• Failure of conservative management

• Billing for items/services not medically necessary

• Billing for non-covered services

Misuse of Provider

Identification Numbers

• Credentialed provider rules

• Shared/Split Visit rules

• Incident-to rules

• Teaching physician rules

Areas of Risk

What to Audit?

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Sample Audit Process Identify the purpose of the audit

– Prospective versus Retrospective

– Preliminary versus Comprehensive

• Accurate coding

• Medical necessity

• Missing charges

• Denials

• Risk issues

Who will conduct the audit

– Internal versus External

• Billing or Coder

• Physician Reviewer

• Consultant

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Sample Audit Process Identify the sample selection

– Select the provider(s) & dates of service

– Select the type of encounters to be audited

– Select ten (10) encounters per provider

Determine what data collection tool will be used

– Templates

– Billing & coding guidelines

– Documentation guidelines

– Strictly CMS rules?

– Carrier specific review?

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Resources

– Updated coding tools (i.e., ICD-10-CM, HCPCS, CPT® )

– Provider Manual

– Medicare, Medicaid, & Other Carrier Newsletters

– National Correct Coding Initiative (NCCI) Edits

– Local and National Coverage Determinations (LCDs & NCDs)

– CMS & Other Carrier Web Sites


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General Principles of Documentation

1. Complete and legible

2. Each patient encounter should include:– reason for the encounter

– relevant history & physical examination findings

– prior diagnostic test results;

– assessment, clinical impression or diagnosis;

– plan for care; and

– date and legible identity of the observer.

3. Rationale for ordering diagnostic and other ancillary services

4. Accessible past and present diagnoses

5. Identification of appropriate health risk factors

6. Patient’s progress, response to and changes in treatment

7. Support the CPT® & ICD-10-CM codes submitted for reimbursement

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Sample Audit Work Sheets

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Documenting Medical Necessity– Medical records should contain appropriate rationale

• Does the rationale support the level of care provided?

• Are all acute and chronic diagnoses with the current status andtreatment plans listed in the progress note?

• Is there documentation supporting that conservative medicalmanagement was tried and failed?

• Is there a signed order for services and the clinical rationale for theorder?

• Is the intensity, frequency, duration and scope of service documented?

• Is the procedure proposed medically necessary with regards tocommunity standards?

• Is there a legible signature of the person rendering the service, orderingand approving treatment plans?

Auditing Tips

17

Diagnostic Codes:

– Must be accurate and specific

– Identify the medical necessity of services by describing thecircumstances of the patient’s condition

– Primary Diagnosis = chief complaint

– Use as many diagnoses as needed

– Code to the highest level of specificity

– Do not code R/O statements

– No definitive diagnosis = code signs and symptoms

– Avoid unspecified codes

Auditing Tips

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E/M Key Components– History

• History of Present Illness (HPI)

• Review of Systems (ROS)

• Past, Family, Social History (PFSH)

– Exam

• 1995 or 1997 Guidelines

– Medical Decision Making

• Number of possible diagnoses or management options

• Amount and complexity of data to be reviewed

• Risk of complications and/or morbidity or mortality– New patients – must meet all 3 elements

– Established patients – must meet 2 of 3 elements

Auditing Tips

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Time– Total time spent with patient must be documented

• Face-to-face time

• Floor/unit time

– Attained when the midpoint is passed

– For E/M Services

• Key factor only when counseling and/or coordination of caredominates (more than 50%) the face-to-face physician/patientencounter

Auditing Tips

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Auditing Tips Surgical Procedures

– Was the provider the surgeon, co-surgeon, assistant surgeon or member of a surgical team?

– Is the date of service, place of service & number of units correct?

– Was the correct code selected based on the operative report?

– Is medical necessity supported in the documentation?

– Was a bilateral procedure performed?

– Was the procedure completed?

– Are the separate procedure guidelines being followed correctly?

– Is the modifier assigned correct for the information documented?

– Can these items be billed separately or are they included in the surgical package?

– Can the follow up care be separately reimbursed?

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Auditing Tips Radiological Services

– What was the service provided? Was it bilateral?

– Was the service for screening or diagnostic purposes?

– Was contrast used?

– Was the procedure done under guidance?

– Was the procedure completed?

– Where was the service performed?

– Who owns the equipment used to perform the service?

– Did the physician provide both the technical and professional components?

– Was more than one procedure performed?

– Are the procedures within the same family?

– Should the multiple procedure reduction apply?

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Auditing Tips Pathology & Laboratory Services

– What is the Clinical Laboratory Improvement Amendment (CLIA) status?

– What type of laboratory is being billed for?

– Are there any restrictions on billing authority?

– Was the correct code selected for the service provided?

– Is this test a part of a panel study?

– Does the diagnostic code support medical necessity?

– Was this diagnostic code previously submitted?

– Is this code a combination of professional and technical components?

– What are the payer policies on billing the professional component of the laboratory service?

23

Auditing Tips

Financial Audit– Were the charges submitted correctly? Timely?

– Were all the codes recognized &/or reimbursed by the payer?

– Were any services considered not medically necessary, routine or non-covered?

– Was a waiver needed?

– Was the waiver executed properly?

– Were there any errors on the Explanation of Benefits (EOBs)?

– Were we paid according to our fee schedule?

– Was a payment adjustment applied? Was it correctly applied?

– Did we collect the co-pay, co-insurance, deductible?

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Auditing Tips

Modifiers– Does the medical record documentation indicate that it is

necessary to assign a modifier?

– Does the medical record documentation give enough detail to support the modifier assignment?

– Is the modifier assigned correct for the information documented?

– Was the modifier appended to the correct procedure code?

– Is the modifier valid for the procedure, according to payer guidelines?

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Sample Audit Process Analyze the results

– Statement of results

– Patterns

– Comparison

– Risk analysis

– Education

– Financial impact

Communicate results– Determine audience

– Written report

– Oral presentation

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Implement follow-up and/or corrective action as appropriate

– Education & training

– Development of policies & procedures

– Templates

– Follow up review

– Refund identified overpayments

– Legal process

– Self-disclosure when necessary

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Audit Discussion Case 1

During a routine billing audit performed for allproviders in a practice, it was discovered that one ofthe six providers had an issue with the documentationof Level 4 new patient visits. Five of the ten recordsaudited for this provider were coded as Level 4 newpatient visits. Four of the five records did not meet thedocumentation requirements.

What would be the appropriate next step?

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Audit Discussion Case 2

A specialist received a letter from a managed carepayor indicating that the provider had a high frequencyof Level 5 visits compared to his peers.

What services would you want to audit? Why?

29

Summary

Audit Strategies

– Conduct audits and reviews routinely

– Be prepared for payer audits and disputes

– Identify main areas of risk

– Be knowledgeable about billing & codingguidelines

– Trend your billing

– Communicate results

– Look for opportunities for improvement

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Questions

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You can contact me at:

Audrey E. Coaxum, CHC, CPC, CEMC, CMC, CMIS, CMOM, CMCO

Excelsis Enterprises, Inc.

Post Office Box 542331

Houston, Texas 77254-2331

Tel: 713.679.0991

Fax: 800.420.9684

[email protected]

Thank you for attending!!

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AUDIT

FORM

TOOLS



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E/M Documentation Auditor’s Instructions

1. HistoryRefer to data section (table below) in order to quantify. After referring to data, circle the entry farthest to the RIGHT in the table, which best describes the HPI, ROS and PFSH. If one column contains three circles, draw a line down that column to the bottom row to identify the type of history. If no column contains three circles, the column containing a circle farthest to the LEFT, identifies the typeof history.

After completing this table which classifies the history, circle the type of history within the appropriate grid in Section 5.

HPI: Status of chronic conditions:q 1 condition q 2 conditions q 3 conditions

OR

HPI (history of present illness) elements:q Location q Severity q Timing q Modifying factors

q Quality q Duration q Context q Associated signs and symptomsROS (review of systems):

q Constitutional q Ears,nose, q q

q GI(wt loss, etc) mouth, throat GU

q Eyes q Card/vasc Musculo q Resp

q q

q Integumentaryq Endo(skin, breast) q

qq

Hem/lymphNeuro All/immunoPsych All others negativ

PFSH (past medical, family, social history) areas:qq

q

Past history ( the patient's past experiences with illnesses, operation, injuries and treatments)Family history (a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk)Social history (an age appropriate review of past and current activities)

Status of Status of 3 chronic

conditions1-2 chronic conditions

qBrief Extended(1-3) (4 or more)

q q qNone Pertinent to

problem(1 system)

Extended(2-9 systems)

*Complete

q qNone Pertinent **Complet

(1 history area) (2 or 3 historareas)

PROBLEMFOCUSED

EXP.PROB.FOCUSED DETAILED COMPRE

HENSIVE

e

*Complete ROS: 10 or more systems or the pertinent positives and/or negatives ofsome systems with a statement “all others negative”.

**Complete PFSH: 2 history areas: a) Established Patients - Office (Outpatient) Care; b) Emergency Department.

3 history areas: a) New Patients - Office (Outpatient) Care, Domiciliary Care, Home Care; b) Initial Hospital Care; c) Initial Hospital Observation; d) Initial Nursing Facility Care.

NOTE:For certain categories of E/M services that include only an interval history, it is not necessary to record information about the PFSH. Please refer to procedure code descriptions.

2. Examination

Refer to data section (table below) in order to quantify. After referring to data, identify the type of examination.Circle the type of examination within the appropriate grid in Section 5.

Limited to affected body area or organ system (one body area or system related to problem) PROBLEM FOCUSED EXAM

Affected body area or organ system and other symptomatic or related organ system(s) (additional systems up to total of 7)

EXPANDED PROBLEMFOCUSED EXAM

Extended exam of affected area(s) and other symptomatic or related organ system(s) (additional systems up to total of 7 or more depth than above)

General multi-system exam (8 or more systems) or complete exam of a single organ system (complete single exam not defined in these instructions)

DETAILED EXAM

COMPREHENSIVE EXAM

A M

E X

q q q qBody areas:q Head, including face q Chest, including breasts and axillaeq Back, including spine qGenitalia, groin, buttocks

)

q

q

Abdomen q NeckEach extremity

1 body area or system

Up to 7 systems

Up to 7 systems

8 or more systems

Organ systems:

q Constitutional q Ears,nose, q Resp q Musculo q Psych(e.g., vitals, gen app mouth, throat q GI q Skin q Hem/lymph/imm

q Eyes q Cardiovascular q GU q Neuro

PROBLEMFOCUSED

EXP.PROB.FOCUSED DETAILED COMPRE-

HENSIVE- 1 -

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q

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Number of Diagnoses or Treatment Options

Identify each problem or treatment option mentioned in the record. Enter the number in each of the categories in Column B in the table below. (There are maximum number in two categories.)

• One self-limited or minor problem,e.g., cold, insect bite, tinea corporis

• Rest• Gargles• Elastic bandages• Superficial dressings

• Elective major surgery (open, percutaneous or endoscopic with identified risk factors)

• Emergency major surgery (open, percutaneous or endoscopic)

• Parenteral controlled substances• Drug therapy requiring intensive monitoring for toxicity• Decision not to resuscitate or to de-escalate care

because of poor prognosis

• Minor surgery with identified risk factors• Elective major surgery (open, percutaneous or

endoscopic) with no identified risk factors• Prescription drug management• Therapeutic nuclear medicine• IV fluids with addititives• Closed treatment of fracture or dislocation without

manipulation

• Over-the-counter drugs• Minor surgery with no identified risk factors• Physical therapy• Occupational therapy• IV fluids without additives

• Cardiovascular imaging studies with contrast with identified risk factors

• Cardiac electrophysiological tests• Diagnostic endoscopies with identified risk factors• Discography

• Physiologic tests under stress, e.g., cardiac stress test, fetal contraction stress test

• Diagnostic endoscopies with no identified risk factors• Deep needle or incisional biopsy• Cardiovascular imaging studies with contrast and no

identified risk factors, e.g., arteriogram cardiac cath• Obtain fluid from body cavity, e.g., lumbar puncture,

thoracentesis, culdocentesis

• Physiologic tests not under stress, e.g.,pulmonary function tests

• Non-cardiovascular imaging studies with contrast, e.g., barium enema

• Superficial needle biopsies• Clincal laboratory tests requiring arterial puncture• Skin biopsies

• Laboratory tests requiring venipuncture• Chest x-rays• EKG/EEG• Urinalysis• Ultrasound, e.g., echo• KOH prep

• One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment

• Acute or chronic illnesses or injuries that may pose a threat to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure

• An abrupt change in neurologic status, e.g., seizure, TIA, weakness or sensory loss

• One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment

• Two or more stable chronic illnesses• Undiagnosed new problem with uncertain prognosis, e.g., lump in breast

• Acute illness with systemic symptoms, e.g., pyelonephritis, pneumonitis, colitis

• Acute complicated injury, e.g., head injury with brief loss of consciousness

• Two or more self-limited or minor problems• One stable chronic illness, e.g., well controlled

hypertension or non-insulin dependent diabetes, cataract, BPH

• Acute uncomplicated illness or injury, e.g., cystitis, allergic rhinitis, simple sprain

Management OptionsSelected

Diagnostic Procedure(s)Ordered

Presenting Problem(s)

High

Moderate

Low

Minimal

Level of Risk

Use the risk table below as a guide to assign risk factors. It is understood that the table below does not contain all specific instances of medical care; the table is intended to be used as a guide. Circle the most appropriate factor(s) in each category. The overall measure of risk is the highest level circled. Enter the level of risk identified in Final Result for Complexity (table below).

4. Time

Does documentation reveal that more than half of the time was counseling or coordinating care?

Does documentation describe the content of counseling or coordinating care?

Yes No

Yes No

Yes NoFace-to-face in outpatient settingDoes documentation reveal total time? Time: Unit/floor in inpatient setting

If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, riskreduction or discussion with another health care provider.

If all answers are "yes", select level based on time.

Risk of Complications and/or Morbidity or Mortality

Final Result for Complexity

A

B

C

Number diagnoses or treatment options

Highest Risk

Amount and complexity of data

Type of decision making

≤ 1Minimal

Minimal

≤ 1Minimalor low

2Limited

3Multiple

Low Moderate

2Limited

3Multiple

STRAIGHT-FORWARD

HIGHCOMPLEX.

MODERATECOMPLEX.

Final Result for ComplexityDraw a line down any column with 2 or 3 circles to identify the type of decision making in that column. Otherwise, draw a line down the column with the 2nd circle from the left.After completing this table, which classifies complexity, circle the type of decision making within the appropriate grid in Section 5.

- 2 -

Amount and/or Complexity of Data Reviewed

For each category of reviewed data identified, circle the number in the points column. Total the points.

Multiply the number in columns B & C and put the product in column D. Enter a total for column D.

Bring total to line A in Final Result for Complexity (table below)

3. Medical Decision MakingM E D I C A L D E C I S I O

N M

A K I N G

≥ 4Extensive

High

≥ 4Extensive

LOW COMPLEX.

1

1

1

1

1

2

2

Review and/or order of clinical lab tests

Review and/or order of tests in the radiology section of CPT

Review and/or order of tests in the medicine section of CPT

Discussion of test results with performing physician

Decision to obtain old records and/or obtain history from someone other than patient

Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider

Independent visualization of image, tracing or specimen itself (not simply review of report)


TOTAL

PointsReviewed Data

Bring total to line C in Final Result for Complexity (table below)


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2

3

4

Max = 2

Max = 1

Self-limited or minor(stable, improved or worsening)

Est. problem (to examiner); stable, improved

Est. problem (to examiner); worsening

New problem (to examiner); no additionalworkup planned

New prob. (to examiner); add. workup planned

TOTAL

ResultPointsNumberProblem(s) StatusB X C = DA



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AUDIT WORKSHEET

Auditor: Type of Review: Date of Review:

Patient Name Acct/MR Number DOS Billed

Provider Resident DOS Rendered

Primary Insurance Secondary Insurance New or Established Patient

CPT Billed CPT Documented Modifier Billed Modifier Documented ICD-10-CM Billed ICD-10-CM Documented

POS Billed POS Documented # of Units Billed # of Units Documented Billable Supplies Non-Billable Supplies

Time: ________________________________________________________________

CPT Code Service performed by:

(Correct) Documentation supports billed charge. Nurse

(Not doc) No documentation found in record. Medical Student

(Not billable) Documentation does not support a billable service. Resident Attestation: Yes / No

(Procedure) Incorrect CPT code billed. PA Shared Visit: Yes / No “Incident to”: Yes / No

(CCI) Procedure billed was bundled into another procedure code. NP Shared Visit: Yes / No “Incident to”: Yes / No

(Unbilled) Service Documented, but not captured for billing. Other Qualified H/C Provider

(Certification) Order for service not found in record. Physician

Auditor Comments:



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E/M Documentation Auditor’s Instructions

1. HistoryRefer to data section (table below) in order to quantify. After referring to data, circle the entry farthest to the RIGHT in the table, which best describes the HPI, ROS and PFSH. If one column contains three circles, draw a line down that column to the bottom row to identify the type of history. If no column contains three circles, the column containing a circle farthest to the LEFT, identifies the typeof history.

After completing this table which classifies the history, circle the type of history within the appropriate grid in Section 5.

HPI: Status of chronic conditions:q 1 condition q 2 conditions q 3 conditions

OR

HPI (history of present illness) elements:q Location q Severity q Timing q Modifying factors

q Quality q Duration q Context q Associated signs and symptomsROS (review of systems):

q Constitutional q Ears,nose, q q

q GI(wt loss, etc) mouth, throat GU

q Eyes q Card/vasc Musculo q Resp

q q

q Integumentaryq Endo(skin, breast) q

qq

Hem/lymphNeuro All/immunoPsych All others negativ

PFSH (past medical, family, social history) areas:qq

q

Past history ( the patient's past experiences with illnesses, operation, injuries and treatments)Family history (a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk)Social history (an age appropriate review of past and current activities)

Status of Status of 3 chronic

conditions1-2 chronic conditions

qBrief Extended(1-3) (4 or more)

q q qNone Pertinent to

problem(1 system)

Extended(2-9 systems)

*Complete

q qNone Pertinent **Complet

(1 history area) (2 or 3 historareas)

PROBLEMFOCUSED

EXP.PROB.FOCUSED DETAILED COMPRE

HENSIVE

e

*Complete ROS: 10 or more systems or the pertinent positives and/or negatives ofsome systems with a statement “all others negative”.

**Complete PFSH: 2 history areas: a) Established Patients - Office (Outpatient) Care; b) Emergency Department.

3 history areas: a) New Patients - Office (Outpatient) Care, Domiciliary Care, Home Care; b) Initial Hospital Care; c) Initial Hospital Observation; d) Initial Nursing Facility Care.

NOTE:For certain categories of E/M services that include only an interval history, it is not necessary to record information about the PFSH. Please refer to procedure code descriptions.

2. Examination

Refer to data section (table below) in order to quantify. After referring to data, identify the type of examination.Circle the type of examination within the appropriate grid in Section 5.

Limited to affected body area or organ system (one body area or system related to problem) PROBLEM FOCUSED EXAM

Affected body area or organ system and other symptomatic or related organ system(s) (additional systems up to total of 7)

EXPANDED PROBLEMFOCUSED EXAM

Extended exam of affected area(s) and other symptomatic or related organ system(s) (additional systems up to total of 7 or more depth than above)

General multi-system exam (8 or more systems) or complete exam of a single organ system (complete single exam not defined in these instructions)

DETAILED EXAM

COMPREHENSIVE EXAM

A M

E X

q q q qBody areas:q Head, including face q Chest, including breasts and axillaeq Back, including spine qGenitalia, groin, buttocks

)

q

q

Abdomen q NeckEach extremity

1 body area or system

Up to 7 systems

Up to 7 systems

8 or more systems

Organ systems:

q Constitutional q Ears,nose, q Resp q Musculo q Psych(e.g., vitals, gen app mouth, throat q GI q Skin q Hem/lymph/imm

q Eyes q Cardiovascular q GU q Neuro

PROBLEMFOCUSED

EXP.PROB.FOCUSED DETAILED COMPRE-

HENSIVE- 1 -

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Identify each problem or treatment option mentioned in the record. Enter the number in each of the categories in Column B in the table below. (There are maximum number in two categories.)

• One self-limited or minor problem,e.g., cold, insect bite, tinea corporis

• Rest• Gargles• Elastic bandages• Superficial dressings

• Elective major surgery (open, percutaneous or endoscopic with identified risk factors)

• Emergency major surgery (open, percutaneous or endoscopic)

• Parenteral controlled substances• Drug therapy requiring intensive monitoring for toxicity• Decision not to resuscitate or to de-escalate care

because of poor prognosis

• Minor surgery with identified risk factors• Elective major surgery (open, percutaneous or

endoscopic) with no identified risk factors• Prescription drug management• Therapeutic nuclear medicine• IV fluids with addititives• Closed treatment of fracture or dislocation without

manipulation

• Over-the-counter drugs• Minor surgery with no identified risk factors• Physical therapy• Occupational therapy• IV fluids without additives

• Cardiovascular imaging studies with contrast with identified risk factors

• Cardiac electrophysiological tests• Diagnostic endoscopies with identified risk factors• Discography

• Physiologic tests under stress, e.g., cardiac stress test, fetal contraction stress test

• Diagnostic endoscopies with no identified risk factors• Deep needle or incisional biopsy• Cardiovascular imaging studies with contrast and no

identified risk factors, e.g., arteriogram cardiac cath• Obtain fluid from body cavity, e.g., lumbar puncture,

thoracentesis, culdocentesis

• Physiologic tests not under stress, e.g.,pulmonary function tests

• Non-cardiovascular imaging studies with contrast, e.g., barium enema

• Superficial needle biopsies• Clincal laboratory tests requiring arterial puncture• Skin biopsies

• Laboratory tests requiring venipuncture• Chest x-rays• EKG/EEG• Urinalysis• Ultrasound, e.g., echo• KOH prep

• One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment

• Acute or chronic illnesses or injuries that may pose a threat to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure

• An abrupt change in neurologic status, e.g., seizure, TIA, weakness or sensory loss

• One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment

• Two or more stable chronic illnesses• Undiagnosed new problem with uncertain prognosis, e.g., lump in breast

• Acute illness with systemic symptoms, e.g., pyelonephritis, pneumonitis, colitis

• Acute complicated injury, e.g., head injury with brief loss of consciousness

• Two or more self-limited or minor problems• One stable chronic illness, e.g., well controlled

hypertension or non-insulin dependent diabetes, cataract, BPH

• Acute uncomplicated illness or injury, e.g., cystitis, allergic rhinitis, simple sprain

Management OptionsSelected

Diagnostic Procedure(s)Ordered

Presenting Problem(s)

High

Moderate

Low

Minimal

Level of Risk

Use the risk table below as a guide to assign risk factors. It is understood that the table below does not contain all specific instances of medical care; the table is intended to be used as a guide. Circle the most appropriate factor(s) in each category. The overall measure of risk is the highest level circled. Enter the level of risk identified in Final Result for Complexity (table below).

4. Time

Does documentation reveal that more than half of the time was counseling or coordinating care?

Does documentation describe the content of counseling or coordinating care?

Yes No

Yes No

Yes NoFace-to-face in outpatient settingDoes documentation reveal total time? Time: Unit/floor in inpatient setting

If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, riskreduction or discussion with another health care provider.

If all answers are "yes", select level based on time.

Risk of Complications and/or Morbidity or Mortality

Final Result for Complexity

A

B

C

Number diagnoses or treatment options

Highest Risk

Amount and complexity of data

Type of decision making

≤ 1Minimal

Minimal

≤ 1Minimalor low

2Limited

3Multiple

Low Moderate

2Limited

3Multiple

STRAIGHT-FORWARD

HIGHCOMPLEX.

MODERATECOMPLEX.

Final Result for ComplexityDraw a line down any column with 2 or 3 circles to identify the type of decision making in that column. Otherwise, draw a line down the column with the 2nd circle from the left.After completing this table, which classifies complexity, circle the type of decision making within the appropriate grid in Section 5.

- 2 -


For each category of reviewed data identified, circle the number in the points column. Total the points.

Multiply the number in columns B & C and put the product in column D. Enter a total for column D.

Bring total to line A in Final Result for Complexity (table below)

3. Medical Decision MakingM E D I C A L D E C I S I O

N M

A K I N G

≥ 4Extensive

High

≥ 4Extensive

LOW COMPLEX.

1

1

1

1

1

2

2

Review and/or order of clinical lab tests

Review and/or order of tests in the radiology section of CPT

Review and/or order of tests in the medicine section of CPT

Discussion of test results with performing physician

Decision to obtain old records and/or obtain history from someone other than patient

Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider

Independent visualization of image, tracing or specimen itself (not simply review of report)


TOTAL

PointsReviewed Data

Bring total to line C in Final Result for Complexity (table below)


11

2

3

4

Max = 2

Max = 1

Self-limited or minor(stable, improved or worsening)

Est. problem (to examiner); stable, improved

Est. problem (to examiner); worsening

New problem (to examiner); no additionalworkup planned

New prob. (to examiner); add. workup planned

TOTAL

ResultPointsNumberProblem(s) StatusB X C = DA



24



25



26

AUDIT WORKSHEET

Auditor: Type of Review: Date of Review:

Patient Name Acct/MR Number DOS Billed

Provider Resident DOS Rendered

Primary Insurance Secondary Insurance New or Established Patient

CPT Billed CPT Documented Modifier Billed Modifier Documented ICD-10-CM Billed ICD-10-CM Documented

POS Billed POS Documented # of Units Billed # of Units Documented Billable Supplies Non-Billable Supplies

Time: ________________________________________________________________

CPT Code Service performed by:

(Correct) Documentation supports billed charge. Nurse

(Not doc) No documentation found in record. Medical Student

(Not billable) Documentation does not support a billable service. Resident Attestation: Yes / No

(Procedure) Incorrect CPT code billed. PA Shared Visit: Yes / No “Incident to”: Yes / No

(CCI) Procedure billed was bundled into another procedure code. NP Shared Visit: Yes / No “Incident to”: Yes / No

(Unbilled) Service Documented, but not captured for billing. Other Qualified H/C Provider

(Certification) Order for service not found in record. Physician

Auditor Comments:



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On the topic: Auditing Essentials for Compliant · 2016-11-21 · Welcome to PMI’s Webinar...

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