Cardiology Coding Alert

Hint: Use professional resources to establish program protocols.

During the 2021 RISKCON session, “Effective Audit Program for Risk Adjustment,” Donna Malone, CPC, CRC, AAPC Approved Instructor, shared how you can create a strong audit program in your practice. Her expert advice includes learning how to conquer common challenges you may face and knowing how to choose your audit cases.

Follow these steps to create a strong audit program in your cardiology practice — today.

Identify Common Audit Program Challenges

You may encounter certain challenges as you work on developing your audit program, according to Malone. These challenges include the following:

Challenge 1: Not enough staff: Rethink who you have on board, Malone said. You must make sure you change with the times and are not just continuing the norm of what you have done for years and years.

Value-based care is not going away, and it’s expanding quite rapidly, according to Malone. The key, Malone said, is training people across the board.

You must train your coders and billers we have on staff holistically, Malone explained. You cannot keep the same mindset of a of fee-for-service driven perspective.

Challenge 2: Potential financial impact: Correcting errors could result in a financial loss, Malone said. You must also understand that not all “deletes” constitute a revenue adjustment. However, this should never be a reason why you don’t perform audits.

“We have a responsibility to the patients we manage,” Malone said. The patient complexity we are messaging to the government programs must be accurate. You don’t want it to be underrepresented, and you don’t want it to be overrepresented.

Challenge 3: Lack of focus on all contracts and contract components: It’s really challenging working with organizations, Malone said.

There is still a high focus on fee-for-service, which you still need to do because that doesn’t go away, but you also must understand that the organizations you work for is dependent on all the contracts you are involved in to be utilized as robustly as possible, according to Malone. When that doesn’t happen, you are not getting the adequate reimbursement to help manage your patient population.

Learn How to Successfully Educate Providers

When you educate providers, you want to make sure you are speaking their language, Malone said.

“Focus on patient complexity. Does this have a revenue impact? Yes, it does,” according to Malone. “But your audience is providers, and they care about taking care of patients. Talk about patient complexity and the importance of stating the true complexity of the patient.”

Your provider’s assessment and plan are the gospel, Malone added. When you are educating your providers, give them this acronym and tell them you need this information in their assessment and plan: DSP. Each letter stands for the following:

• D — Diagnosis. To the highest level of complexity known
• S — Status. Is the patient stable, worsening, improving, etc.?
• P — Plan. What are you doing about it? Steer clear from blanket statements like “Continue current treatment.”

Don’t miss: Working with your payers is vital, according to Malone. Ask for data and get that information. Build relationships with the appropriate people to make sure you can share information back and forth.

Carefully Choose Audit Cases

When you are developing a strong audit program, you will choose cases to look at, Malone said. You should include a mixed case selection based on both a random and targeted approach.

Random review: You can perform a true random selection where you randomly choose 10-25 encounters per physician. But you can also perform a random selection of an identified cohort. Examples of cohorts you can select include the following:

• High-complexity visits
• Annual wellness visits
• Preventive medicine visits
• Telehealth/telemedicine

Then from the cohort, you decide how many cases you should sample based on what is best for your organization and your people, Malone explained.

Targeted review: When it comes to a targeted review, you will look at specific targeted high-risk conditions such as:

1. History/resolved versus active conditions. Note: Cancer is a particularly high-risk condition, Malone said.

2. Stroke and pulmonary embolism in the office setting. You need to ask — Is it the right diagnosis for that place of service? Stroke in the office will not pass audit, Malone said.

“The provider might be absolutely spot on, but where is the diagnosis confirmed?” Malone added. It is confirmed in the emergency department (ED) if that person really has a stroke, so it’s going to be captured there.

3. Conditions appropriate for mother’s chart versus baby’s chart

4. Fracture coding. Note: Seventh character use is always challenging when choosing ICD-10 codes for fractures, Malone said.

5. Drug dependence versus long-term use

On the other hand, when you perform a targeted audit, you should also look at common unspecified and under documented conditions such as: depression, chronic kidney disease (CKD), diabetes, amputations, ostomies, and HIV-positive.

Finally, you can perform targeted review based on the on Officer of Inspector General (OIG) work plan, payer audit results, and internal chart reviews, Malone said.

Editor’s note: Want more great coding info like this? You can register for the upcoming educational events here: https://www.aapc.com/resources/events.aspx.