1. From Registration to Accounts Receivable – The Whole Can of Worms 2007 UBO/UBU Conference 1 Briefing:Basic Skills for Coding Auditors Date: 21 Mar 2007 Time: 0800 - 0850

2. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2 Identify the most appropriate form of audit Identify the most common errors in the MHS for – E&M – CPT procedures – HCPCS – ICD-9 Apply audit results to correcting coding Objectives

3. 2007 UBO/UBU Conference From Registration to Accounts Receivable 3 Why Audit Why? To determine the confidence you will place in your data – If you look at documented telephone calls, do you need more doctors or nurses? – What is needed more, a diabetic nurse educator or a physical therapist?

4. 2007 UBO/UBU Conference From Registration to Accounts Receivable 4 Types of Audits Random – To identify possible coding issues – Each record in the entire field of records has an equal chance of selection Targeted – To identify the actual issue – To identify size of issue – Records with certain attributes are selected Telephone calls A specific doctor Trained by a certain AHLTA trainer A specific clinic All records with a specific diagnosis

5. 2007 UBO/UBU Conference From Registration to Accounts Receivable 5 How to Select Type of Audit Determine your objective – Clean up a number of errors quickly Look at aggregate data, such as all CPT/HCPCS by MEPRS for a month, sorted by quantity – To know if a new provider needs additional one-on- one training Random selection of his records for the past month – To see which clinic needs the most help Aggregate data of clinics – Look at percentages of codes, for instance, for most clinics, E&M should have 5-20% new office 5-10% physicals 1-10% telephone calls 1-15% consults 10-80% established office

6. 2007 UBO/UBU Conference From Registration to Accounts Receivable 6 Protected Health Information Appropriately dispose of copies of records with patient identifying information – Anything linking patient and diagnosis – Anything with SSAN When collecting data, be sure to be able to produce the original documentation again – Usually done by annotating the EDIPN or Pseudo- SSAN on the data collection form along with date of encounter and name of clinic

7. 2007 UBO/UBU Conference From Registration to Accounts Receivable 7 Sample Size Statistical significance is for large numbers, not small For statistical significance, check all, up to 139 for a reasonable confidence level – Meaning if you only have 17 encounters all month, you must do all of them – If you have 240 encounters in a month, 139 RANDOM records – If you have 2,400 encounters in a month, 139 RANDOM records

8. 2007 UBO/UBU Conference From Registration to Accounts Receivable 8 Trends A person will tend to code in the same manner in which he or she has always coded unless acted upon by an outside force Without feedback, coding will not change Unless time is a variable, it can not be used to determine a trend 8 data points using data related by a variable determines a trend

9. 2007 UBO/UBU Conference From Registration to Accounts Receivable 9 Displaying Data What does this tell you?

10. 2007 UBO/UBU Conference From Registration to Accounts Receivable 10 Displaying Data There were more errors to find in April? Errors are going up? Nothing?

11. 2007 UBO/UBU Conference From Registration to Accounts Receivable 11 Displaying Data Nothing So you found more errors in April. Time is not a variable so there is nothing to be learned from this chart I audited 15 charts in Jan, 100 in Feb, 200 in March and 1,000 in April – so... – 100 % errors in January – 20 % errors in February – 8 % errors in March – 3 % errors in April

12. 2007 UBO/UBU Conference From Registration to Accounts Receivable 12 Identifying common errors in: – Evaluation and Management coding – CPT codes – HCPCS codes – ICD-9 Codes – Top coding errors Errors

13. 2007 UBO/UBU Conference From Registration to Accounts Receivable 13 Legal Medical Record Federal Rules of Evidence Rule 803. Hearsay Exceptions; Availability of Declarant Immaterial The following are not excluded by the hearsay rule, even though the declarant is available as a witness: (6) Records of regularly conducted activity. A memorandum, report, record, or data compilation, in any form, of acts, events, conditions, opinions, or diagnoses, made at or near the time by, or from information transmitted by, a person with knowledge*, if kept in the course of a regularly conducted business activity, and if it was the regular practice of that business activity to make the memorandum, report, record or data compilation, all as shown by the testimony of the custodian or other qualified witness, or by certification that complies with Rule 902(11), Rule 902(12), or a statute permitting certification, unless the source of information or the method or circumstances of preparation indicate lack of trustworthiness. The term "business" as used in this paragraph includes business, institution, association, profession, occupation, and calling of every kind, whether or not conducted for profit.Rule 902(11)Rule 902(12) *emphasis added to “a person with knowledge”

14. 2007 UBO/UBU Conference From Registration to Accounts Receivable 14 “…a person with knowledge…” If a patient comes in for a suture check, which is done by the technician without the presence or direct supervision of the provider, and documented by the technician, – But not signed by the technician – And the only signature on the document is the provider’s signature Is this a legal medical record?

15. 2007 UBO/UBU Conference From Registration to Accounts Receivable 15 Legal Medical Record No, It is not Counter signatures – The individual doing the documentation signs which he or she documented – Another privileged provider reviews the documentation and annotates the reason, such as “reviewed and concur with,” and then signs Initials are to be avoided unless there is a signature sheet in the record or the name and initials were used in another nearby entry so the documenter is always is obvious to a reader

16. 2007 UBO/UBU Conference From Registration to Accounts Receivable 16 MOST Common Outpatient “Error” An encounter done by someone other than the individual whose name is on the Standard Ambulatory Data Record – Telephone calls where only the nurse spoke with the patient Nurse telephone triage Telephone calls to the clinic Nurses calling to provide anticipated laboratory results (e.g., negative strep) – Other nurse only encounters, such as for management of long term anticoagulation therapy – Physical therapy done by a technician but coded under the physical therapist’s name

17. 2007 UBO/UBU Conference From Registration to Accounts Receivable 17 MOST Common Outpatient “Error” How to identify: – Check documentation for handwriting variations – See if every similar encounter has similar documentation If a provider is actually speaking with different patients, there will be secondary issues for some patients but nurses following a protocol cannot address new issues Work with your patient advocate, many locations will have a certain percentage of patients called as follow-up to obtain patient satisfaction data – ask for a list of encounters where the patient denies having had an encounter with a provider For physical therapy, check that all technicians have approximately the same amount of work, usually between 4 and 8 hours of patient care

18. 2007 UBO/UBU Conference From Registration to Accounts Receivable 18 Other Common CPT/HCPCS Errors Referrals (which should be coded as new or established office visits) coded as consults Telephone calls which are really continuations of prior encounters Uncoded ambulance runs Supplies coded in the Emergency Department Encounters done by residents coded under the supervising provider Overseas clearances coded as something

19. 2007 UBO/UBU Conference From Registration to Accounts Receivable 19 Other Common CPT/HCPCS Errors How to identify: Referrals – check that there are new office visits (e.g., 99201-99215) in all clinics with office visits (e.g., would not expect in PT, OT, or Nutritional Medicine) Telephone calls which are really continuations of prior encounters – check if the patient had an office visit the same day or the prior day Uncoded ambulance runs – check the ambulance logs to ensure every patient transported, who was not an inpatient, has a coded encounter Supplies coded when they are standard supplies – ask for a report of CPT/HCPCS for the month by MEPRS code

20. 2007 UBO/UBU Conference From Registration to Accounts Receivable 20 Specific CPT/HCPCS Errors Anesthesia – Usually not coded to most specific anesthesia code – When there are multiple procedures, not using the anesthesia code with the highest base units – Wrong location Screenings vs. Therapeutic/Diagnostic – Colonoscopies Not coding the separately identifiable E&M on the same day, and if coded, missing the modifier 25 For one Service, unbundling laboratory procedures (and not using modifier QP)

21. 2007 UBO/UBU Conference From Registration to Accounts Receivable 21 Common Diagnosis Errors Elevated blood pressure vs. hypertension Acute nasopharngitis vs. viral syndrome Missing external causes of injury Observation for condition not found Coding an unconfirmed, possible, probable diagnosis instead of symptoms for outpatients

22. 2007 UBO/UBU Conference From Registration to Accounts Receivable 22 ICD-9 – Specificity – History codes – Co-morbid conditions – Aftercare – Invalid linkage Top Coding Errors

23. 2007 UBO/UBU Conference From Registration to Accounts Receivable 23 Top Specific Coding Errors ICD __________________

24. 2007 UBO/UBU Conference From Registration to Accounts Receivable 24 Top Specific Coding Errors E&M __________________

25. 2007 UBO/UBU Conference From Registration to Accounts Receivable 25 Top Specific Coding Errors CPT __________________

26. 2007 UBO/UBU Conference From Registration to Accounts Receivable 26 Top Specific Coding Errors HCPCS __________________

27. 2007 UBO/UBU Conference From Registration to Accounts Receivable 27 Training – Get to the new provider first – don’t let another provider teach him or her bad habits – Do a 5-minute coding update at every professional staff meeting – make them funny Comply with DoD Coding Guidelines Standardization Follow-up Coding Errors – Cures

28. 2007 UBO/UBU Conference From Registration to Accounts Receivable 28 Why Audit Types of Audits Reporting Findings Common Errors Summary

29. 2007 UBO/UBU Conference From Registration to Accounts Receivable 29 Quiz What common errors are associated with: Patient has blood pressure of 165/100 Screening colonoscopy, normal risk Diabetic foot check on normal foot Suture check

30. 2007 UBO/UBU Conference From Registration to Accounts Receivable 30 Quiz Is time usually a variable for audits? What is usually a variable for audits? – Was there training? – Did you update a cheat sheet? – How many records were reviewed? – Was the audit random? – Did a new provider come? – Did a certain provider leave? – Did you get a new coder in the clinic?