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AIS's Health Business Daily
Featured Story, June 4, 2010 The Scoring of Audits Gets Docs’ Attention and Takes Advantage of Their Competitiveness Reprinted from REPORT ON MEDICARE COMPLIANCE, the nation's leading source of news and strategic information on false claims, overpayments, compliance programs, billing errors and other Medicare compliance issues. By Nina Youngstrom, Managing Editor
It looked bad for one physician after her first audit as a member of MedicalEdge Healthcare Group, a Dallas-based physician management organization. The audit turned up serious flaws with her evaluation and management (E/M) documentation. For new patients, Medicare requires documentation of three key components — history, physical and medical decision making. But this physician recorded little about the patient’s history, barely mentioning any “review of systems,” which is a Medicare requirement for taking a patient’s history. Yet the chart reflected the physician’s instructions for treating various disease states. As a result, the physician was upcoding E/M services.
“She could recall every patient, even from months before, but that doesn’t help with an auditor,” says Lynn Myers, M.D., vice president of coding, compliance and education at MedicalEdge. “If you turn in a charge and you can’t supply documentation, that’s fraud.” So Myers showed the physician her errors and explained how to fix them. Three months later, the physician got an excellent score on her re-audit, which means she’s free of an internal audit for a year. “Our approach is to provide them with good education in the event they get reviewed by an outside payer or regulator,” Myers says.
Whether physicians code their own charts or coders do it for them, the stakes are high for scrutiny of coding and documentation. Under the health reform law, every physician group will be required to have an effective compliance program as a condition of Medicare and Medicaid enrollment, and auditing is a core element of an effective compliance program.
“Pulling in a consultant once a year to teach doctors about documenting and coding would not, by itself, be an effective auditing and monitoring program,” says attorney Ed Gaines, chief compliance officer for Medical Management Professionals. Recovery audit contractors (RACs) and zone program integrity contractors (ZPICs) also are targeting physician billing.
Health care organizations use different approaches. For example, MedicalEdge physicians code their own charts and MedicalEdge audits them on a regular basis, depending on the outcome of each audit. Five charts are randomly pulled per physician, and a compliance analyst audits the charts against the code assigned. Does the level of service match the documentation? Are there diagnosis discrepancies? Does the diagnosis lack specificity? Were teaching physician rules satisfied? Did the physician use E/M codes for consults when patients are covered by Medicare? Was the chief complaint documented?
Based on the errors identified, the compliance analyst assigns points using a modified version of a proprietary scoring method. Lower scores are best. If physicians overcode, they are assessed points. Overcoding by one level costs them two points; two levels costs four points; three levels results in six points; and four levels is eight points. Undercoding is scored the same way. If documentation for a procedure doesn’t match the procedure coded, the physician gets three points. Unbundling triggers three points. Editing with the wrong modifier equals one point.
Physicians who score below seven points are not audited again for a year. If they score between seven and 12, physicians have a telephone intervention with the compliance analyst. Physicians who score above a 12 meet with Myers for more coding and documentation compliance training.
Even if a physician scores below a seven, he or she may not escape remediation if the errors are all concentrated in a particular category (e.g., modifiers). And the compliance analyst’s gut plays a role in the audit. If something seems awry despite a good audit score, the compliance analyst will convey his or her misgivings to Myers. As a physician, it’s up to Myers to probe more deeply into her colleagues’ coding and documentation behavior.
For example, a physician who scored well on his audit caught the attention of the compliance analyst because he did all his rounds at 2 a.m. It turned out he was caring for a disabled grandchild during the day and coming in very late to do rounds. That wasn’t in the best interest of his patients because the hospital wasn’t set up for middle-of-the-night rounding (e.g., non-emergency specialty consults).
Lack of Medical Necessity Flagged in Audits
Also, Myers says cases may be referred to her when the scores are OK but the compliance analyst is concerned the chart won’t support medical necessity for the claim. For example, one physician scored a four because he was documenting sufficiently for a level five E/M service in terms of problems. “But he seemed to lack medical necessity for a level five,” she says. “[The charts] would not survive a medical review.” Addressing medical necessity with physicians is no walk in the park. “You get bluster,” she says. “For example, the physicians say ‘these patients are very complex, they come in from rural areas and they wait until they are sicker [to see the doctor].’ So I say ‘why isn’t that reflected in your documentation?’”
Sometimes the audits turn up patterns of bad documentation, such as inappropriate cloning of data from previous encounters. Other times, there are anomalies. For example, in one physician’s chart, the CPT code was transposed so MedicalEdge charged for a cystoscopy (CPT 52250) instead of vasectomy (55250) — what she calls a “spurious inconsistency.” The physician still got points for the error, but the mistake probably won’t be repeated.
Because compliance is low on the list of most physicians’ priorities, the audit scoring method is an effective way to get their attention, Myers says. It plays into their natural competitiveness. Physicians don’t want to be bested by their peers. “They take it seriously only when they see it will keep happening until they improve their score and we get competitive juices flowing,” she says. “They want to score better.”
Also, if physicians are “grossly out of compliance, there are triggers we can pull.” For example, MedicalEdge can refuse to drop their bills until their coding compliance improves or hold them in breach of contract. But “what hurts them hurts us,” so the emphasis is on improving compliance.
Coders Train With Dummy Charts
Coders do the coding for the emergency room physicians, radiologists, interventional radiologists, anesthesiologists and pathologists who sign on with Medical Management Professionals. But “when we hire a new coder, they don’t see a real chart for weeks,” Gaines says. “They code dummy charts and they are subject to a 100% focused review.” An experienced coding Q/A specialist sits with the new coder, pointing out misinterpretations of documentation (e.g., a laceration repair was intermediate, not complex, based on the documentation). “Coders need continual feedback about what they are coding and whether it’s correct and the reasons why.”
Annual or twice-annual audits are inadequate to overcome the fact that professional coders occasionally “bump their heads,” Gaines says. “We see this dynamic. They can have a high quality assurance (QA) score and then there is a change in payer policy, documentation standards or the provider’s documentation method (e.g., the practice converts from paper charts to electronic) and their QA score is impacted. If you are continually sampling charts you are more likely to find that dynamic.”
When coders’ QA scores drop significantly, a coding trainer reviews their coding before the bills are dropped, pursuant to a detailed policy and procedure. If a low QA score is an aberration, corrective action may take one road — for example, detailed instruction from the QA specialist regarding techniques and strategies to avoid these errors. But “if it looks like the coding errors reflect gaps in knowledge or understanding, we make other choices. We may have coder Q/A specialists sit with the coder in a focused review setting and do a side-by-side review,” Gaines says.
Systemic issues trigger an entirely different response. “Is there something in your knowledge or experience that is missing? You are not making the error occasionally; you are making it all the time,” Gaines says. “For example, you may simply misunderstand that ultrasound guidance for a certain procedure must be documented in a certain way.” That’s relatively easy to fix, requiring more education and oversight.
And sometimes coders have to make judgment calls about critical care based on physician documentation, Gaines says. For example, some coders think most ED chest-pain workups are a level-five E/M (CPT 99285) service, while others think chest pain could be coded as critical care under certain documentation and circumstances (CPT 99291). The message here is that “you are not looking for perfection. You are looking for systemic gaps in knowledge and understanding,” Gaines says. It’s important to stay on top of coders because payers change documentation and coding standards as new and different procedures are performed, he says. For example, same-day observation services are increasingly used in the ED and the coders and physicians must be constantly provided coding and documentation feedback regarding these payer-specific requirements, he says. “Once the practice begins providing these new services, the feedback loop must continue to recheck the physician’s and coder’s understanding of the payer-specific requirements.”
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