Audit Process

agaluski

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My providers are currently undergoing an internal audit and I seem to have a difference of opinion on the way things are being evaluated. The scenerio is quite simple. Each provider is assigned a particular day that all there claims are going immediately on hold pending compliance review. Upon completion of the review, the auditor sends back the analysis. My difference of opinion is coming because they are only looking at the one note from that particular day and are not taking any other information into consideration when determining the level of service. In my opinion, it is important to know when the patient was last seen and the level of service that was billed. By only focusing on the one visit, I believe they are ending up coding a higer level in some instances. In my experience the audits we usually undergo from the insurance companies focus on the whole chart (or the last year anyways) and if we are billing a level 4 everytime the patient comes in because the patient has 3 chronic, but stable conditions, that screams red flag to me. I know there are many more pieces to the puzzle but I am pretty sure that medical decision making is what should drive an E/M selection and I simply feel the way they are evaluating visits is going to lead to overcoding. Any feedback would be greatly appreciated.
 
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when I audit a chart the medical necessity is what should drive the level not the
amount of documentation.
I would tend to agree with you because the frequency a pt returns for follow ups
should be deamed necessary also.
 

Love Coding!

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My two cents

Ok, I am a medical auditor and I agree that Medical Necessity drives the visit and the amount of documentation should not influence the level of service. According to the example of the 3 chronics that are stable poses a "red" flag and billing level 4's on the follow ups. I disagree, if the physician is working with multiple problems with the patient and the patient say comes in every three months to follow up. To achieve a level 4 follow up is really easy, four elements in the HPI, one area of the PFSH, 2-9 systems reviewed, why not give a level 4 each time if the note supports it? The table of risk says it all, 2 or more stable chronic illnesses. It has been said that 99213's are the most utilized code yet so many physicians "short change" themselves because of the "safe" factor of the code not too little not too high. There are coders out there that are involved on the billing side of things and you have coders that are just auditors, at times we see things entirely different and always up for a good debate. I say give the physician credit to what he/she is documenting unless those elements are not met to support a level 4, I say give it to them...by the way I work in Nephrology we see chronic conditions all the time...that's my opinion, anyone else?
 

agaluski

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Thank you for your responses. I'm all about giving the physician credit and billing at the highest level deemed medically necessary. I guess I just disagree with the overall calculation of the MDM level when the physician saw the patient a few weeks ago. Just to add, the HPI was audited at EPF with a comprehensive Exam. I guess I just don't understand because if I always go by the table of risk without regard for when the patient was last seen and level of service billed, that means everytime this patient comes in, whether it be every week for a year straight, I would always have a moderate MDM because the patient is going to always have there 3 chronic illnesses. At some point they may not be stable but the 3 diagnosis will always be there.
 
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.

yes i do agree that as a coder whatever is documented should be taken in consideration.... it dosent matters what level it reachs......... even if the patient is coming for follow up and the provider is doing his work of examination of level 4 than he deserves it........ no matter for what the patient is coming for....... cause the provider is spending his time for the patient and same he is documenting....
and every time its not possible to match up the providers work with medical nessesity...... Some times provider has to go beyond the required just for the wellnes of the patient.....


Please suggest me if any one has diffrent views or something they would like add up.....
 

LLovett

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What is the scope of your audit?

There are different types of audits that can be done and different elements that are looked at in each of them. Based on your description of holding a days worth of services for audit you should be auditing the services on those days only. Does the documentation support the charges for that day, are the codes assigned correct, is the documentation complete, etc...

The issues you are referring to would be outside the scope of this type of audit. Medical necessity should be done by a clinical provider, patterns of coding should be done based on data mining for that specifically not just auditing entire charts of patients seen on a random day.

I happen to disagree with MDM always being the driving factor on level selection but I do know some carriers require it be one of the levels in 2 of 3 codes. So if dealing with a carrier that reqiures it obviously you have to follow that.

Bottom line is you need to do the right things for the right reasons. Define your scope and stick to it. If you find other problems don't ignore them but don't let them muddy the waters. Deal with them appropriately and separately. This will help to keep your results accurate not skew them one way or the other.

Hope this was helpful,

Laura, CPC, CPMA, CEMC
 
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I see situations like this quite often in the practices I am asked to audit.
Parameters are set by management and when results start coming in someone ( usually not involed in decision making ) wants to move the goal line.
Auditing is a very precise discipline, if we are only charged with reviewing a snapshot in time then that's all we will do. We will not go willy nilly pulling in information that falls outside of the scope. That, in essence would redefine the audit resulting in the loss of the original purpose.
There is a reason that management defined the scope of the audit the way they did.
They are searching for something. Something you may not be aware of. Perhaps some benchmarking was done and the results indicated that some of the physicians were over utlilizing level threes thus making them outliers?
I know if I benchmarked a practice and saw something like that I would begin looking at snapshots just the way your practice is now. Then once patterns are established focus can be moved to the overall pt chart.

For what ever thier reasons may be they are more than likely looking for something very specific. Just something you may want to consider.
 
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