Auditing Physician Services

Verifying Accuracy in Physician Services and E/M Coding to Protect Medical Practices

Betsy Nicoletti

• Publisher: American Association for Physician Leadership
• Year: 2018
• ISBN:
  9780998498577
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

Auditing Physician Services: Verifying Accuracy in Physician Services and E/M Coding to Protect Medical Practices, 3rd edition

by Betsy Nicoletti, MS, CPC

Take the steps to audit your practice...before the Government or Third-Party Payer does!

New for the 3rd Edition - Overall updating of all chapters PLUS:

• New! Auditing non-face-to-face prolonged services--now covered by Medicare
  
  

• Updates to TCM and CCM based on new CMS rules including the initiation visit before CCM
  
  

• New! HCPCS codes for Collaborative Care Model and Behavioral Health Initiative
  
  

• New! HCPCS code for cognitive assessment
  
  

The key topics covered include a welcome amount of in-depth coding information -- topics and activities that practices perform every week.

Protect your practice from governmental and third-party payer audits! This book explains complex reimbursement and coding rules and provides audit sheets for key, high-risk areas including E/M services.

Today, medical practices face major risks if they don’t code physician services accurately. Practices that violate the complex government regulations governing coding may face audits by the Office of the Inspector General for HHS, Recovery Audit Contractors and Medicare Administrative Contractors, and the consequences of such audits can be severe.

However, physicians and their staff now have a comprehensive guide available which helps practices audit high-risk areas themselves, before payers get involved. Auditing Physician Services: Verifying Accuracy in Physicians Services and E/M Coding To Protect Medical Practices, written by nationally-renowned coding and auditing expert Betsy Nicoletti, MS, CPC, offers critical information, support and plain-English explanations of how to avoid high-risk coding behavior.

Auditing Physician Services, provides clear, practical, concrete explanations of complicated coding issues and E/M guidelines, advice on auditing EMR notes, and a range of worksheets allowing physicians to conduct valid, defensible audits.

The book also includes a detailed analysis of the OIG Work Plan which offers insight into how the agency selects physician practices for further review.

Chapter 1

General Principles of Medical Documentation

The Documentation Guidelines provide specific criteria for billing each level of Evaluation and Management service. We use these guidelines when we audit provider records to make sure the level of service billed corresponds to the level of service documented. But few of us pay attention to the general medical records guidelines at the start of the Documentation Guidelines until a problem is identified. Sometimes, these problems come to light by way of the State Board of Medical Practice. If a patient or former staff member makes a complaint to the State Board of Medical Practice about billing or a treatment issue, the Board may review the physician’s records. A managed-care payer may identify problems with records when visiting the practice to do quality assurance audits. An employer may question a physician’s standard record keeping. Or, a new physician coming into the practice will notice records that may not be at the standard of care—records everyone else in the practice has taken for granted. When the quality of the medical record is questioned, these General Principles can provide guidance.

The emergence of electronic health records (EHR) changes the format of our medical records, solves some problems, and creates new ones. Practices that have an EHR may want to develop a set of procedures and protocols that meet the guidelines but take into account the different work processes involved in using an EHR.

Why Is Documentation Important?

The Guidelines tell us that the medical record is important because it facilitates the ability of the physician and other healthcare professionals to treat the patient over time and allows for communication and continuity of care among physicians and other healthcare professionals. An accurate medical record also supports accurate and timely claims review and payment, utilization review, and collection of data for research purposes.

Payers need information to support the claim submitted to them, including site of service, the medical necessity and appropriateness of the diagnostic or therapeutic services provided, and to know that the services provided are accurately reported on the claim form.

The Medical Record as a Whole

Assuming a paper record—an assumption that can be made less frequently each year—there are a few things I look at when I assess an office chart. (I’ll talk about EHR records and two recent OIG reports later in the chapter.) I want to see the patient’s name and one other identifier on the chart cover and on each page of the record. This identifier could be date of birth or medical records number. The practice should have a system in place to distinguish charts when two or more patients have the same name. Name alert stickers work well for this. They alert the staff member or provider who is using the chart to double check that the David Allen in front of them is the David Allen identified in the chart they are holding.

The patient’s allergies should be prominently and consistently recorded in the record.

Good paper records have up-to-date medication lists and problem lists. It sounds simple, but can require an extensive amount of work in a busy practice. The medication list is a particular problem for patients who are taking multiple drugs or being seen by multiple providers. The practice needs to be confident that the dosages and frequencies of the medications on the medication list are accurate and current. Some practices combine the medication list with a prescription renewal form; others keep this as a separate document. Most charts also have a health history sheet, which not only documents pertinent past medical, family, and social history, but also allows the providers and staff to record the dates of preventive medicine services. At a glance, a provider can tell if the patient is overdue for a tetanus shot or needs a mammogram. This not only improves quality of care, but can provide a revenue boost to a practice.

Each document in the patient’s chart should include his name and one other identifier, such as medical record number or date of birth. All pages in the chart should be affixed. That is, there should never be loose pages in a medical record. The best records have a consistent order to them and within each section (lab, progress notes, etc.), the documents are recorded chronologically. Reports and documents produced outside the office should be reviewed and initialed by the provider before they are filed in the chart.

A system must be in place to record telephone calls and the office response to the phone calls. Taking messages and recording office responses on post-it style notes is not effective without a system to permanently affix them to the chart.

All entries into the medical record should be dated and signed. If the signature or initials do not readily identify the signer, develop and use a master signature sheet. Type the name of every employee authorized to enter data into medical records. Have two date columns: date started working at the practice and date left the practice (if no longer there). Ask each staff person to initial/sign the log in her usual style and date the signature. All entries into an EHR need to be signed with the identity of the staff member. This information may be missing in the history of the present illness. I discuss that scenario later in the chapter.

The goal in this record keeping is identified in the Documentation Guidelines. All bolded sections that follow are from the Documentation Guidelines.

The medical record facilitates:

• The ability of the physician and other health care professionals to evaluate and plan the patient’s immediate treatment, and to monitor his/her health care over time; and
• Communication and continuity of care among physicians and other health care professionals involved in the patient’s care.

In other words, the care of the patient should not rely only on the physician’s memory of that patient, but on the recording of facts, findings, diagnoses, and previous treatments documented in the record. Should that physician be on vacation, leave the practice, or retire, another physician or provider should be able to take over the care of the patient using the patient chart as the source of information.

Individual encounters in the medical record also are discussed in the General Principles section of the Documentation Guidelines. They are applicable to all types of medical and surgical services in all settings. The examples in this section relate to office records, but these guidelines serve as overarching criteria for documenting all encounters with patients.

The first principle is one that we all agree with but don’t always comply with.

The medical record should be complete and legible.

Handwritten notes in the office note or hospital progress notes continue to be a problem for some physicians and providers. Handwritten notes present several problems, including legibility. If the note is not legible, no payer will consider it a reimbursable service. In addition, no one will deny the importance to patient care of notes that can be read by the provider, by the staff when the provider is away, and by other physicians and providers who participate in the care of the patient. Also, as the day wears on and additional patients are seen, the physician documents less and the handwritten notes get shorter. This affects both the quality of the record and the level of service that can be billed. Physicians who handwrite their notes rarely take the time to document all of the negative responses in the Review of Systems or all of the negative exam elements in the physical exam.

Remind physicians that legibility means more than the ability of their own partners and staff to read their writing. The note should be legible to caregivers and reviewers outside the practice as well.

If you have a provider whose handwriting is difficult to read, your practice should implement a policy to test legibility.

• The reader should be able to read along a line of writing at a regular pace. Even if every word is not decipherable, the reader should be able to understand enough to make the whole intelligible.
• If the reader needs to decipher each word, the record is not legible.
• If the clinician cannot read back his own writing after a period of time, the record is not legible.
• If healthcare professionals who do not regularly work with the clinician cannot read the record, it is not legible.

The documentation of each patient encounter should include:

• Reason for the encounter and relevant history, physical examination findings and prior diagnostic test results;
• Assessment, clinical impression or diagnosis;
• Plan for care; and
• Date and legible identity of the observer.

This second general principle of medical record documentation covers a lot of ground. Notice that the guidelines say for each patient encounter. Many times, looking at th...

Table of contents

• About the Author
• Medical Practice Compliance and the OIG Workplan
• Chapter 1
• Chapter 2
• Chapter 3
• Chapter 4
• Chapter 5
• Chapter 6
• Chapter 7
• Chapter 8
• Chapter 9
• Chapter 10
• Chapter 11
• Chapter 12
• Chapter 13
• Chapter 14
• Final Thoughts
• Appendix 1