Internal Chart Audit Program

1. Internal Chart Audit Program

2. Overview • “A joint effort between the health care provider and the clinic staff is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.”

3. Reason For Audit • Improvement of patient care (improved documentation) • Assess performance against standards (CMS, MGMA) • Ensure appropriate payment • Recover lost revenue through unbilled services • Identify areas of risk and meet compliance standards

4. Standards • Evaluation & Service Management Guidelines • http://www.cms.hhs.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf • CMS 1995 Documentation Guidelines • http://www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf • CMS 1997 Documentation Guidelines • http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf • Medicare E/M Distribution 2008 or latest available data • Individual payer guidelines as necessary

5. Prep & Plan • Quarterly audit • Office E/M codes – retrospective & concurrent • 12 random office medical records per provider • New patient • Established patient • Consults • Audit Schedule • Advance Notification • Letter to clinic manager to notify of upcoming audit • Request for medical records and scanned documents as necessary – 2 weeks

6. Actual Audit • Audit Tool • Patient chart components to be reviewed • Progress note • Orders for lab/x-rays, etc. • Results for lab/x-rays, etc • Other documents as needed • Fee ticket used for posting charges • Code Review • CPT code level of service and over/under coding) • Diagnosis code(s) assigned according to ICD-9-CM guidelines • Documentation • All services, supplies, & diagnoses reported • Is clear, legible, signed and dated by provider and/or nurse • Codes (for procedures, labs, & supplies appropriate and valid for DOS) • Findings requiring immediate attention reported to director/manager

7. Audit Report & Education • 1 hour meeting with Clinic • Provider, group, office manager/director, nurse • Report findings of audit • Provide supporting guidelines from appropriate resources • 1995/1997 guidelines • ICD-9-CM / CPT guidelines • Copies of report to: • Provider/Group • Manager/Director • CEO/COO

8. Reports • Reports kept to identify: • Refunds • Payments received on re-billed services • All results from audits • Monthly summary • Audit activity & results presented at managers meeting • Quarterly summary • Presented to ABC Executive Committee/Board

9. When will this start? • First audit will start the week of January 1st Questions!!