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Louisiana Department of
Health and Hospitals
Bureau of Primary Care and
Rural Health
Procedural Coding
Sub-title
Analysis/Chart Audit
About the Bureau
The Louisiana Department of Health and Hospitals
supports improved access to primary care services in
rural and underserved areas through the Bureau of
Primary Care and Rural Health
The Bureau of Primary Care and Rural Health
developed Health Systems Development to address
primary and preventive health care access in the
Louisiana.
Our Mission
The Bureau of Primary Care and Rural
Health's mission is to improve the health
status of Louisiana residents in rural and
underserved areas by working
proactively to build community health
systems' capacity to provide integrated,
efficient and effective health care
services.
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Why Audit?
• All healthcare providers have a duty to
ensure that the claims submitted to
Federal Healthcare Programs are true and
accurate.
• To assure all information charted and
billed are in compliance should you have
an outside audit
Why?
• Identify non- compliance
• Identify deficiencies in documentation,
coding and billing
• Identify areas of revenue opportunities
• Identify communication breakdowns
Website of Office of Inspector General
Recommends
• Baseline audit which will become your
practice benchmark
• To measure progress
• To reduce or eliminate areas of
vulnerability
• To allow practices to tracks its compliance
efforts
OIG
• *OIG Compliance Program for Individual
and Small Group Practices, Federal
Register Vol 65 No. 194/October 5, 2000
Baseline Audit
• Follows transaction through revenue cycle
– How does service become a charge
– Are there safeguards in place to ensure
charges are captured?
– Are there safeguards in place to ensure all
services were rendered?
– Are charge entry staff knowledgeable in
coding?
– What happens to denials?
Following Baseline Audits…
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Periodic Audits
At least once a year
To insure continued compliance
As part of ongoing auditing and monitoring
“Delay is the deadliest form of denial.”
Selecting Records to Audit
• A practice can effectively conduct a chart
audit by:
– Prospective Review ( Before claims
submission)
– Retrospective Review (After you get paid)
– Concurrent Review ( to follow provider and
give information)
Auditing Records
• Prospective Review
– Catch errors before filed
– Slows down claims
– No repayment necessary
– Can prevent loss of revenue
Auditing Records
• Retrospective Review
– Claims Filed Timely
– Clean Flow and Clean Claim
– Can select those that may need additional
information
– Disclosure Issues
Auditing Records
• Concurrent Review
– Claim filed as record audited
– Auditor follows physician
– Can point out documentation lapses
– Provides real-time education
– May be confidentiality Issues
– Slows down patient flow
Who Should Conduct the Audit ?
• Internal vs. external review (consultant)
• Internal
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May use team approach
Need clinical input
Provide time to do them
Make sure knowledgeable in documentation
guidelines
Who Should Conduct the Audit ?
• External
– Consider 2-3 years
– Needs to be Certified
How Many Records?
• OIG says “No set formula”
• Suggest…
– 5 or more per payer
– 5-10 per physician
– Expanded scope if problems are identified
Selecting Records
• Random sample of claims/services (
choose all records on 1 date)
• Claims paid for selected services (Focus
on 99214, 99233)
• Claims paid on selected payers (Medicare
and Medicaid)
• Identified Risk areas ( Consultations, New
Patients)
• Use consistent methodology for accurate
tracking
Steps to a Successful Audit
Criteria- What should be…
Condition- What is…
Cause- Why did condition happen
Effect- Difference and impact between
what should be and what is
5. Recommendations- Actions needed to
correct cause
1.
2.
3.
4.
Step #1 Define Criteria –
What Should Be……
• CMS documentation guidelines 95’ & 97’
– Can use either years’ guidelines
– CPT Manual Guidelines
– ICD-9 Coding Guidelines
– Special Medicare Directives
– Local Medical Review Policy
Filing claims that meet medical necessity
Identify Risk Areas For Your Practice
• Global Surgery Compliance
• Professional/Technical Components
• Appropriate Modifiers
• Medical Necessity for Services
• Teaching Physician Guidelines
• “Incident To” Guidelines
• Specialty-Specific Issues
Where are your denials?
Step # 2- Condition- What Is
• Is chief compliant present on every
record?
• Does documentation in chart support
code?
• Is Diagnosis stated?
• Is the reason for ordered test clearly
stated?
• Are modifiers used appropriately?
• Are preventative healthcare visits coded
correctly… not as sick visits?
Step # 2- Condition- What Is
• Are consults documented with…
– Request?
– Recommendations?
– Report?
If time based code, Is the time documented?
Process Review
• Does date and place of service on CMS
form reflect chart documentation?
• Are diagnosis codes specific?
• Are Advance Beneficiary Notices on file?
• Check EOB Denials
• Are there outstanding credit balances?
Reasons for Poor Compliances
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Absence of written policies
Inadequate staff training/education
Inappropriate staffing levels
Work flow hinders communication
Lack of support from physicians
Poor practice management system
Steps #4 and # 5: Effect and
Recommendation
• Increase Scope
• Return overpayments to Medicare in 60
days
• Develop Corrective action plan
– Additional Education
– EMR system/templates
– Improved systems work flow
– Consult outside firm
Findings
• Depends on circumstances
• Preserve information relating to identification
• Create brief report for file
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Result of audit
Problems detected
Action taken
Follow-up time frame
• Important to make an appropriate
response when problems are found as quickly
as possible
– Generating repayment
– Consult with (Healthcare attorney if needed
Self Disclosure
• Recent CMS transmittal, CMS Pub.100-08
(Program Integrity Manual) Transmittal 90
says carriers only may start a non-random
prepayment review in self disclosure
cases if there’s high likelihood of large
errors
www.cms.hhs.gov/manuals/pm
trans/R90PI.pdf
Helpful Hints:
• Handle audits in medical records/billing
office
• Do your own audit of request before
releasing records
– Superbill/Encounter form
– Sign In Sheet
– Charting
– EOB
– Have Physician or Provider go over
information before released
How to Contact Us
Department Of Health and Hospitals
Bureau of Primary Care and Rural Health
Practice Management Consultants:
Susie Hutchinson, CAPPM -Statewide-Program Manager - 225-342-1584
[email protected]
Lynn Kinchen- Statewide- Program Monitor- 225-342-0057
[email protected]
Health Systems Development:
Tracie Ingram- Community Developer- Statewide
225-342-1233 [email protected]