What To Look For In A Coding Audit Don’t Leave Money On The Table Wiks Moffat Laurie Zabel, CHC, CHPC, CPC

Agenda  Regulatory Compliance  7 Elements/4 Challenges of Compliance  Looking Forward  Audit Types  Process  Who Conducts the Audit  Common Pitfalls/Concerns  Corrective Action Plan  Helpful Hints

Compliance Program  HIPAA – HITECH  Corporate Compliance  OSHA

Corporate Compliance  Code of Conduct  Anti-Kickback & Stark Self-Referral  Fraud & Abuse Laws  Reporting Structure & Disciplinary Actions  Whistle Blowers  Documentation  Training  Monitoring & Auditing

Achieving Compliance Best Practice Methodology  7 Elements  4 Challenges

Seven Fundamental Elements  IMPLEMENTING written policies, procedures and standards of conduct.  Designating a COMPLIANCE officer and compliance committee  Conducting effective training and EDUCATION  RESPONDING promptly to detected offenses and undertaking corrective action  AUDITING and conducting internal monitoring.  Developing effective lines of COMMUNICATION  ENFORCING standards through well-publicized disciplinary guidelines

Four Challenges  Paperwork, Record Keeping  Manuals, compliance forms, P & P’s  Employee Training  Document it, Continuously, Annually  Mechanism to Maintain Compliance  Continuous Readiness  New Hires  New Regulations  Compliance Issue Remediation

Things To Look Forward To  ICD-10  ACA  PQRS

CMS Chart Audits

What Audits Are Being Conducted  RAC – Recovery Audit Program (Contractor)  Mission - The Recovery Audit Program’s mission is to identify and correct Medicare improper payments through the efficient detection and collection of overpayments made on claims of health care services provided to Medicare beneficiaries, and the identification of underpayments to providers so that the CMS can implement actions that will prevent future improper payments in all 50 states.

Types of Audits Being Conducted  MIC – Medicaid Integrity Audit (Contractor)  Ensure that paid claims were:  For services provided and properly documented;  For services billed properly, using correct and appropriate procedure codes;  For covered services; and  Paid according to Federal and State laws, regulations, and policies.  5

OIG  OIG – The Office of Inspector General provides a list yearly that outlines all audits that they will be conducting for each specific year. This OIG “work plan” may be found at:  publications/archives/workplan/2015/FY15-Work- Plan.pdf  Evaluation and Management (E & M) services have been an area that the OIG has been auditing for many years.

Audit Selection Process  Targeted in the OIG Workplan  Criteria based on Medicare rules and regulations  Accepted clinical practice  Coding and billing policies  Data mining

CMS Audit Process  Letter requesting chart note copies  30 days to produce  Respond  Recie

Who Will Conduct the Audit  Certified Coders  Professional Clinicians  Physicians  Medical Directors  Nurses  Therapists

Common Pitfalls/Concerns of Documentation and Coding  Undercoding – to  = 4 HPI, 2 ROS, 1 PSFH, Moderate MDM  Overcoding – to or to  & = 4 HPI, 10 ROS, 3 PFSH, 8 Organ System Exam, Moderate MDM (99204), High MDM (99223)  Additionally billable services – E & M service with a Well Visit/Physical  Cloning/copying and pasting/templates – Copied HPI, HPI/ROS mismatch

Corrective Action Plan  Auditing plan must include Corrective Action Plan  Ensure that re-audits are part of plan  Document all steps of CAP  Educate, Educate, Educate

Helpful Hints  Establish a budget  Too big to do alone. Enlist internal resources to help and external resources when necessary  Remember…..you are never done. Apply the continuous readiness strategy  If you step up to the 4 challenges and the 7 elements, you will be fine!!

THANK YOU Wiks Moffat Laurie Zabel CHC, CHPC, CPC