April 22, 2022 | By Grant Huang, CPMA, CPC
You’ve taken the time to complete a painstaking audit of a provider, combing through their documentation on an EHR or maybe even navigating through a handful of handwritten notes. You’ve calculated their score – it doesn’t look too good – and now it’s time for that most important step of the audit process: provider education.
What good is a carefully conducted audit, or even a carefully written audit report, if the provider who was the object of that audit doesn’t receive the proper education? Ultimately, the purpose of an audit, as part of an effective compliance program, is to assess whether providers are complying with the rules, and crucially, to implement steps that will correct non-compliance and develop better coding and documentation habits.
The role of provider education is reflected in the HHS Office of Inspector General’s (OIG) six-point definition of what constitutes the government’s idea of a compliance program, found in the OIG’s seminal document, “Compliance Program Guidance for Individual and Small Group Physician Practices.” This guidance was first published in October 2000 but remains the foundation for an effective compliance program today. The six steps are:
- Conduct internal monitoring and auditing.
- Implement compliance and practice standards.
- Designate a compliance officer or contact.
- Respond appropriately to detected offenses and develop corrective action plan.
- Develop open lines of communication.
- Enforce disciplinary standards through well-publicized guidelines.
Those last two items in this list are call for effective provider education, which will again take center stage because of major coding changes on the horizon. Recently, the AMA published a further set of revisions to its CPT guidelines for evaluation and management (E/M) services, set to take effect in 2023, that will essentially apply the 2021 E/M revisions to hospital-based E/M codes. Working in conjunction with CMS, the AMA aims to complete a total overhaul of E/M codes, which are the most heavily utilized CPT by physicians of all specialties, and now across all settings. Those providers who report E/M codes in the inpatient setting will need education on how their documentation will be impacted.
Effective provider education
When you are tasked with educating a provider on their audit results, make sure you take the following steps to ensure a successful outcome – one in which the provider will remember what you teach them and modify their behavior in response to your guidance.
- Be prepared. Review the audit results in detail so you know not only the overall gist of the errors, but specific examples (e.g. the physician has an EHR template that does not prompt for family history, thus all his E/M notes lack of family history, leading to a lot of errors, but a single fix). Memorize the audit scores so you won’t have to fumble around to find out a specific score or statistic.
- Be familiar with the provider’s specialty, patient mix, most commonly managed conditions and injuries, and all the associated procedures, treatments, medications, anatomy and physiology, and medical terminology including abbreviations. Developing a cheat sheet for these items is strongly recommended, particularly if you are new to coding/auditing a specialty.
- Acknowledge the provider’s perspective. All providers are trained as clinicians first and will tend to view compliance concerns through a clinical lens. Acknowledge that for providers, all the coding and compliance rules are secondary to their first priority, which is taking care of patients. Emphasize that following the rules will result in fewer payer audits, documentation requests, and overpayment demands – ultimately supporting better clinical outcomes.
- Be confident and authoritative about your area of expertise. When you educate providers, especially if it’s your first meeting with them, you will be evaluated for your credibility and knowledge. Remember that your coding and auditing credentials represent specialized training in areas that providers do not spend much time in. Be confident in what you do know, and if you do not know the answer to a question, don’t hedge or try to give a vague answer to avoid embarrassment. Instead, come right and say you don’t know the answer, but that you will research the issue and get back to them. If you don’t come across as credible, providers won’t take your feedback as seriously and may be reluctant to adopt your suggested changes.
Remember that all the work of auditing goes for nothing if the providers do not take on board your feedback and change their behavior. Also remember that providers are clinicians first and will respond better to feedback when you couch learning “the rules” in terms of how it will improve clinical care and quality. Below are some useful auditor principles, phrased as “I” statements, that help illustrate your role, and the role of the education you provide, in an effective compliance program:
KEY AUDITOR PRINCIPLES (“I” Statements)
- I am a clinician advocate, dedicated to reducing your compliance risk, and helping you understand the administrative, legal, and technical rules for documenting and billing your services.
- I am here to protect you, the doctor or provider, by preemptively identifying and correcting lapses in documentation or errors in coding.
- I am not here to judge your decision making, test your knowledge, or grade your performance; I am here to improve your documentation and explain the complex non-clinical billing and compliance aspects of healthcare.
- I am responsible for explaining the rules, but ultimately you will be liable because your signature will be on each medical record and outgoing claim.
- I am not a clinician, and I would never challenge your clinical judgment, but I am an expert in CPT, ICD-10, and applicable payer guidelines, therefore your notes must be written not solely for clinicians, but to satisfy compliance rules.