OMG IT IS OIG !!! WILL YOU BE READY?

1. OMG IT IS OIG !!! WILL YOU BE READY? Presented by Lynn Graham, CPC Revenue Cycle Manager

2. What is the role of OIG • What does OIG stand for? • Who do they do Audits for? • What is a Work plan? • What is a Whistleblower?

3. CIA • What does CIA stand for? • What is the purpose of the CIA? • Does OIG endorse or assist a provider in choosing an independent Review Organization?

4. The Audit Process • Where do you begin? • Can you ask for assistance? • How do I know if I am correct?

5. Auditor must be a detective • An auditor must look beyond the point system and look at the medical necessity for the patient encounter from the presenting problem to the data documented in the history, the exam performed, and all elements of the patient assessment along with the plan of care.

6. What Do Auditors Look For? • Place-of-service misrepresentations • Monitor your denials • Do not look only at documentation when submitting claims • Modifier usage • Time based

7. Coding • CPT-4 AND ICD-9 CODES • The Doctor Always Uses The Same CPT Code • The Doctor Always Uses The Same ICD-9 Code • Drill Down To Find The Most Appropriate Codes • Soon to be I-10

8. Documentation • What do you have to work with? • Encounter Forms • Progress Notes • Lab Studies, X-rays • Down in the list • Medication List • I assume I know what the doctor means • If it is not written, it does not exist

9. Guidelines for Coding and Documentation Compliance • Was the patient in the office on the date of service? • Does the physician charge too many of any one particular code, while not charging any of a very common code for the specialty? • Was the amount charged for the office visit and procedure(s) reasonable for the services rendered? • Can every chart stand up to an audit?

10. CONSULTATIONS • CRITERIA FOR CONSULTATIONS: • Difference is in the verbiage • Consult: • Request for an “OPINION” • Requires: Verbal or written request • Must be followed up with a letter to the requesting physician • The letter should state: the opinion • Remember the 3 “Rs”: Request, Render and Report • CAREFUL WITH VERBIAGE: • Thank you for allowing me to participate in this patient’s care –indicates it is now transferring care to the to the physician and is no longer a consultation • VS • Patient was seen by me today and the diagnosis is….. I started the patient on a regimen of XXXXX. The patient will return to see you… if I may be of further assistance, please do not hesitate to contact me.

11. Critical Care Servicesshould be documented in the record services influenced in critical care when performed by the provider providing critical care include: cardiac output measurements, chest x-rays, pulse oximetry, ABG’s and data stored in computers, gastric intubation, transcutaneous pacing, ventilator mgt, and vascular access procedures. Time is bedside and unit time in care of that patient. Time does not have to be continuous. Time spent performing separately reportable procedures or services should not be included in the time reported as critical care. Care to the patient during critical care time is exclusive to that patient. Time

12. Quality Assurance in the Medical Record • General Charting Protocols • Is there evidence the patient demographic form has been updated? • Are there “scratch” over on the patient demographic form? • Is a patient found in the software system? • Is a copy of the current insurance card in the system? • Is the patient’s ID (full name) on every page? • Is each encounter dated? • Does the date in the medical record correspond with the date on the encounter form? • Is the medication / problem list current?

13. HIPAA • Sets a national standard for accessing and handling medical information • National standards include the right of the patient to – See, copy, and request to amend their own medical records • Health care providers, health plans, and other health care services have to abide by the minimum standards set by HIPAA • Provider can charge for copies of records – HIPAA sets limits on the fees

14. Few HIPAA Requirements • Consent must state that the individual has the right to request restrictions on the use and disclosure of his or her personal medical information, but it must also state that the covered entity may refuse the request.

15. Deciphering the physician note

16. Common EMR/EHR pitfalls

17. It is all in the approach Audit is an opportunity. • An Audit is not an accusation • Auditor’s role • Advocate to the coder and provider • Educator • Trainer • Attitude • Communication among various departments • Written communication • Do not overwhelm for the provider

18. Resources • Publicly available on the HHS OIG website: http://oig.hhs.gov/reports-and-publications/archives/workplan/2014/work-plan-2014.pdf Provider Compliance Training http://oig.hha.gove/compliance/provider compliance-training/index.asp