Briefing: Analyzing the Codes: How an Auditor Looks at Your Codes Speaker: Anne Burns

1. Briefing: Analyzing the Codes: How an Auditor Looks at Your Codes Speaker: Anne Burns Date: 22 March 2007 Time: 0900 - 0950

2. Objectives At the conclusion of our discussion, you will have a better understanding of: • What information an auditor is looking for • How an audit is performed • Tools and resources used to audit records

3. Analyzing the Codes • What’s the purpose of the audit? • Does it matter to the person performing the audit? • An audit can be as brief as verifying every chart has a reason for the visit (chief complaint) and that the provider signed the chart • An audit can be as complicated as auditing an inpatient record

4. Analyzing the Codes Once the reason for the audit has been decided, in order to reach a valid conclusion, the elements need to be identified that will give you that information For example: If you’re auditing a department, you may want to audit all the records over a specific period of time to get a general picture of E/M documentation and procedures performed You can isolate a specific area, such as E/M codes, to see the average level of service provided

5. Analyzing the Codes • After your sampling methodology has been determined, you need to know what your resources will be • CMS • UBU • If UBU, what version? • Will you be allowed to use a software product to assign DRGs, or will that be a manual process? • Will you be able to reference civilian sources?

6. Analyzing the Codes Is an EMR in place where you will be auditing? Are you auditing from the paper chart or EMR? Does the auditor know the system well enough to know if all coding elements (modifiers) are being captured and displayed correctly?

7. Analyzing the Codes Let’s talk some specifics! How does an auditor look at the level of service? • Look at the History section first? • Look at the Exam section first? • Look at MDM first? • Are we auditing to the ’95 or the ’97 guidelines?

8. Analyzing the Codes I go to the Medical Decision Making (MDM) first By using a table with the point system, you can objectively arrive at the level for the MDM Please refer to the MDM chart

9. Analyzing the Codes The MDM point system provides a repeatable and objective way for the provider/coder/auditor to measure the cognitive labor required to address the clinical issues of an encounter Many providers underestimate the value of their MDM because they think of “routine” as being “straightforward”

10. Analyzing the Codes The history section: Direct from HCFA: Documenting a History • "The chief complaint, review of systems, and past, family, social history may be listed as separate elements of history or they may be included in the description of the history of the present illness." • "A review of system and/or past, family, social history obtained during an earlier encounter does not need to be re-recordedif there is evidence that the physician reviewed and updated the previous information.”

11. Analyzing the Codes • This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record • The review and update may be documented by describing any new review of system and/or past, family, social history information; or noting there has been no change in the information and noting the date and location of the earlier review of system and/or past, family, social history

12. Analyzing the Codes • "The review of system and/or past, family, social history may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others." • "If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history."

13. Analyzing the Codes "The medical record should clearly reflect the chief complaint, which is defined as a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter, usually stated in the patient's words."

14. Analyzing the Codes Auditors look for: • E/M not supported by documentation • Incorrect ICD-9-CM diagnosis code • ICD-9-CM diagnosis code that does not support medical necessity • Missing modifiers • Incorrect modifiers • Forms missing from the chart • Procedures performed, but not documented • Procedures coded, but not documented

15. Q&A Questions? If you audit, what do you look for? What’s working for you? Have you devised a foolproof method?

16. Contact Information Anne Burns, CPC, PMCC 703/385-9140 annehb949@aol.com Standard Technology, Inc. 5203 Leesburg Pike, Suite 605 Falls Church, Virginia 22041