looking for chart audit guidelines

LisaAnn

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Local Chapter Officer
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Blythe, Georgia
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hi-I work for a mental health group and they have decided auditing e/m is important now. I am in need of a policy on how many charts and guidelines you use for your company. I don't want to know your company, our compliance officer isn't to sure of how to write something like that. I am just the coder/billing...thanks in advance for your help
 

kroemer4

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Local Chapter Officer
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Van Nuys, CA
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Compliance Audits Overview

Ours is a health system, and we categorize our audits as follows:

For exploratory audits, we generally audit 10 encounters per provider/specific CPT code. For example, if you have 50 providers and you want a snapshot of each of their notes, 10/provider for a specific period of time (previous FY/Q) = a lot of notes (500 over likely a year or so). If you use a bimodal distribution report, just the outliers and 10 per outlier. A bimodal distribution report compares like-specialties against Medicare's benchmark. And, since payors are concerned with outliers, your compliance program should be as well.

Random.org (https://www.random.org/) is a nice, easy-to-use, free website to help identify a random sample. I prefer to use the "Integer Set Generator", though my colleague likes "Integer Generator". Integer Set Generator removes duplicate numbers and results in a manner that is easy to copy & paste into an audit workbook.

If there's a glaring issue, we'll look at 10-20 more records per glaring issue (specific provider, CPT code, habit, etc.). A passing rate is anything at or above 90%. Those less than 90% are re-audited based on the distance from 90%, and the availability of auditors. Generally, 0-50%, monthly; 60-70%, quarterly; 80-90% bi-annually.

For internally defined targeted audits (based on the OIG work plan, CERT audits, issues that comparable hospitals/health systems have had audited, etc.), then we're looking at a statistically valid random sample per physician/specific CPT code. Sample size is based on the audit focus.

We also generally have follow-up audits to ensure our recommendations were implemented and/or other improvements implemented. Those are generally a focused quick look (10 notes based on whatever the errors were). Maybe 10 99214s for Dr A since his exploratory audit showed that his area of opportunity landed with 99214s that he consistently charged as 99213s. Or, with a 5-panel lab audit (originally 50 lab encounters), only the lipid panel failed in appropriate diagnoses, frequency limitations, and physician orders; the follow-up audit focuses only on the lipid panel since the other 4 audits achieved 90% accuracy or above.

We also look at enterprise risk audits and those are more process based, so not very quantifiable. Basically, we're following the process and identifying any gaps.

I'd be happy to work further with you and/or your compliance officer. I have extensive experience implementing and monitoring E/M audit processes. I can also help set up a bimodal distribution report (it takes a lot of the stress off identifying those to audit). Email is roemerk@genesishealth.com


OIG work plan: https://oig.hhs.gov/reports-and-publications/archives/workplan/2017/HHS OIG Work Plan 2017.pdf
 
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