1. Comprehensive Health Insurance Billing, Coding, and Reimbursement Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Chapter 8 Auditing

2. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Purpose of an Audit  Assess completeness and accuracy of documentation supporting the charges.  Facilitate high-quality patient care and provide legal documentation of correct billing.  Discover lost revenue and prevent future losses.

3. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Top Coding and Documentation Errors  Upcoding: Procedure coded is more involved than procedure documented in the chart.  Downcoding: Documentation supports a higher code but coder is trying to avoid government investigation.

4. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Top Coding and Documentation Errors  Missing or unclear documentation may include chief complaint, diagnoses, tests, medication, or assessment.  Encounter form is missing, incomplete, or incorrect.  Diagnosis is incorrectly referenced.

5. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Types of Audits  Internal audit is done within the practice to ensure correct coding and compliance.  External audit is done by private payer’s or government investigator’s review of selected records.  Accreditation audit is done by managed care companies to ensure compliance with proper documentation.

6. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Private Payer Regulations  Code edits to screen for improper or incorrect reporting of procedure codes.  Rules and policies differ among private payers.

7. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medical Necessity for E/M Services  Documentation guidelines  Frequency of services  Intensity of Services  Key components of E/M selection include extent of history, extent of examination, and the extent of medical decision making documented.

8. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Preparing for the Audit  Chart selection should include ten to fifteen charts, including new patients, established patients, consultations, encounter forms, and insurance information.

9. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Preparing for the Audit  Examine encounter forms to verify completeness.  Examine EOBs to determine if billed and reimbursed codes were correct according to documentation.

10. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Key Elements of E/M Services  Level of history including chief complaint, history of present illness and past, family and social history  Level of examination, either general multisystem or single organ system  Complexity of the medical decision making

11. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Levels of History  Problem focused  Expanded problem focused  Detailed  Comprehensive

12. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Levels of Examination  Problem focused  Expanded problem focused  Detailed  Comprehensive

13. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Levels of Medical Decision Making  Straightforward  Low complexity  Moderate complexity  High complexity

14. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Tips for Preventing Coding Errors with Specific E/M Codes  High level services and the “comprehensive codes” require three key components.  Physician must re-record or annotate with specific comments any history obtained in order to be paid.  Coding subsequent services requires special attention to medical necessity.

15. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Tips for Preventing Coding Errors with Specific E/M Codes  See questions regarding consultation on page 203 of the student text.  See questions regarding critical care on page 204 of the student text.