November 19, 2021 | By Susan O’Loughlin, CPC, CPMA, CRC
Director of Professional Coding and Provider Education – UVM Health Network CVPH
Prospective, Retrospective, Random, Comprehensive, Focused…
Which one to utilize is based on the type and scope of audit for your organization.
If you are responsible for auditing your provider’s documentation, you know that there are several ways of auditing the chart notes, whether outpatient or inpatient as well as minor and major procedures and which area you are focusing on.
My personal favorite type of audit is a random audit. You may ask, why? A random audit as an educator provides me the opportunity to review the provider’s notes, and if outpatient only, are they following the new 2021 E/M guidelines and meeting the requirements for billing based on time or MDM? A random audit also allows me to gain insight into the provider’s specialty and are they documenting and assigning the appropriate levels of service, procedure codes, and coding the diagnosis codes to the highest specificity as well as capturing all that was addressed during the visit? If they are ordering tests, x-rays, lab work, are the diagnosis codes meeting medical necessity, and are they documented in the chart?
In our organization, we like to perform a ten-chart random audit for each provider, all specialties on an annual basis, as well as perform a 10-chart review for each new provider thirty to sixty days after their employment start date. For the annual audit, the focus is always on appropriate level of service based on new versus established patient, as well as the proper diagnosis coding. For the new provider chart reviews, we follow the same criteria but they can determine if the provider is in need of additional education and where his or her strengths and weaknesses are. Providers love feedback, whether constructive or rewarding!
Providers, just like any of us, do not like to hear the word audit. Whether it’s an IRS audit, accounting audit, RAC audit, just the word audit can be anxiety-producing. I like to view my provider audits as an opportunity for me to review the chart notes, look for opportunities and share communication with the provider. There may be a preventative code that is clearly being documented but the provider was not aware that it is a separately billing service! Or, perhaps they have a complicated patient, and the provider documents that he/she spent over 120 minutes with the patient, perfect opportunity for billing prolonged services. Our meeting to review the outcome(s) is a learning opportunity for both myself and the provider and a great way to establish a working relationship with your provider. A random or prospective audit should be educational, a casual meeting with the provider to learn more about their specialty, and allow the provider to ask questions that they may have been wanting to ask, but never had the opportunity. There are many tip sheets that can be shared at this time, such as a chart that contains both the 2021 guideline requirements for time and or medical decision making. Another tool I hand out to our providers is our local Medicare Intermediary E/M audit tool, and what an auditor is using to arrive at the correct level of service based on HPI, ROS (if inpatient), Exam, MDM, and the table of Risk, as well as data, reviewed.
Whether your audit is a compliance audit, or a chart review for education purposes, a summary of the work you have performed is essential. The summary should contain the scope, the actions that need to be taken such as refunding the payer, additional education needed, the services reviewed, and the findings at a minimum.
As a certified auditor, I learn something new with each review and it is rewarding to share the educational opportunities with our providers.