Bill Dunbar and Associates, LLC Presented to Indiana Rural Health Association How to Do Chart Reviews / Audits and Supp

1. Bill Dunbar and Associates, LLC Presented to Indiana Rural Health Association How to Do Chart Reviews / Audits and Supportive Coding October 27, 2010

2. Speakers Janelle Frey, RHIT, CPC,CCS-P National Dir. of Emergency Services / Regional Director of Client Services Terri L. Scales, CPC,CCS-P National Dir. of Business Development / Regional Director of Client Services A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

3. Objectives • Coding Basics • Evaluation and Management Guidelines • What is a Chart Audit? • EMR Woes • Auditing Tools • Practice Audit • Highlights of 2011 OIG Work Plan A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

4. Coding Basics • ICD-9-CM(revised October 1) • Reason for encounter • CPT(revised January 1) • Services & procedures provided • HCPCS(revised January 1) • Drugs, supplies, other services • Periodic updates throughout the year • Obtain new code books eachyear • Update billing system • Update charge documents A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

5. Who Updates Information? • Computer System • Updated internally? • Updated by software company? • Charge Documents • Do not keep out-dated forms! • Deleted codes will cause denials • Omission of new codes result in lost revenue • Coding Reference Tools • Supply Lists • DME companies may have outdated HCPCS codes on the supply boxes A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

6. Evaluation and Management (E&M) Codes • 1995 vs. 1997 • Medicare allows physicians / providers to choose either the 1995 or the 1997 documentation guidelines. • Utilize the set which results in the greatest benefit to your practice. A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

7. New vs. Established Patient • New Patient • A New Patient is one who has not received any professional services, i.e., evaluation and management service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years. • The Medicare Claims Processing Manual (Chapter 12, Section 30.6.7) A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

8. New vs. Established Patient • Established Patient • An Established Patient has received professional services from the physician or another physician in the same group and the same specialty within the prior three years. A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

9. New vs. Established Patient • Example #1 • You provided the interpretation of an EKG for an inpatient you did not actually meet in person. When you see the patient in your office (within the next three years), you would report the E/M service as a new patient code since there was no face-to-face encounter during the inpatient stay. A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

10. New vs. Established Patient • Example #2 • Consider the patient who is new to the community and needs a refill of her oral contraceptives. You agree to call in a prescription that will meet her needs until she can be seen in your office the following week. When you see her for her well-woman visit, you report a new patient preventive medicine service code since you did not have a face-to-face encounter with the patient when calling in her prescription. A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

11. New vs. Established Patient • Example #3 • In a multispecialty practice, a patient might be considered new even if he/she has received care from several other physicians in the group and a medical record is available. The distinguishing factor here is the specialtydesignation of the provider. • Patient seen by same specialty – established • Patient seen by different specialty - new A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

12. New vs. Established Patient • Example #4 • Your partner saw a patient who is new to your practice in the emergency department (ED) over the weekend. The following week you see the patient in the office. Since someone else in your practice has seen the patient within the last three years, you would use an established patient code. • This is the case even though the patient had not been seen in the office and there was not an established medical record there. A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

13. Consultation • Service provided by a physician whose opinion or advice regarding a specific problem is requested by another physician or appropriate source • Appropriate source • Physician assistants (PA) • Nurse Practitioners (NP) • Insurance company • School • Requesting provider name & UPIN must be identified on the claim with the consultation code A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

14. Consultation • Request • can be verbal or written, but must be documented in the medical record • Recommendation • consultant’s opinion & services ordered or performed must be documented in the medical record and communicated to the requesting provider • Report • communication must be in written form and sent to the requesting provider A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

15. Consultation • Example • Pre-operative clearance is an example of consultation services. A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

16. Electronic Medical Record (EMR) Woes • As EMR usage increases so will the amount paid to each physician for E&M services • Scrutiny of EMR generated coding levels will increase • Auditors are evaluating EHR documentation trends • Focus in 2011 OIG Work Plan A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

17. EMR Woes • Increase in usage of 99214 • Physicians are surprised that relatively little documentation is needed (best 2/3), e.g., • History • 4 HPI elements, 2 ROS, 1 PFSH component • Exam • 12 Physical examination bullets or Detailed Exam • Moderate complexity of medical decision making • Improved documentation associated with 99204 & 99214 A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

18. EMR Woes • 1995 Exam Guidelines too vague for EMRs to use in calculation without input from EMR user • 1997 Exam Guidelines much more suitable for automated E&M coding • Systems and bullets defined • Rules that allow determination of level are published A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

19. EMR Exam Woes Vitals: BP 124/80 (sitting right arm); P 72/min (regular, right radial); Respirations: 12/min (unlabored) Constitutional: Well nourished, well developed white male in NAD Eye: pupils round, equal, reactive to light and accommodation Cardiovascular: Regular rhythm, normal heart sounds, no gallop, no murmurs, no rubs. Respiratory: Good air entry bilaterally. No crackles, no wheezing, no dullness. Neuro: Alert & oriented x 3. DTR equal and symmetrical. Skin: Normal color and turgor. No rash. What exam level have we reached? (i.e., problem focused, expanded problem focused, detailed, or comprehensive) 1. The 1997 general multisystem examination? 2. The 1995 examination? A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

20. EMR Woes – 1997 Exam Vitals: BP 124/80 (sitting right arm); P 72/min (regular, right radial); Respirations: 12/min (unlabored) Constitutional: Well nourished, well developed white male in NAD Eye: pupils round, equal, reactive to light and accommodation Cardiovascular: Regular rhythm, normal heart sounds, no gallop, no murmurs, no rubs. Respiratory: Good air entry bilaterally. No crackles, no wheezing, no dullness. Neuro: Alert & oriented x 3. DTR equal and symmetrical. Skin: Normal color and turgor. No rash. • 1997 General Multisystem Examination = Expanded Problem Exam (6-11 bullets) • Measure 3 Vitals (1 bullet) • Constitutional (1 bullet) • Pupils & Irises (1 bullet) • Heart auscultation & sounds (1 bullet) • Respiratory effort (1 bullet) 10 Bullets • Percuss chest (1 bullet) • Orientation x 3 (1 bullet) • DTR (1 bullet) • Skin inspection (1 bullet) • Skin palpation (1 bullet) A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

21. EMR Woes – 1995 Exam Vitals: BP 124/80 (sitting right arm); P 72/min (regular, right radial); Respirations: 12/min (unlabored) Constitutional: Well nourished, well developed white male in NAD Eye: pupils round, equal, reactive to light and accommodation Cardiovascular: Regular rhythm, normal heart sounds, no gallop, no murmurs, no rubs. Respiratory: Good air entry bilaterally. No crackles, no wheezing, no dullness. Neuro: Alert & oriented x 3. DTR equal and symmetrical. Skin:Normal color and turgor. No rash. • 1995 Examination = Detailed • • Constitutional (1 organ system) • • Eye (1 organ system) • • Cardiovascular (1 organ system) • • Respiratory (1 organ system) • • Neuro (1 organ system) • Skin (1 organ system) A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

22. EMR Cautions • Which E/M Guideline is your EMR utilizing (95 or 97)? • Evaluate if the coding can be changed if needed • Override the code A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

23. Chart Audit • A chart audit is an examination of medical records (electronic and / or hard copy) to determine what has been done and see if it can be done better. A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

24. Auditors Find • If your doctor is using automation to pull information forward: • Encourage them not use default “pull forward” settings • Encourage them to manually review all information that is pulled forward to see if it is medically necessary for the current visit or pertains to the visit • e.g., Is the negative family history of cancer in a deceased relative appropriate for every visit (unless it is relevant to the encounter at hand) • Test the coding engine to see what level of documentation is needed in each section to provide E&M credit for that section A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

25. Auditors Find • The ROS is a frequent source of errors in electronic records • Weakens any medical-legal case that may arise • Physicians tend to skim over the ROS section • Make sure all information was obtained on that visit • Remove any questions that were not answered • Make sure there are no conflicts between the HPI and the ROS • Credit can be given for ROS from documentation in HPI • Evaluate if this is supported by rules engine A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

26. Auditing Tools A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

27. Auditing Tools - continued • Body Areas: • Head/Face  Neck  Chest/Breast/Axillae  Abdomen  Genitalia/Groin/Buttocks • Back/Spine  Rt Upper Ext  Lt Upper Ext  Rt Lower Ext  Lt Lower Ext • Organ Systems: • Constitutional  Eyes  ENMT  Respiratory  Cardiovascular  GI  GU • Musculoskeletal  Skin  Neuro  Psych  Hem/Lymph/Immun. A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

28. Audit Tools • E/M Bell Curves • This measurement provides a useful tool for measuring the coding knowledge of an individual or group of physicians. • It is also used to measure productivity and even the reimbursement potential of a practice. A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

29. Audit Preparation • Before beginning an audit, find out whether all your patient encounters are entered into the appointment system (including walk-ins, add-ons and nurse visits). • Compare all charge sheets from a given day with that day's appointment schedule. • Do you have a charge sheet for each patient in the appointment system? • Do you have an appointment to match each charge slip? A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

30. Practice Management Tools A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

31. Practice Management Tools A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

32. How to Conduct a Chart Audit • 7 steps to conducting a formal chart audit. • Although the process is not necessarily linear, this list represents the general steps involved. • Select a Topic (E/M levels, coding patterns, accuracy of billing, etc.) • Determine Sample Size • Select Timeline (post billing, pre billing) • Create / Obtain Audit Tools • Collect Data • Summarize Results • Analyze and Apply Results A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

33. Random Audits • Should take place quarterly • Include at least 20 patients per provider • For each patient, work with your staff to track all the reimbursement paperwork related to a date of service. • Charges are posted. • Claims are filed. • Explanation of Benefits (EOBs) from the payer are reviewed.

34. Getting Started • Produce a hard copy of your schedule for a given week. Select a manageable sample of the appointments -- for example, every fourth one -- that will include several patients from each day. Highlight those patients' names and pull their charts. A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

35. Steps • Examine the chart notes and verify that the documentation matches the service(s) identified on the charge sheet. • Charge sheet might indicate a problem-focused exam was performed, but the chart note reveals a detailed examination. • Lab & X-ray services are documented in the chart, but not identified on the charge sheet. • If Lab and X-ray services were ordered are the results in the patient’s chart? • Are the diagnoses identified in the patient’s record the same as those documented on the charge sheet? A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

36. Steps • Compare the charge sheet to the patient's ledger. • Verify that all codes are entered appropriately from the charge sheet into the accounts receivable system. • Verify that ICD-9 diagnosis codes are “linked” appropriately to the CPT codes to indicate medical necessity. • Verify that same day payments were entered into the system appropriately on the correct date. • Verify that a claim was submitted to the appropriate third-party payer. A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

37. Steps • Review the payer's EOB. • Don't assume that the insurer processes all claims correctly. • Confirm that the insurer considered all the services you submitted. • Scrutinize the EOB to confirm that any adjustments were appropriate. • Verify that your office has collected (or is trying to collect) what's owed by a secondary insurer or the patient. A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

38. Financial Impact • Tally dollar value of the discrepancies your audit reveals. Use this amount to project the financial impact of reimbursement-related errors in your practice. • Audit of 20 patient visits (one-fifth of 100 visits in a week) reveals $90 in lost revenue. • $90.00 x 5 • Potential lost revenue for this one provider • $450.00 / week • $1800.00 / month A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

39. Areas of Concern • Is one physician the primary culprit or are the mistakes distributed among several doctors? • Do errors occur most often in one particular aspect of record keeping such as the diagnosis, service code or date of service? • Is information often missing or incorrect? A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

40. Expectations? • Obviously, you want 100 percent of what's due to you, but settling for 95 percent may be more realistic. • If you find errors in more than 10 percent of audited visits, you have a serious problem that needs a well-organized solution. A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

41. Be Pro-Active • Eligibility denials • Check the patient’s eligibility before the visit by calling the insurance company’s automated line or check their Web site. • Coding errors • Use software (Claim Scrubber) that runs edits which identify errors related to bundling, diagnosis coding, units, medical necessity, modifier use, etc. A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

42. Be Pro-Active • Minor surgical procedures • All minor surgical procedure codes and descriptions that are performed by your practice should be the charge sheet / charge screen. • If not available to select, chances are it won’t get billed. • Ancillary services • If performing in-office lab & radiology services, maintain a log of all tests performed and review to make sure all tests are getting charged. A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

43. Be Pro-Active • Healthcare Common Procedure Coding System (HCPCS) • Identifies codes for medications and corresponding dosages, along with many other supplies and services. • Medications need to be appropriately documented and charged. • 40 mg of Kenalog was given • HCPCS code = J3301, 10 mg • Appropriate coding & billing for 40 mg of Kenalog • J3301 x 4

44. Highlights of 2011 OIG Work Plan for Physicians • Place of service • ASC and Hospital Outpatient Dept. • Coding and Payments for E/M services • E/M during global period A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

45. Place of Service (OIG 2011) • Federal regulations at 42 CFR § 414.32 provide for different levels of payments to physicians depending on where the services are performed. Medicare pays a physician a higher amount when a service is performed in a nonfacility setting, such as a physician’s office, than it does when the service is performed in a hospital outpatient department or, with certain exceptions, in an ASC. The OIG will determine whether physicians properly coded the places of service on claims for services provided in ASCs and hospital outpatient departments. A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

46. Coding of Evaluation and Management Services(OIG 2011) • The OIG will review evaluation and management (E&M) claims to identify trends in the coding of E&M services. Medicare paid $25 billion for E&M services in 2009, representing 19 percent of all Medicare Part B payments. Pursuant to CMS’s Medicare Claims Processing Manual, Pub. No. 100‐04, ch. 12, § 30.6.1, providers are responsible for ensuring that the codes they submit accurately reflect the services they provide. E&M codes represent the type, setting, and complexity of services provided and the patient status, such as new or established. We will review E&M claims to determine whether coding patterns vary by provider characteristics. A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

47. Payments for Evaluation and Management Services(OIG 2011) • The OIG will review the extent of potentially inappropriate payments for E&M services and the consistency of E&M medical review determinations. CMS’s Medicare Claims Processing Manual, Pub. No. 100‐04, ch. 12, § 30.6.1 instructs providers to “select the code for the service based upon the content of the service” and says that “documentation should support the level of service reported.” Medicare contractors have noted an increased frequency of medical records with identical documentation across services. We will also review multiple E&M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

48. Evaluation and Management Services During Global Surgery Periods (OIG 2011) • The OIG will review industry practices related to the number of E&M services provided by physicians and reimbursed as part of the global surgery fee. CMS’s Medicare Claims Processing Manual, Pub. No. 100‐04, ch. 12, § 40, contains the criteria for the global surgery policy. Under the global surgery fee concept, physicians bill a single fee for all of their services that are usually associated with a surgical procedure and related E&M services provided during the global surgery period. We will determine whether industry practices related to the number of E&M services provided during the global surgery period have changed since the global surgery fee concept was developed in 1992. A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

49. Internet Resources • OIG 2011 Work Plan • http://www.oig.hhs.gov/publications/workplan/2011/ • The Medicare Claims Processing Manual A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”

50. Time for Questions A Presentation by Bill Dunbar and Associates for Indiana Rural Health Association “How to Do Chart Reviews / Audits and Supportive Coding”