1. E/M Coding: Documentation Deficiencies Presented by: Carrie L. Weiss, L.P.N., C.E.M.C.

2. Objectives Review general documentation guidelines and E/M components Review general documentation guidelines and E/M components Identify frequent documentation deficiencies related to E&M services Identify frequent documentation deficiencies related to E&M services Discuss tips for communicating audit findings Discuss tips for communicating audit findings Provide valuable resources Provide valuable resources

3. Disclaimer The following presentation was created for educational purposes only. The information presented during today’s meeting was current at the time presented and is based on the author’s experience and interpretation of the AMA and CMS guidelines. All CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Applicable FARS/DFARS apply.

4. General Documentation Guidelines The documentation should be complete, concise and legible The documentation should be complete, concise and legible The encounter should include: The encounter should include: Reason for encounter and relevant history, physical examination findings, and prior diagnostic test results Reason for encounter and relevant history, physical examination findings, and prior diagnostic test results Assessment, clinical impression, or diagnosis Assessment, clinical impression, or diagnosis Plan for care Plan for care Date and legible identity of the observer Date and legible identity of the observer

5. General Documentation Guidelines If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred Past and present diagnoses should be accessible to the treating and/or consulting physician Past and present diagnoses should be accessible to the treating and/or consulting physician Appropriate health risk factors should be identified Appropriate health risk factors should be identified The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record

6. General Documentation Deficiencies Documentation missing: Documentation missing: Beneficiaries name Beneficiaries name Date of service Date of service Appropriate documentation (incomplete) Appropriate documentation (incomplete) Supporting documentation (referred to ROS, PFSH, or orders) Supporting documentation (referred to ROS, PFSH, or orders) Documentation did not support the level of service billed (down coding/up coding) Documentation did not support the level of service billed (down coding/up coding) Documentation did not support medical necessity Documentation did not support medical necessity No documentation received No documentation received Used unapproved abbreviations and did not provide a key Used unapproved abbreviations and did not provide a key

7. General Documentation Deficiencies Illegible documentation Illegible documentation Missing, illegible or invalid signature Missing, illegible or invalid signature Chronic late entries or signatures Chronic late entries or signatures The CPT codes and ICD-9 CM codes reported on the CMS 1500 claim do not match the documentation The CPT codes and ICD-9 CM codes reported on the CMS 1500 claim do not match the documentation

8. Electronic Health Records Improves continuity of care Improves continuity of care Aids with workflow (maybe not at the beginning) Aids with workflow (maybe not at the beginning) Assists with quality, accuracy and clarity Assists with quality, accuracy and clarity Can help select/determine CPT/ICD-9 CM codes Can help select/determine CPT/ICD-9 CM codes Templates to assist providers/staff with documentation Templates to assist providers/staff with documentation Great tool when used appropriately Understand the logic

9. Electronic Health Records Deficiencies Cloning Cloning Copying/Pasting Copying/Pasting Missing or invalid signatures Missing or invalid signatures Unable to determine if guidelines were met: Unable to determine if guidelines were met: Addendums Addendums Split/Shared services Split/Shared services Signatures Signatures Incident To services Incident To services Scribes Scribes

10. Electronic Health Records Deficiencies Submits screen shots Submits screen shots Relies on system to select level of service Relies on system to select level of service Relies on system to perform “audits” Relies on system to perform “audits” Based on “counting” and is unable to determine medical necessity (need human interaction) Based on “counting” and is unable to determine medical necessity (need human interaction) System/Format is not conducive for specialty System/Format is not conducive for specialty

11. Electronic Health Records Deficiencies Provider selected/used wrong template Provider selected/used wrong template Discrepancy in time (provided by system and documented by provider) Discrepancy in time (provided by system and documented by provider) Problem lists (out dated or not addressed during encounter) Problem lists (out dated or not addressed during encounter)

12. Scribes Service rendered by physician or non-physician practitioner (NPP) Service rendered by physician or non-physician practitioner (NPP) Written or dictated by another individual “scribe” Written or dictated by another individual “scribe” The scribe must identify the situation. Example: “Written by Carrie Weiss, L.P.N,” acting as a scribe for Dr. Smith.” The scribe must identify the situation. Example: “Written by Carrie Weiss, L.P.N,” acting as a scribe for Dr. Smith.” Should be co-signed by the rendering provider Should be co-signed by the rendering provider

13. Scribes If ancillary staff is playing a dual role by performing the Review of Systems and Past/Family/Social History; and scribing, both guidelines must be met If ancillary staff is playing a dual role by performing the Review of Systems and Past/Family/Social History; and scribing, both guidelines must be met The scribe can not round and document the service during a separate encounter and then have the physician round and co-sign the documentation The scribe can not round and document the service during a separate encounter and then have the physician round and co-sign the documentation CGS: http://www.cgsmedicare.com/kyb/pubs/news/20 12/0412/cope18560.html CGS: http://www.cgsmedicare.com/kyb/pubs/news/20 12/0412/cope18560.html http://www.cgsmedicare.com/kyb/pubs/news/20 12/0412/cope18560.html http://www.cgsmedicare.com/kyb/pubs/news/20 12/0412/cope18560.html

14. Scribe Deficiencies Unable to determine who rendered the service Unable to determine who rendered the service Missing signatures Missing signatures Only co-signed the documentation Only co-signed the documentation

15. Evaluation and Management Services Grouped by categories: Grouped by categories: Patient type Patient type Place of service Place of service Level of service Level of service Two sets of guidelines: Two sets of guidelines: 1995 and 1997 1995 and 1997 May use either set May use either set

16. Components of an E/M Service Key Components: 1.History  History of Present Illness (HPI)  Review of Systems (ROS)  Past, Family, and Social History (PFSH) 2.Examination 3.Medical Decision Making  Diagnosis/Management Options  Type of Data  Risk Assessment

17. Components of an E/M Service Contributing components: 4. Nature of presenting problem 5. Counseling* 6. Coordination of care* 7. Time* *Time may be the controlling factory component if greater than 50% of the E/M encounter included counseling/coordination of care

18. Chief Complaint (CC) Usually stated in the patient’s own words Usually stated in the patient’s own words The medical record should clearly reflect the CC The medical record should clearly reflect the CC

19. Chief Complaint (CC) Deficiencies Missing CC Missing CC Documented, “Follow up” without elaboration Documented, “Follow up” without elaboration Documented the patient was there for a prescription drug refill or results of tests Documented the patient was there for a prescription drug refill or results of tests Patient presented for acute and chronic conditions, but wasn’t documented Patient presented for acute and chronic conditions, but wasn’t documented Documented by ancillary staff Documented by ancillary staff

20. History of Present Illness (HPI) A chronological description of the patient’s present illness from the first sign/or symptom or from the previous encounter to the present A chronological description of the patient’s present illness from the first sign/or symptom or from the previous encounter to the present Contains 8 elements Contains 8 elements LOCATION (back, arm…) LOCATION (back, arm…) QUALITY (sharp, dull…) QUALITY (sharp, dull…) SEVERITY (scale of 1-10, severe…) SEVERITY (scale of 1-10, severe…) DURATION (started three days ago) DURATION (started three days ago) TIMING (it is constant, it comes and goes…) TIMING (it is constant, it comes and goes…) CONTEXT (lifted large object at work) CONTEXT (lifted large object at work) MODIFYING FACTORS (applied ice, took a Tylenol…) MODIFYING FACTORS (applied ice, took a Tylenol…) ASSOCIATED SIGNS & SYMPTOMS (swelling, pain…) ASSOCIATED SIGNS & SYMPTOMS (swelling, pain…)

21. Brief = 1 – 3 elements Extended = 4 or more elements; or the status of 3 or more chronic/inactive conditions History of Present Illness (HPI)

22. History of Present Illness (HPI) Deficiencies Documented by ancillary staff Documented by ancillary staff Double dipped Double dipped No HPI elements for service that required all 3 elements (new patient, emergency department, etc.) No HPI elements for service that required all 3 elements (new patient, emergency department, etc.) Billed higher level services that required four or more HPI elements or a description of the status of three or more chronic problems Billed higher level services that required four or more HPI elements or a description of the status of three or more chronic problems

23. Review of Systems (ROS) CONSTITUTIONAL (fever, wt. loss…) CONSTITUTIONAL (fever, wt. loss…) EYES EYES ENT ENT CARDIOVASCULAR CARDIOVASCULAR RESPIRATORY RESPIRATORY GASTROINTESTINAL GASTROINTESTINAL GENITOURINARY GENITOURINARY MUSCULOSKEETAL MUSCULOSKEETAL INTEGUMENTARY INTEGUMENTARY NEUROLOGICAL NEUROLOGICAL PSYCHIATRIC PSYCHIATRIC HEMATOLOGIC/ LYMPHATIC HEMATOLOGIC/ LYMPHATIC ENDOCRINE ENDOCRINE ALLERGIC/ IMMUNOLOGIC ALLERGIC/ IMMUNOLOGIC ROS is an inventory of body systems obtained by asking a series of questions in order to identify signs and/or symptoms that the patient may be experiencing or has experienced

24. Review of Systems (ROS) NONE PROBLEM PERTINENT EXTENDED 2 - 9 COMPLETE 10 or greater

25. Review of Systems (ROS) Deficiencies Used statement “all others negative,” but pertinent findings related to CC/presenting problem(s) were not addressed Used statement “all others negative,” but pertinent findings related to CC/presenting problem(s) were not addressed Referred to HPI, but the HPI did not contain additional information Referred to HPI, but the HPI did not contain additional information Used diagnoses instead of signs/symptoms Used diagnoses instead of signs/symptoms Extensive ROS that was not medically necessary Extensive ROS that was not medically necessary Stated, “negative” for a presenting problem/contradicting information Stated, “negative” for a presenting problem/contradicting information Missing ROS for the system(s) related to the presenting problem Missing ROS for the system(s) related to the presenting problem

26. Past, Family and Social History (PFSH) Past History: Past history including surgeries, medications, illnesses, allergies, etc. Past History: Past history including surgeries, medications, illnesses, allergies, etc. Family History: Medical events, diseases, and hereditary conditions that may place the patient at risk Family History: Medical events, diseases, and hereditary conditions that may place the patient at risk Social History: Age appropriate review of past and current activities (use of tobacco/alcohol, living arrangements, recreational drug use, etc.) Social History: Age appropriate review of past and current activities (use of tobacco/alcohol, living arrangements, recreational drug use, etc.)

27. Past, Family and Social History (PFSH) Types: Pertinent: Pertinent: o Directly related to the problem(s) identified in the HPI o Must document at least one item from any of the three history areas Complete: Complete: o A review of two or all three of the areas, depending on the category of E/M service

28. Past, Family and Social History (PFSH) Complete: At least one specific item from two of the three history areas for: At least one specific item from two of the three history areas for: o Office or other outpatient services, established patient o Emergency department o Domiciliary care, established patient o Home care, established patient At least one specific item from each of the history areas for: At least one specific item from each of the history areas for: o Office or other outpatient services, new patient o Hospital observation services o Hospital inpatient services, initial care o Comprehensive NF assessments o Domiciliary care, new patient o Home care, new patient

29. Past, Family and Social History (PFSH) Interval History: Associated Categories: Associated Categories: o Subsequent Hospital Care Visits o Subsequent Nursing Facility Care Visits Pertains to the Past, Family, and Social History only Pertains to the Past, Family, and Social History only

30. Past, Family and Social History (PFSH) Deficiencies Used “noncontributory” under PFSH Used “noncontributory” under PFSH Double dipped (allergies) Double dipped (allergies) Extensive PFSH that was not medically necessary Extensive PFSH that was not medically necessary A complete PFSH was missing for a higher level service (new patient, etc.) A complete PFSH was missing for a higher level service (new patient, etc.)

31. History Type HPIBrief 1 - 3 Elements Extended 4 Elements or 3 or more chronic/inactive conditions ROSNone Problem Pertinent Extended 2 – 9 Complete 10 or more PFSHN/AN/APertinentComplete HISTORY TYPE PROBLEM FOCUSED EXPANDED PROBLEM FOCUSED DETAILEDCOMPREHENSIVE CCRequiredRequiredRequiredRequired

32. History Component Deficiencies The provider referred to a previous ROS and/or PFSH, but the documentation requirements were not met The provider referred to a previous ROS and/or PFSH, but the documentation requirements were not met The ROS and/or PFSH was recorded by ancillary staff or patient, but the documentation requirements were not met The ROS and/or PFSH was recorded by ancillary staff or patient, but the documentation requirements were not met Double dipped between the three areas Double dipped between the three areas

33. History Component Deficiencies The documentation guidelines for “unable to obtain” were not met The documentation guidelines for “unable to obtain” were not met Ancillary staff documentation guidelines were not met (vital signs, ROS and PFSH) Ancillary staff documentation guidelines were not met (vital signs, ROS and PFSH)

34. Examination 1995 HEAD HEAD NECK NECK CHEST CHEST ABDOMEN ABDOMEN BACK/SPINE BACK/SPINE GENITALIA/GROIN/ BUTTOCKS GENITALIA/GROIN/ BUTTOCKS RT UPPER EXT RT UPPER EXT LT UPPER EXT LT UPPER EXT RT LOWER EXT RT LOWER EXT LT LOWER EXT LT LOWER EXT CONSTITUTIONAL CONSTITUTIONAL EYES EYES EARS/NOSE/MOUTH/ THROAT EARS/NOSE/MOUTH/ THROAT CARDIOVASCULAR CARDIOVASCULAR RESPIRATORY RESPIRATORY GASTROINTESTINAL GASTROINTESTINAL GENITOURINARY GENITOURINARY INTEGUMENTARY INTEGUMENTARY MUSCULOSKELETAL MUSCULOSKELETAL NEUROLOGICAL NEUROLOGICAL PSYCHIATRIC PSYCHIATRIC HEM/LYMPH/IMMUNO HEM/LYMPH/IMMUNO Organ Systems Two sets of guidelines (Body Areas and Organ Systems) Body Areas

35. Examination Type 1995 Problem Focused – A limited examination of the affected body area or organ system Problem Focused – A limited examination of the affected body area or organ system Expanded Problem Focused (2-7) – A limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s) Expanded Problem Focused (2-7) – A limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s) Detailed (2-7) – An extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s) Detailed (2-7) – An extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s) Comprehensive (8+) – A general multi-system examination or complete examination of a single organ system Comprehensive (8+) – A general multi-system examination or complete examination of a single organ system

36. Examination 1995 Deficiencies Combined body areas and organ systems to determine complexity Combined body areas and organ systems to determine complexity Documentation supported expanded problem-focused examination not a detailed examination (billed the higher level code) Documentation supported expanded problem-focused examination not a detailed examination (billed the higher level code)

37. Examination 1997 EYES EYES EARS,MOUTH,NOSE,THROAT EARS,MOUTH,NOSE,THROAT CARDIOVASCULAR CARDIOVASCULAR RESPIRATORY RESPIRATORY GENITOURINARY GENITOURINARY INTEGUMENTARY INTEGUMENTARY MUSCULOSKELETAL MUSCULOSKELETAL NEUROLOGICAL NEUROLOGICAL PSYCHIATRIC PSYCHIATRIC HEMATOLOGIC/ LYMPHATIC/IMMUNOLOGIC HEMATOLOGIC/ LYMPHATIC/IMMUNOLOGIC Two types of examinations: General Multi-System or Single Organ System Examination Determined by the number of elements (bullets) Requirements are listed at the end of each examination

38. Examination 1997 Deficiencies The documentation requirements described under the bullet were not met The documentation requirements described under the bullet were not met

39. Examination 1995 and 1997 Deficiencies Extensive examination that was not medically necessary Extensive examination that was not medically necessary Missing an examination of the system(s)/area(s) related to the presenting problem Missing an examination of the system(s)/area(s) related to the presenting problem Used “normal, negative or WNL” notations for system(s)/area(s) related to the presenting problem Used “normal, negative or WNL” notations for system(s)/area(s) related to the presenting problem

40. Medical Decision Making: Diagnosis/Management Options Medical Decision Making is measured by: Medical Decision Making is measured by: The number of possible diagnoses and/or the number of management options that must be considered; The number of possible diagnoses and/or the number of management options that must be considered; The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed; and The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed; and The risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options. The risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options. Medical Decision Making=Medical Necessity

41. Medical Decision Making (MDM) Number of Diagnoses or Management Options Amount and/or Complexity of Data to be Reviewed Risk of Complications and/or Morbidity or Mortality Type of Medical Decision Making Minimal Minimal or None MinimalStraightforward LimitedLimitedLow Low Complexity MultipleModerateModerate Moderate Complexity ExtensiveExtensiveHigh High Complexity Two of the three elements in the table must be either met or exceeded

42. Diagnosis/Management Options PROBLEM CATEGORIES NUMBER POINT S SCORE SELF-LIMITED OR MINOR STABLE, IMPROVING, OR WORSENING MAX = 2 1 ESTABLISHED DX/PROBLEM STABLE, IMPROVED 1 ESTABLISHED DX/PROBLEM WORSENING 2 NEW PROBLEM NO ADDITIONAL WORKUP PLANNED MAX = 1 3 NEW PROBLEM ADDITIONAL WORKUP PLANNED, CONSULTATION 4 TOTAL Palmetto GBA’s Chart/Point System

43. Diagnosis/Management Options Deficiencies The documentation did not support the presence of an old diagnosis increased the physician’s work The documentation did not support the presence of an old diagnosis increased the physician’s work The assessment contained diagnoses that were not addressed/managed during the encounter The assessment contained diagnoses that were not addressed/managed during the encounter Unable to determine if the problem(s) were new or established Unable to determine if the problem(s) were new or established Unable to determine if the problem(s) were stable, worsening etc. Unable to determine if the problem(s) were stable, worsening etc. Missing an assessment Missing an assessment Unable to determine if a consult was requested Unable to determine if a consult was requested

44. Type of Data POINT S TYPE OF DATA 1 REVIEW &/OR ORDER CLINICAL LAB TESTS 1 REVIEW &/OR ORDER TESTS IN CPT 7xxxx SERIES 1 REVIEW &/OR ORDER TESTS IN CPT 9xxxx SERIES 1 DISCUSS TEST RESULTS WITH PERFORMING PHYSICIAN 2 INDEPENDENT REVIEW OF IMAGE, TRACING, OR SPECIMEN 1 DECISION TO OBTAIN OLD RECORDS, &/OR HISTORY FROM OTHERS 2 REVIEW & SUMMARIZE OLD RECORDS &/OR HISTORY OBTAINED FROM OTHERS TOTAL Palmetto GBA’s Chart/Point System

45. Type of Data Deficiencies Documented “labs reviewed” without further information Documented “labs reviewed” without further information Unable to determine if the physician/NPP independently reviewed image, tracing or specimen Unable to determine if the physician/NPP independently reviewed image, tracing or specimen Did not summarize old records or history from others Did not summarize old records or history from others Summarized old records or history from others and was documented under the HPI, but did not have documentation to support HPI (double dipping) Summarized old records or history from others and was documented under the HPI, but did not have documentation to support HPI (double dipping) Missing supporting documentation (initialed and dated report) Missing supporting documentation (initialed and dated report) Missing orders or documentation to support tests, etc. were ordered, reviewed or provided Missing orders or documentation to support tests, etc. were ordered, reviewed or provided

46. Table of Risk

47. Risk Assessment Deficiencies Used the “presenting signs/symptoms/problem” to determine the risk for “Presenting Problem(s)” Used the “presenting signs/symptoms/problem” to determine the risk for “Presenting Problem(s)” Unable to determine if the patient is having a mild or severe exacerbation Unable to determine if the patient is having a mild or severe exacerbation Unable to determine if the patient has identified risk factors Unable to determine if the patient has identified risk factors The type of procedure scheduled or performed at the encounter was not documented The type of procedure scheduled or performed at the encounter was not documented Unable to determine if a referral or decision to perform surgical or invasive diagnostic was urgent Unable to determine if a referral or decision to perform surgical or invasive diagnostic was urgent

48. Medical Decision Making Deficiencies Relied on Diagnosis/Management Options in order to determine overall MDM Relied on Diagnosis/Management Options in order to determine overall MDM Missing orders or documentation to support tests, drugs, etc. were ordered, given or provided Missing orders or documentation to support tests, drugs, etc. were ordered, given or provided

49. Counseling/Coordination of Care When counseling and/or coordination of care dominates (more than 50 percent) the encounter, time is the key or controlling factor in selecting the level of service (conjunction with Medical Decision Making) Office/Outpatient Setting: Must be face-to-face time provided in the presence of the patient Office/Outpatient Setting: Must be face-to-face time provided in the presence of the patient Hospital/Nursing Facility: Must be provided at the bedside or on the patient’s hospital floor or unit that is associated with an individual patient Hospital/Nursing Facility: Must be provided at the bedside or on the patient’s hospital floor or unit that is associated with an individual patient

50. Counseling/Coordination of Care Documentation: Duration of counseling/coordination of care Duration of counseling/coordination of care Duration of the visit Duration of the visit Sufficient documentation to support counseling/coordination of care Sufficient documentation to support counseling/coordination of care

51. Counseling/Coordination of Care Deficiencies Missing time (duration of counseling/coordination of care and/or duration of visit Missing time (duration of counseling/coordination of care and/or duration of visit Time requirements were not met Time requirements were not met Insufficient documentation of counseling/coordination of care rendered Insufficient documentation of counseling/coordination of care rendered Every encounter was based on counseling/coordination of care Every encounter was based on counseling/coordination of care

52. Split/Shared Services “Split/shared E/M services is a medically necessary encounter with a patient where the physician and the qualified NPP each personally perform a substantive portion of an E/M visit (face-to- face) with the same patient on the same date of service”

53. Split/Shared Services Office Setting: “Incident To” requirements met: may be submitted under the physician “Incident To” requirements met: may be submitted under the physician “Incident To” requirements are not met: must be submitted under the NPP “Incident To” requirements are not met: must be submitted under the NPP

54. Split/Shared Services Hospital Inpatient, Hospital Outpatient, or Emergency Department Setting If physician and NPP are in the same group practice, and the physician performs any face-to-face portion of the E/M encounter with the patient, the service may be submitted under either the physician or NPP If physician and NPP are in the same group practice, and the physician performs any face-to-face portion of the E/M encounter with the patient, the service may be submitted under either the physician or NPP If there was no face-to-face encounter between the physician and the patient (e.g., if the physician reviewed a portion of the patient’s medical records but did not “see” the patient), the service may only be submitted under the NPP If there was no face-to-face encounter between the physician and the patient (e.g., if the physician reviewed a portion of the patient’s medical records but did not “see” the patient), the service may only be submitted under the NPP

55. Split/Shared Services Deficiencies Signature requirements were not met Signature requirements were not met Performed/Billed for split/shared for a critical care or nursing facility visit Performed/Billed for split/shared for a critical care or nursing facility visit NPP was not a member of the group NPP was not a member of the group “Incident to” requirements were not met “Incident to” requirements were not met The physician did not document a substantive portion of the E/M service The physician did not document a substantive portion of the E/M service

56. Other Types of E/M Deficiencies “Incident to” requirements were not met “Incident to” requirements were not met Appended modifier 24 or 25 and the documentation did not support a separately identifiable service E/M Appended modifier 24 or 25 and the documentation did not support a separately identifiable service E/M Minimal documentation requirements were not met Minimal documentation requirements were not met

57. Tips for Communicating Audit Findings Communication, Communication, Communication Communication, Communication, Communication Pre Audit (external): Pre Audit (external): Be proactive: Be proactive: Prepare providers/staff for possibility of external audits (MACs, RACs, CERT etc.) Prepare providers/staff for possibility of external audits (MACs, RACs, CERT etc.) Discuss recent audit findings published by CERT, OIG etc. Discuss recent audit findings published by CERT, OIG etc. Perform internal audits Perform internal audits Perform internal audits on any claims selected for review (by another entity) prior to submitting documentation with Additional Documentation Request (ADR) Perform internal audits on any claims selected for review (by another entity) prior to submitting documentation with Additional Documentation Request (ADR)

58. Tips for Communicating Audit Findings Determine if you are using the appropriate guidelines (95 vs. 97) Determine if you are using the appropriate guidelines (95 vs. 97) Contact MAC (CGS) and request clarification on gray areas Contact MAC (CGS) and request clarification on gray areas Attend education events (webinars, seminars etc.) Attend education events (webinars, seminars etc.) Familiarize/Use tools, guidelines, reports and websites: Familiarize/Use tools, guidelines, reports and websites: E/M tools E/M tools Contractors websites Contractors websites CMS’ website CMS’ website Comparative Billing Reports Comparative Billing Reports Bell Curve Bell Curve

59. Tips for Communicating Audit Findings Post Audit (internal or external): Post Audit (internal or external): Provide detailed results (that are beneficial to providers) Provide detailed results (that are beneficial to providers) Provide financial results Provide financial results Remind/Educate provider of three key components and counseling/coordination of care guidelines Remind/Educate provider of three key components and counseling/coordination of care guidelines Codes are not based on quantity (pages of documentation) Codes are not based on quantity (pages of documentation) Just because a provider sees a patient once or twice a year doesn’t mean it is the highest code Just because a provider sees a patient once or twice a year doesn’t mean it is the highest code “Paint the picture” “Paint the picture”

60. Tips for Communicating Audit Findings Provide educational sessions in a group and/or 1:1 (depends on situation) Provide educational sessions in a group and/or 1:1 (depends on situation) Provide E/M weekly tips Provide E/M weekly tips Explain it isn’t how to code then document or a specific diagnoses/problem requires a specific code Explain it isn’t how to code then document or a specific diagnoses/problem requires a specific code Have the provider explain why he/she billed a code Have the provider explain why he/she billed a code Develop a plan and possible training program Develop a plan and possible training program

61. Resources Resources www.cms.gov/manuals/IOM/list.asp www.cms.gov/manuals/IOM/list.asp www.cms.gov/manuals/IOM/list.asp Pub. 100-02, Chapter 15 Pub. 100-02, Chapter 15 Pub.100-04 Chapter 12, 23, and 30 Pub.100-04 Chapter 12, 23, and 30 Pub.100-08 Chapter 3 and 30 Pub.100-08 Chapter 3 and 30 https://www.cgsmedicare.com/ohb/index. html https://www.cgsmedicare.com/ohb/index. html https://www.cgsmedicare.com/ohb/index. html https://www.cgsmedicare.com/ohb/index. html

62. Resources Resources https://www.cms.gov/Outreach-and- Education/Medicare-Learning-Network- MLN/MLNEdWebGuide/EMDOC.html https://www.cms.gov/Outreach-and- Education/Medicare-Learning-Network- MLN/MLNEdWebGuide/EMDOC.html https://www.cms.gov/Outreach-and- Education/Medicare-Learning-Network- MLN/MLNEdWebGuide/EMDOC.html https://www.cms.gov/Outreach-and- Education/Medicare-Learning-Network- MLN/MLNEdWebGuide/EMDOC.html Evaluation and Management Services Guide Evaluation and Management Services Guide Current Procedural Terminology CPT Book Current Procedural Terminology CPT Book

63. Questions