Dont Land in Hot Water

Audit Proof your Coding and

Documentation
Presented by:
Nikki Taylor, MBA, COC,CPC, CPMA
Auditor-The Coding Institute

Learning Objectives
Government Audits
How they work
Areas of Concern

How self-audits and external audits can:

Identify areas for improvements in documentation

Point out corrections that need to be made
Review diagnosis coding to ensure specificity and accuracy
Crack-down on insufficient provider documentation
Avoid undercoding, overcoding, and bad coding habits

Identify great resources and tools

EM Auditor
CCI Edits Checker
TCI Consulting & Revenue Cycle Solutions

Why Audits are Important

Good Practice
Audits ensure regular check-ups

Boost up compliance
Reel in reimbursement
Increased payer scrutiny=increased risk
Includes:
Internal/In-house
External/Third Party

Why Audits are Important, cont.

Audits help:
Ensure proper billing and coding
Correct reimbursement
New reimbursement opportunities

Fight back against government audits

Payer medical record requests and denials

Ensure provider education

Documentation requirements

Quality patient care

Malpractice litigation

Documentation Issues
Not just for coding!
Documentation equally important!
Clinical staff
Providers

Enter documentation at time of service

Shortly thereafter
Timelines for compliance
Good patient care

Documentation Issues, cont.

Signature requirements

CMS guidelines
Legible-hand written
Signature stamps-NOT appropriate
Electronic-often require physician code or login
Signatures = provider reviewed and agree

Dates and Time

All entries
Allow medical treatment to be reconstructed at a later time
If time of service and time of entry are different -document why

Documentation Issues, cont.

Types:

Handwritten
Dictation
Templates
Electronic

Handwritten:
Often illegible

Dictation:

Clear and thorough

Timing-transcription
Summaries
Signatures

Documentation Issues, cont.

Templates:
Cloning
Information lacking key details
Not thorough

Electronic
Cloning
Built-in templates
Over documenting/medical necessity

RAC Audits
Recovery Audit Program (RAC)
Mission:
Identify and correct improper payments
Overpayment detection and collection
Identifying underpayments
Prevent future improper payments

https://www.cms.gov

RAC Audits, cont.

National Recovery Audit program

Demo program- utilized Recovery Auditors

Medicare overpayments and underpayments
Between 2005 and 2008
Resulted in > $900 million being returned to the Medicare Trust Fund
Nearly $38 million in underpayments to health care providers.
Secretary of the Department of Health and Human Services
Instituted permanent and national Recovery Audit program
https://www.cms.gov

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RAC Audits, cont.

Post-payment basis
Follows Medicare policies
Carriers, FIs and MACs: NCDs, LCDs and CMS Manuals

Two types of reviews:

Automated (no medical record needed)
Complex (medical record required)

No claims paid prior to October 1, 2007

Can go back three years
Date of payment

Staff consists of nurses, therapists, certified coders, and a physician CMD

https://www.cms.gov

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RAC Audits, cont.

Demand letter is issued by RAC
Opportunity for provider
Discuss the determination with the RAC
Not part of the normal appeal process

Issues reviewed by RAC - approved by CMS

Issues approved are posted to website before
widespread review
https://www.cms.gov

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RAC Audits, cont.

RAC contractors are paid a contingency fee
% of every dollar in overpayments collected
Lose the appeal-must pay fee back

Focus--organizations with billings higher than the majority

Other providers/suppliers
Medicare services only

Nearly ANY inconsistency is grounds recovery demand

https://www.cms.gov

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RAC Audits, cont.

Top issues for 1st Quarter:

Non-covered services
Duplicate claims
Incorrectly coded services
Incorrect payment amounts
Prolonged services
Physician-referring/ordering info
Insufficient documentation

https://www.cms.gov

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RAC Audits, cont.

Check the RAC website
www.cms.hhs.gov/RAC

Check CERT reports

www.cms.hhs.gov/cert

OIG reports
www.oig.hhs.gov/reports.html

Locate the types of improper payments found in the reviews

https://www.cms.gov

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