1. Michele Jenkins Manager, Coding Education & Compliance 443-481-6462
New Provider Handout
Michele Jenkins
Manager, Coding Education & Compliance

2. Identification of Coding Risks
OIG requires

3. Why Perform Audits?
CMS States: Audit to ensure quality and compliance. The Improper Payments Information Act of 2002, as amended by the Improper Payments Elimination and Recovery Improvement Act of 2012, requires CMS to calculate the national Medicare FFS improper payment rate. Providers are urged to self-audit in an effort to identify claims errors and overpayments. HCE Coding Education and Compliance Auditors are here to help identify potential errors that may exists through a review of your claims. We will perform a pre-payment review of 20 claims yearly. This sampling will help identify potential underpayments or overpayments (if they exist) and provide education to the provider of potential risk factors – Provider Self Audits (Rev.425, Issued: , Effective: , Implementation; ) Providers may conduct self-audits to identify coverage and coding errors. The Office of Inspector General (OIG) Compliance Program Guidelines state most errors do not represent fraud. Most errors are not acts that were committed knowingly, willfully, and intentionally. For example, some errors will be the result of provider misunderstanding or failure to pay adequate attention to Medicare policy. Other errors will represent calculated plans to knowingly acquire unwarranted payment. Per chapter 4, section 4.2.1, ACs and MACs shall take action commensurate with errors made. ACs and MACs shall evaluate the circumstances surrounding the errors and proceed with the appropriate plan of correction.
Michele Jenkins, MA, CCS, CPC

4. CMS/AMA Audit Criteria utilized

5. Notify
Audit Department will send request to Billing Manager to hold claims for provider due for review.
Pre-Bill hold will be placed on claims
Pull
Audit Dept. will randomly select patient encounters from hold bucket
Audit Dept. will notify Billing Manager to release remaining claims for processing
Audit
20 claims per provider will be audited from encounters that broadly reflect the providers range of services
Audit analysis and education is prepared.
Michele Jenkins, MA, CCS, CPC

6. Findings and recommendations reported to Provider, Directors & Managers
Provider education takes place and makes any agreed corrections within days
Managers/Directors help provider with any amendments and claim corrections in Epic
Corrected claims released for processing
Any uncorrected claims or system issues are reviewed
Managers / Directors notify when corrections have been made.
Audit department continues to next provider review
Managers/Directors determine further action and claim completion
Report forwarded to audit department for file and any re-education needed.

7. Example of spreadsheet completed by HCE Auditors for each record reviewed

8. Example of Summary report given to providers
Scoring Results
80% to 100%: Random Audits
A .Next evaluation within 12 months
B .Mandatory education focusing on main points of concern
70% to 79%:
Focused Audits
a. Next evaluation within 6 months
c. Failure to achieve at least 80% within 12 months will result in referral
to the Physician Enterprise and / or the Anne Arundel Health System Compliance Committee.
69 % or less:
A .Mandatory education focusing on main points of concern
b. Next evaluation within 1 month
c. Failure to achieve at least 80% within 3 months will result in referral to the
Physician Enterprise and / or the Anne Arundel Health System Compliance Committee.
Dr. Smith

9. Examples CPT Code Errors
Principal
Secondary
Impacts reimbursement
Incorrect Code utilized
Incorrect modifier to bypass edits
Examples:
Breast lesion excision coded as breast biopsy.
E&M level 5 selected when documentation supports level 4
Does not impact reimbursement
More accurate procedure code
Multiple modifier error
Examples:
EGD with biopsy was actually EGD with band ligation
E&M same day as procedure no modifier utilized.

10. Examples Diagnosis Code Errors
Principal
Secondary
Impacts Reimbursement
Incorrect code utilized
Missing digits
Examples:
Appendicitis coded as abdominal pain
3 digit code selected for code with 5 digits
Does not impact reimbursement
Secondary code
Inaccurate 5th digit
Examples
Missing painful as descriptive for mole excision
Pain RUQ coded as LLQ

11. Criteria
Coding decisions for edits are based on conventions defined in the American Medical Association’s (AMA’s)
“CPT Manual,” national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices.
Code auditing is a comprehensive set of rules addressing coding inaccuracies such as: unbundling, fragmentation, up-coding, duplication, invalid codes, and mutually exclusive procedures.

12. HCE Random Audit Policy

13. Documentation Requirements
Minimum Documentation Requirements for Coding Purposes
Absent specific exceptions services must be provided based on the order of physicians or those authorized by the medical staff bylaws, rules and regulations to order such tests and services.
Refer to the Medical Staff policy MS Rules for a Complete Medical Record in determining co-signature requirements as well as authentication rules for orders.
Anne Arundel Medical Center must follow medical necessity guidelines and only perform and charge for services which have been ordered by a physician.
The following outlines the required documentation to support complete test orders, coding and billing of outpatient services. Required documentation is maintained in the legal medical record associated with the specific account for which services are billed.
Outpatient Referrals (diagnostic lab, x-ray, etc.)
Documentation must include, but should not be limited to, as appropriate to the service:
An authenticated physician order for services;
A diagnosis or reason for the service;
Test result;
Demographic information;
Signed consent for services (if required).
Referred Specimens: Documentation for laboratory tests on referred specimens only, where there is no patient contact with the laboratory, must include, as appropriate to the service:
An authenticated physician order for testing;
Date and time of specimen collection;
A diagnosis or reason for ordering each test;
Demographic information (if required).
Outpatient Visits
Documentation maintained may include, but should not be limited to, as appropriate to the service:
An initial evaluation or History and Physical;
Clinician visit notes or progress notes;
Test results;
Therapies;
Problem list;
Medication list;
Required consents; and
Procedure Reports.

14. Documentation Requirements Continued
Coding of the diagnosis must be completed using the medical record that is completed by the provider except for diagnostic testing services.
Documentation in the medical record must support the diagnosis and CPT codes marked on the test requisition or order form for diagnostic testing services. All testing requisition forms with preprinted ICD-9-CM and CPT codes should be reviewed at least annually for accuracy and reflect current services available and any updated ICD-9-CM and CPT codes.
The documentation or source document referred to by the coder should describe the patient’s condition, using terminology that includes specific diagnoses as well as symptoms, problems or reasons for the service. Coders may assign diagnosis codes based on the reason for the referral. A specific diagnosis based on test results usually is not available and may not be available until after subsequent evaluations or physician visits.
Documentation for the date of service for therapeutic services must clearly indicate the diagnosis for which the service is being provided. Coders should review the evaluation/treatment plan for the date(s) of service being billed and all other documentation from the provider that supports the date of service being billed (i.e., order for the service, evaluation supporting the treatment plan for the service provided, treatment plan, progress notes).
Emergency Visits
Documentation maintained must include, but should not be limited to, as appropriate to the service:
Physician’s emergency documentation;
Physician orders;
Nursing notes;
Test results;
Problem List;
Required consents;
Demographic information; and
Treatment.
ICD-9-CM diagnosis codes and CPT and/or ICD-9-CM surgical procedure codes must be assigned by the coder based on the diagnosis and treatment recorded by the physician along with test results.

15. Documentation Requirements Continued
Observation Visits
Documentation must include but should not be limited to:
A history and physical;
Physician progress notes;
Physician’s orders for placement in observation and for treatment;
Clinical observations including the reason for observation services;
Final progress note or summary that includes the diagnosis and any procedures performed and treatment rendered;
Problem List; and
Discharge order by the physician that reflects the clock time by the physician (or in the absence of the clock time, it must reflect the time that the order is signed off on by the nurse).
The observation unit medical record is reviewed by the coder to assist in the code assignment process.
Ambulatory Surgical or Diagnostic Procedural Services
As applicable, documentation maintained must include an ambulatory medical record that includes, but should not be limited to:
Physician’s order for services;
A history and physical examination;
Results of previous diagnostic tests related to this encounter;
Operative/procedure report;
Pathology report if applicable;
Medication list;
Problem List;
Demographic information; and
Signed consent(s) for services.
ICD-9-CM diagnosis codes and CPT or ICD-9-CM surgical procedure codes must be assigned by the coder based on the diagnosis and treatment recorded by the physician in the ambulatory medical record.
The physician’s operative report, including review of the post-operative diagnosis, and any pathology report should be reviewed to assist in accurate code assignment.

16. Process for HCE Compliance Audits
Summary
Process for HCE Compliance Audits
HCE performs Random audits on providers monthly. July-2015 to June 2016
The providers score will determine if a focused audit is needed and the time frame.
Example:
Random audits will continue for provider scores of %
Scores of 70-79% require education and a focused audit within 6 months time.
Scores of 69% or less result in all claims to be held, education and focused audits with of risk errors.
RAC, CERT audits are reviewed, appealed or refunded immediately upon receipt