In most offices across the country, audits are being performed, have been performed or are slated to be performed. Some are being performed internally, some externally. In every case, there's the lingering question: what do we do when the audit is finished? My suggested answer is to educate, plan, act and revise. This process can be repeated over and over, and adjusted accordingly as one goal is met and another is sought.
Education is the main outcome of any audit. The type of audit performed will drive the type of education that will need to be provided, and to whom. In our article, we will discuss documentation and leveling audits.
I recommend that baseline education is offered to all providers before performing any audits. Discuss the nature of the audits and why they are being performed. If the audit is going to consist mainly of evaluation and management coding, go over the 1995 or 1997 guidelines with the providers, depending on which you use. If you have audit tools, show them to providers and run through a few examples using their own patient notes. Answer any questions that they have and let them know when the audits will begin. This will give all providers a chance to get used to any new documentation policies or practices before the audit occurs.
After the audits have been performed, it is time to educate again. I recommend meeting with providers individually. Go over the audit, covering good points for reinforcement and also deficiencies that were found. For every deficiency, make sure to have explanations and suggestions for improvement. Bring a copy of the E/M guidelines and any facility policies and procedure guidelines with you in case the provider has any questions or you need to clarify any points.
From a compliance standpoint, I suggest keeping a file for each provider with a copy of the audit findings and a copy of your meeting notes. Depending on how the provider performed in the audit, you may be scheduling follow-up education, a follow-up audit, both or neither. If a provider's audit is within an acceptable range for your practice, then he/she should go back into the "regular rotation" of audits (yearly, quarterly, etc.). If a provider's audit is not within the acceptable range, you will need to schedule a follow-up audit soon after your educational session. You may need to have a few more educational sessions with the provider before the follow-up audit, depending on the provider's needs.
The same procedure would be followed if you were auditing your own coders or auditors. You would meet with them and discuss any discrepancies that were found, and document the meeting.
It is also important to get input from providers, coders and auditors regarding policies and procedures, documentation barriers, system issues, etc. This will be used in the next step: planning.
In the planning phase, all of the information from the audits is gathered and common errors and issues are identified. If there were a number of common errors found, this may show a need for an education plan for the providers, coders, auditors and/or educators, depending on responsibility. For example, if different auditors are identifying the same elements in visits to different places, there may be a consistency issue throughout the practice. You want to make sure that all coders, auditors and educators are on the "same page" when viewing or discussing documentation and coding so that no matter who a provider speaks with from the practice regarding a coding or documentation issue, the answer is always the same.
Because some areas of E/M can be grey, this is where policies and procedures become vital. Were deficiencies found in the coding policies and procedures? The compliance plan and policies may need to be revised to reflect changes in the industry or changes in the office. The change in CMS policy on consultations is an example. Did you change just for Medicare, or also for some commercial insurers? Do you have clear guidelines on how to handle this issue? After any necessary revisions or additions are made to your policies and procedures, it is time to act.
In the acting phase, you will roll out the new or revised policies and procedures. Depending on how extensive the revisions are, you also may need to schedule some follow-up educational sessions to explain them. It only will hurt your practice to make changes to how you are going to evaluate providers' documentation without giving them time to adjust. Education is a continuous part of the audit process. It is unfair to expect someone to "just know" how to do it right. Time and guidance need to be given to all affected staff (physicians, managers, coders, etc.) to ensure that everyone understands and is adhering to the new policies.
You also should look for feedback on the new policies to make sure that all the kinks have been worked out. There may be some scenarios popping up that were not thought of when work was being done designing, updating or changing your policies. This leads to the final phase...
In the final phase, you will need to go back and make any necessary changes. Feedback from the providers, coders and auditors should be assembled, and any deficiencies should be addressed. The policies that require revision should be revised. Compliance plans, policies and procedures are like living things. They aren't "one and done" concepts. You always will be revising and changing plans and policies because CMS healthcare policies and those of other payers are always changing. A flexible attitude is imperative: as with all things in our field, once we have everything where we want it, it is time to start all over again!
About the Author
Betty A. Johnson, BA, CPC, CPC-I, CCS-P, PCS, RMC, CIC, CCP, CPC-H, CDERC, is the regional director for AAPC Physicians Services. Johnson is a healthcare consultant with more than 20 years of experience in physician coding, billing, auditing and education. She holds a BA in healthcare administration. In addition, she has many years of practice management experience in a variety of healthcare specialties.
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