Internal Chart Audit Program

Overview “A joint effort between the health care provider and the clinic staff is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.”

Reason For Audit Improvement of patient care (improved documentation) Assess performance against standards (CMS, MGMA) Ensure appropriate payment Recover lost revenue through unbilled services Identify areas of risk and meet compliance standards

Standards Evaluation & Service Management Guidelines http://www.cms.hhs.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf CMS 1995 Documentation Guidelines http://www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf CMS 1997 Documentation Guidelines http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf Medicare E/M Distribution 2008 or latest available data Individual payer guidelines as necessary

Prep & Plan Quarterly audit Audit Schedule Advance Notification Office E/M codes – retrospective & concurrent 12 random office medical records per provider New patient Established patient Consults Audit Schedule Advance Notification Letter to clinic manager to notify of upcoming audit Request for medical records and scanned documents as necessary – 2 weeks

Actual Audit Audit Tool Patient chart components to be reviewed Progress note Orders for lab/x-rays, etc. Results for lab/x-rays, etc Other documents as needed Fee ticket used for posting charges Code Review CPT code level of service and over/under coding) Diagnosis code(s) assigned according to ICD-9-CM guidelines Documentation All services, supplies, & diagnoses reported Is clear, legible, signed and dated by provider and/or nurse Codes (for procedures, labs, & supplies appropriate and valid for DOS) Findings requiring immediate attention reported to director/manager

Audit Report & Education 1 hour meeting with Clinic Provider, group, office manager/director, nurse Report findings of audit Provide supporting guidelines from appropriate resources 1995/1997 guidelines ICD-9-CM / CPT guidelines Copies of report to: Provider/Group Manager/Director CEO/COO

Reports Reports kept to identify: Monthly summary Quarterly summary Refunds Payments received on re-billed services All results from audits Monthly summary Audit activity & results presented at managers meeting Quarterly summary Presented to ABC Executive Committee/Board

When will this start? First audit will start the week of January 1st Questions!!