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Physician documentation issues during an audit go beyond CDI.

EDITOR’S NOTE: This is the first in a four-part series that examines physician documentation issues as seen by an auditor.

One of the services I offer, aside from coding and billing education, is practice audits for evaluation and management (E&M) procedural services, and ICD-10-CM coding.

Lately, as auditing season is heating up, physician practices with documentation concerns contact me daily to review their clinical documentation improvement (CDI) policies so they are secure in their practices to avoid documentation issues that can lead to negative payor audits. This week, after already auditing more than 1,000 records, I wanted to have a discussion on what is important when it comes to why you could pass or fail an audit, and what I am seeing as a professional auditor, to assist you as you move forward in your administrative decisions and processes.

Before I assist clients or payers, I always request a mix of medical records for new and established patients and/or consults. Once I audit the records, they are used as educational tools for both negatives and positives for the physicians.

I have found there is an increased risk especially with electronic medical records (EMRs) to give records the appearance of being complete, due to the ability to click through review of organ systems (ROS) that maybe weren’t actually reviewed, or, for example, marking negative on an exam system that is the affected area or reason for the visit/chief complaint. This issue now makes for a conflicting record.

Example: Patient presents with back pain but the exam of the musculoskeletal system states “Negative” or “Normal.” This is a red flag to an auditor, because then they may look for other inconsistencies, as I would, and the trust that the documentation was accurate is gone. In addition, when I see different typesetting or fonts within the EMR, meaning the standard or generic electronic font is changed, and then the actual free type of the physician is added, it can look like what was actually performed was only what the physician free-typed.

Now, errors can occur on both sides—physician documentation and coding. However, CPT® and ICD-10 coding does become less risky when documentation is done properly. Unfortunately, even with pro-active CDI departments correcting documentation behaviors, it’s an ongoing process. Providers get busy treating patients with their ever-increasing volumes, and then I notice they start to forget some of the good documentation and coding behavior they were educated and trained on over time. In my experience, there is marked improved within the first three to six months after training sessions, and then the decline in accurate documentation starts to show. Many records start to feel like they were rushed to get through. 

In medical practices, it is so important to have coders, billers, and knowledgeable clinical staff to help close the gap between errors. Especially in larger practices where compliance can sometimes be at issue, it is highly recommended to self-audit first, internally, with qualified staff. Sure, it can be costly, but how much more cost would you incur if you’re audited and have to pay back not just money paid to you, but fees added on for the error? Not only that—once you are formally audited by a payer, you now have a target on your back. They may continue to watch your coding and billing habits for a long time. Enlisting certified coders and/or accredited billers has been known to be protective your practice and your physicians’, because they are protecting their reputation as well. It’s something to think about as you look at the current auditing climate, or if you are considering an external audit of documentation as well.

All it takes is 20 to 30 encounters found to have been coded one level higher than they should have been or, an ICD-10 code reported that was not found within the narrative documentation, or within the documentation. I’ve known several physicians and practices where this exact scenario has happened. The insurance company (payer) requested back approximately $45,000 in monies paid, but guess what? The actual amount paid back to the payer, after the fees, interest, and penalties were added, ended up being about $1.5 million in total.

Physicians from smaller practices say, “That’s ok, I won’t get audited.” Please don’t assume that you are untouchable for an audit. If you are a primary care physician or specialist, or if you traditionally report level 4 and 5 services, it’s not a matter of whether but when they will audit you.

In addition, assigning codes lower than what is supported by the documentation does not keep you safe from audit exposure either. That can be as much of an audit flag as coding all level 4’s and 5’s. Remember, what triggers an audit to begin with is an outlying physician, based on your geographic location and specialty. For example, if you are a general surgeon and you report a majority of level 3 new and established patient visits, but your sub-specialty is colorectal surgery, a specialty that is known to be a high-risk patient population in itself, this inaccurate coding could warrant a payer audit, or at the very least an inquiry, because it is not consistent with your peers’ coding, or patient medical necessity.

As we dive more into this topic of auditing pitfalls in this four-part series, we will next address the importance of the E&M and break it down for you in the history, exam, and medical-decision making (MDM) key elements; how ICD-10 coding may also impact an auditor’s decision; and your physician training. We will also instruct you on how to influence your physicians on these topics to make this a positive function for your overall practice health.

Part of my passion—to protect physicians at the front end—is fueled by auditing. It is imperative to really dive into and dissect the process so that there are no surprises. There is nothing more important to me than taking the business of medicine to the next level in the coding and reimbursement process in order to maintain healthy practice. We look forward to having you on Talk-10-Tuesday and follow us as we continue in this series each week for the next four weeks.

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Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC, is a healthcare coding consultant, educator, and auditor with more than 30 years of experience. Terry is a past member of the national advisory board for AAPC, past chair of the AAPCCA, and an AAPC national and regional conference educator. Terry is the author of several coding and reimbursement publications, as well as a practice auditor for multiple specialty practices around the country. Her coding and reimbursement specialties include cardiology, peripheral cardiology, gastroenterology, E&M auditing, orthopedics, general surgery, neurology, interventional radiology, and telehealth/telemedicine. Terry is a member of the ICD10monitor editorial board and a popular panelist on Talk Ten Tuesdays.

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