1. 2015 User Conference Surviving an Insurance Audit April 24, 2015 (PM-290) Presented by: Susan J. Kressly, MD, FAAP Medical Director PM Session

2. 2015 Office Practicum User Conference Learning Objectives ▪ Review who gets audited ▪ Understand the implications of an insurance audit ▪ Identify 3 ways you can use best practices to decrease audit vulnerability ▪ Outline important steps to take in response to an insurance audit

3. 2015 Office Practicum User Conference Who gets audited? ▪ Coding “outliers” ▪Higher use of 99214 or 99215 compared to peers ▪Higher use of modifiers ▪Higher use of other CPTs ▪ Random selection ▪Some payers have mandatory random audit quotas ▪ Allegations of fraud ▪ ANYONE can be audited at ANY time

4. 2015 Office Practicum User Conference Why do audits happen? ▪ Public insurance companies (Medicare/Medicaid) have oversight mandates ▪ Attempts to identify/eliminate fraud ▪ All payers attempting to decrease/eliminate overpayment ▪ The bottom line ▪ Technically under-coding is also subject to corrective action (have never seen it happen)

5. 2015 Office Practicum User Conference What are the implications of an audit? ▪ Commonly ask for a review of a finite number of charts (example 40) ▪ Example: if they believe you inappropriately coded ten 99214s they feel should have been 99213s (25%) and… ▪ The difference in payment for your practice is $35 for this payer….. ▪ And your practice submitted claims using 99214 a total of 3,000 times over past 2 years ▪ They assume they overpaid you $26,250 and want the $$$ back

6. 2015 Office Practicum User Conference Take-backs ▪ Length of time they can pursue for take-backs depends on state regulations ▪ Can ask for check immediately or take from claims submitted going forward ▪ Can be subject to additional interest/penalties ▪ Many payers use third-party companies which get to keep a % of monies collected

7. 2015 Office Practicum User Conference Who is ultimately responsible? ▪ The owners ▪ The billing providers

8. 2015 Office Practicum User Conference E/M coding distribution ▪ Is not a bell shaped curve ▪ In Pediatrics most providers should be billing >30% 99214s or you are likely leaving $$$ on the table ▪ Some pediatricians bill > 50% 99214s ▪ 99215 is underutilized ▪ Few pediatricians bill a large # of 99212s ▪Exception is well/sick at the same time ▪ 99211 should not be used for vaccine only appointments unless additional separately identifiable reason for visit

9. E/M coding distribution

10. 2015 Office Practicum User Conference Procedures ▪ Make sure you are using the appropriate CPT code for commonly used codes such as: ▪Hearing/Vision ▪In house lab tests ▪Wart treatments ▪Burn/wound care ▪Chemical cautery of skin lesions ▪Frenulotomy ▪Urinary bladder catheterization

11. 2015 Office Practicum User Conference Best Practices to Limit Vulnerability ▪ Coding education ▪Providers ▪Billing staff ▪ Periodic internal coding surveillance audits ▪Internal if have expertise ▪Hire outside consultant if internal expertise lacking ▪ Track E/M coding distribution by provider

12. 2015 Office Practicum User Conference Cardinal Rules of Coding ▪ Do what is indicated by the patient’s presenting complaint(s) and conditions ▪ Document what you do (including thought processes in medical- decision-making) ▪ Code appropriately as supported by your documentation

13. 2015 Office Practicum User Conference OP Coding Decision Support ▪ Is based on the 1997 CMS coding guidelines1997 CMS ▪ While the 1995 guidelines may be more “pediatric friendly” they do not lend themselves to “bullet counting” by a computer

14. 2015 Office Practicum User Conference Keys to Coding Success in OP ▪ Understand how “suggested” coding occurs ▪ Use the coding calculator to make sure your documentation supports your coding choice ▪ Medical-decision- making is a manual process

15. 2015 Office Practicum User Conference Help, I’m being audited! What now? ▪ BREATHE…….. ▪ If you have documented and coded appropriately, you have nothing to fear ▪ Look at your time line ▪ Read the request for ‘gotchas’ ▪May state only the first response will be used for the audit, supporting documents will not be counted ▪Details about how far back they may extrapolate ▪Consider response that you want the opportunity to do more extensive review/submission with more charts ▪ Review all documentation before you send!

16. 2015 Office Practicum User Conference New OP 14 Audit Notes ▪ Available from the chart itself ▪ Encounter notes and Well Visits ▪ OP 14 upon finalization of note: ▪automatically builds and saves a note summary based on practice report rules ▪automatically builds and saves an audit report note (criteria not customizable)

17. 2015 Office Practicum User Conference Audit Note Contents ▪ Confidential disclaimer with all notes ▪ MU Information ▪ Location

18. 2015 Office Practicum User Conference Audit Note Contents (continued) Plan and Patient Instructions (if available) included

19. 2015 Office Practicum User Conference Audit Note Contents (continued) ▪ New section for coding/audit support ▪ Contains summary on what was used to calculate code ▪ Note started time: first time any user opened note (nurse/MA/provider)

20. 2015 Office Practicum User Conference Medical Decision Making ▪ Computer cannot compute what provider is thinking (nor can billing staff) ▪ Provider must go to coding decision tab and select appropriate levels ▪ MDM must have documentation within the body of the note to support choosing level ▪ Must check box for Coding Count Override to be included in audit note

21. MDM Audit Note

22. 2015 Office Practicum User Conference MDM Information in Audit Note ▪ MDM only appears if user checks “coding override” box

23. 2015 Office Practicum User Conference Overriding Suggested Code ▪ May put PMH or SH in HPI or other section ▪ May feel ROS/exam elements not counted correctly by OP (would document why you think this somewhere in note) ▪ Must pay attention to MDM section if choose to override as these details will be included in audit note

24. 2015 Office Practicum User Conference Coding Based on Time ▪ Best practice is to insert wording: “spent x minutes face to face with patient/parent” discussing/counseling on concerns and diagnosis” ▪ Can be put in plan section, counseling/care coordination section or both

25. 2015 Office Practicum User Conference Time Coding Decision Support ▪ Key component: time ▪ Record total visit length

26. 2015 Office Practicum User Conference Audit Note for Time Based Coding ▪ Total visit time included in visit information ▪ Counseling duration included (with confidential information withheld) ▪ Audit support reinforces counseling is key factor

27. 2015 Office Practicum User Conference What about my old notes? ▪ Can reconstruct using new audit note rules ▪ Go to alternate note tab ▪ Choose summary report criteria: Audit Report Note ▪ Use edit pencil to enter comments/purpose ▪ Click on Rebuild Summary

28. 2015 Office Practicum User Conference Review Before Releasing Documentation ▪ Have internal/external expert review notes to do an assessment whether documentation fits coding level put on claim ▪ Include additional print outs of surveys, etc. ▪ If you feel there is missing information, call OP before you send! ▪there may be additional information that can be added to your documentation to support your claim ▪OP may be able to provide a letter regarding how reports are constructed or changes in versions

29. 2015 Office Practicum User Conference Looking for more education/consulting? ▪ AAP coding resources ▪ E/M University has coding videos, pediatric specific learning modules, and auditing tools * E/M University ▪ The Verden Group* The Verden Group ▪ Pediatric Management Institute* Pediatric Management Institute * Office Practicum does not specifically endorse this product/group

31. 2015 Office Practicum User Conference Questions ?

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