Wiki Opinions for Scoring Chart Reviews

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RebeccaWoodward*

RebeccaWoodward*

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Hello to all~

I need some feedback from those of you that perform chart reviews (AKA audits). Currently, we have a procedure in place to conduct chart reviews every three months. Within these three months, a certain amount of random charts are pulled. When I'm reviewing these charts, I am looking for documentation to support the E/M service selected, medical necessity, missed charges, inappropriate codes, etc,etc.... Here's my question...... How do you factor the missed charges, inappropriate charges into the ultimate score? The physician may have documented all the components of the selected E/M level but there are other errors that don't alter his prelimanary score; such as missed charges at the time of posting. Do you create two separate scores or do you merge them into one? Any feedback is appreciated~
 
What we are currently doing is much the same. Providers are all audited on a scheduled basis, and all charges submitted (E/M, procedures, labs, etc) in that providers name/number are reviewed. We also look for missed charges. Sometimes we find things like a flu shot that the nurse recorded in the chart, but billed only the vaccine and not the administration. Or mention in the chart that U/A was performed, but it was not billed. Or, the person keying the charges enters the incorrect provider number because she transposed it or something. The doctor is usually unaware of these errors. We do make note of the missed opportunities to bill and bring these to his attention, but we do not count it against his score at all since there is no compliance risk there. Likewise, we note the other incidences by the nurse or billing staff as administrative errors and also do not count those against the provider. We do, however, take the action of notifying the clinic's Practice Director and having them see that the incorrect billing is backed out, refunded if appropriate, and rekeyed since it may still essentially be a "false claim" and the provider is made aware of these. So, overall, the only things we truly "ding" the provider for is E/M's that are over/under coded, incorrect catagory (new patient vs. consult), procedures billed for but not adequately documented, bundling issues (E/M not supported by documentation reported with a scheduled minor procedure) etc, etc. For the scoring, we figure it both with and without the administrative errors. The score is sometimes very close, but it at least makes the provider feel a little better in that they are not held responsible or "punished" for someone elses mistakes. It also helps us identify clinics or practices that may have staff doing sloppy work that needs to be addressed.

Does this help ??
 
Barbara,

This is very, very close to what I was looking for. The example I'm using for this discussion is a missed arthrocentesis. The provider documented beautifully and it supports his level; however, he did not provide this charge to the poster. If this is truly a provider error, do you "ding" the provider or are you allowing it to "pass" per se and simply note his missed opportunity for extra revenue?
 
No, we don't ding for the missed charges. If he had marked and E/M instead of the procedure, we would ding for wrong CPT catagory. Or if the E/M wasn't significant and separately identifiable and didn't warrent use of 25 mod, we would also ding.

We are going to start using a product called MDAudit next month that scores providers based on a point value system rather than just a percentage of right/wrong. It is set up so that it is weighted based on compliance risk. For example, overcoding a visit by 2 levels would count more "points" against a provider than overcoding by only 1 level. Undercoding may only count a fraction of a point. Some administrative errors do not have any points. Missed charges are reported with a $ amount, but no penalty points. From what I have seen so far with setting up the software and learning to use it, I think we have been on the right track for the most part with the way we have been deciding what actions to take after an audit, i.e., provider training, re audit soon, 100% prospective audit, etc.
 
I have found that there are some vast differences on how each practice handles these type of issues. However, the goal is ultimately the same. We're currently reviewing which compliance program/method will work best for our providers and the company as a whole. There are many, many variables to consider.

I really appreciate your feedback~
 
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