Hello, I apologize if this isn't the best spot to ask but I'm not finding other resources. I audit E/M Behav Health and have been asked to create an audit summary tool that will provide results with recommendations. Anyone have anything to help me get started, i.e. templates, suggestions, resources...anything? TIA!
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Wiki Auditing
- Thread starter jamie.mcalpin57@gmail.com
- Start date
TThivierge
True Blue
Hi Jamie
Ok I ll give you some tips on info to look for when reviewing documentation for clinical staff and the beh. health coders. Naturally group it by type of providers, (Psychistrist vs psychologists vs therapist LPC or LCSW and QMHP which assist helping in the outpt. beh health setting. Also review types of payer billing or the denials to see if there is a trend. I 'd do base pre type of clinician by reviewing 10-20 of their pt records. Hopefully 95% of their med documentation is correct. Also see if get a lot of denials per payer with certain CPT codes or programs.
As the behavior health auditing tool (create a grid) you can check for the following...
1.Per the type of mobility of the visit (clinic or telehealth or face to face in office) ensure it is medical necessary. Eval mgnt check on each record, HPI, Past family and socials history , any chronic conditions listed, mental or per treated on for the day, personality problems, medications, number of dx noticed presenting problem vs follow up, medical decision making, Ensure the assessment or dx listed for every record .Ensure explain or describe pt needs in in for the date of treatment. Ensure the gender is correct listed and if sub abuse problem list type
2.Ensure it is signed with professional title and date is listed or authenticated from EHR
3 Each record has treatment plan or certain screenings if supported (Depressions, Sub Abuses, Suicide, Developmental ) per pt type and their illness
4 Ensure tell if pt is new or established plus must add minutes treated in beh health documentation. If telehealth must add modifier 95 and minutes on phone call or video in med record.
5 Ensure pt must be treated for at least 15 minutes in order to bill
6.Watch out for cloned documentation, integral coding, Excludes 1 Rule and unbundling
7.Ensure the history of old illness has a date whereas current illness or if the pt has remission vs recurrent listed. (see dx block codes F32,F31 F19 F18 F10)
8. If pt is homeless hopefully can tell why; illness, economics, mental ill, drug abuse, Etc
9. Some be. health ds have stages such as Dementia,F03 ,G31 DepressionF32 , Moods,F06 & F34 PTSD F43 Conduct DO F91 or Suicide R45.85 if listed did medical coders abstract it? Was the dx put in proper sequence order?
10. Need 2 dx codes or combo codes such as G47.01 is Sleep Apnea due to illness hopefully provider list reason, Cirrhosis of Liver, past sub abuse listed or current
11,Hopefully coders add proper Z dx codes per supporting documentation in record Z91, Z53, Z56, Z62 Z65 Z73 Z63 Z02.83 Z86.69 Z13 to name a few
12. If smoking cessation done ensure add minutes in documentation with dx F17
13. If pt is funded by Medicare ensure signed an ABN form
14. If group therapy 90853 done.....note for each pt there.
15 If pt ordered to do lab work, hopefully put rationale in there too
16 If pt referred to your office, hopefully put referring physician name down who sent the pt there.
17 Pre authorization done correctly and faxed or completed online in timely per payer regs
18 Using unspecific dx codes in OP setting all the time can create denials or get less payment. This is a problem if documentation details support not unspecified in outpt setting. Clinical staff may need to be trained to put more details. WE know medical coders can only code/abstract what see.
Well I hope I helped a little bit.
Lady T
Ok I ll give you some tips on info to look for when reviewing documentation for clinical staff and the beh. health coders. Naturally group it by type of providers, (Psychistrist vs psychologists vs therapist LPC or LCSW and QMHP which assist helping in the outpt. beh health setting. Also review types of payer billing or the denials to see if there is a trend. I 'd do base pre type of clinician by reviewing 10-20 of their pt records. Hopefully 95% of their med documentation is correct. Also see if get a lot of denials per payer with certain CPT codes or programs.
As the behavior health auditing tool (create a grid) you can check for the following...
1.Per the type of mobility of the visit (clinic or telehealth or face to face in office) ensure it is medical necessary. Eval mgnt check on each record, HPI, Past family and socials history , any chronic conditions listed, mental or per treated on for the day, personality problems, medications, number of dx noticed presenting problem vs follow up, medical decision making, Ensure the assessment or dx listed for every record .Ensure explain or describe pt needs in in for the date of treatment. Ensure the gender is correct listed and if sub abuse problem list type
2.Ensure it is signed with professional title and date is listed or authenticated from EHR
3 Each record has treatment plan or certain screenings if supported (Depressions, Sub Abuses, Suicide, Developmental ) per pt type and their illness
4 Ensure tell if pt is new or established plus must add minutes treated in beh health documentation. If telehealth must add modifier 95 and minutes on phone call or video in med record.
5 Ensure pt must be treated for at least 15 minutes in order to bill
6.Watch out for cloned documentation, integral coding, Excludes 1 Rule and unbundling
7.Ensure the history of old illness has a date whereas current illness or if the pt has remission vs recurrent listed. (see dx block codes F32,F31 F19 F18 F10)
8. If pt is homeless hopefully can tell why; illness, economics, mental ill, drug abuse, Etc
9. Some be. health ds have stages such as Dementia,F03 ,G31 DepressionF32 , Moods,F06 & F34 PTSD F43 Conduct DO F91 or Suicide R45.85 if listed did medical coders abstract it? Was the dx put in proper sequence order?
10. Need 2 dx codes or combo codes such as G47.01 is Sleep Apnea due to illness hopefully provider list reason, Cirrhosis of Liver, past sub abuse listed or current
11,Hopefully coders add proper Z dx codes per supporting documentation in record Z91, Z53, Z56, Z62 Z65 Z73 Z63 Z02.83 Z86.69 Z13 to name a few
12. If smoking cessation done ensure add minutes in documentation with dx F17
13. If pt is funded by Medicare ensure signed an ABN form
14. If group therapy 90853 done.....note for each pt there.
15 If pt ordered to do lab work, hopefully put rationale in there too
16 If pt referred to your office, hopefully put referring physician name down who sent the pt there.
17 Pre authorization done correctly and faxed or completed online in timely per payer regs
18 Using unspecific dx codes in OP setting all the time can create denials or get less payment. This is a problem if documentation details support not unspecified in outpt setting. Clinical staff may need to be trained to put more details. WE know medical coders can only code/abstract what see.
Well I hope I helped a little bit.
Lady T
Last edited:
amyjph
True Blue
MGMA, NAMAS, AHIMA & APA may have resources as well. I wouldn't reinvent the wheel, there's probably one you could incorporate.