June 3, 2022 | By Pam Brooks, MHA, COC, PCS, CPC, Fellow
Federal oversight makes healthcare one of the most highly regulated industries in the United States. From a compliance perspective, that oversight poses significant risk for organizations who are unaware of the federal requirements, as well as providing opportunities for compliance professionals to intervene for the benefit of healthcare providers. We know that auditing is not limited to Evaluation and Management services. With that, the resources necessary to support audit findings related to medical records, surgical services, provider compensation, licensure, and medical necessity for certain procedures and treatments are readily available, if not universally known. Understanding the options available for published regulatory guidance can be a key resource for auditors to support their findings and make operational recommendations for compliance. The resources are many, all are available online, but there are several that should be an integral part of every auditor’s reference library.
The Code of Federal Regulations is the listing of all requirements for any industry that is federally regulated. Title 42 (Public Health) outlines the requirements that providers and hospitals must follow in order to participate in federal health programs (such as Medicare and Medicaid). Here also are the Standards of Certification, which define the operational requirements for facilities. eCFR :: Title 42 of the CFR — Public Health
Medicare Manuals (otherwise known as the Internet-Only-Manuals) outline many areas of Medicare compliance, including coverage, billing rules and claims processing, state operations, and program integrity. The information included in these manuals will help auditors support that which CPT and ICD-10 alone may not—particularly from a coverage and compliance perspective. Although not all commercial payers follow Medicare or Medicaid’s guidance, generally speaking, Medicare can be the ‘gold standard’ for operational compliance. Internet-Only Manuals (IOMs) | CMS
Local and National Coverage Determinations are published to provide information and documentation standards for certain high-reimbursement or high-utilization services. CMS and local MACs provide the rationale; correct coding/billing, documentation guidance, and service limitations for a vast number of services. This is the supporting guidance required to accompany audit results where medical necessity is not entirely met. Using LCDs or NCDs to support operational areas such as care delivery, EMR templates, and documentation requirements is critical when pre- or post-pay audits identify potential problems and is an excellent pro-active way to prevent payer recoupment. National Coverage NCD Report Results (cms.gov)
Coding Manuals such as ICD-10-CM (and PCS), CPT®, and HCPCS II are expected to be in every coder/auditor’s toolbox. The instructional notes in particular illustrate the correct and compliant ways in which these codes are to be reported. Beyond those publications, however, other resources such as the American Hospital Association’s Coding Clinic often provide clarification and rationale with regards to diagnostic coding specifics when ICD-10-CM is unclear or ambiguous, often in an easily-readable Q&A format. In the same way, the American Medical Association’s CPT Assistant provides procedure code clarification or recommendation with regards to procedure coding. Often, when citing an audit finding, there will be differences of opinion with providers and coders; clarification from either of these sources is the best way to support the correct use of codes to meet accuracy and compliance standards. Note that both the AHA and the AMA require membership in order to access these resources.
Other tools, such as the Social Security Act Social Security Act Table of Contents (ssa.gov), your State licensure organizations, your State insurance board as well as the Federal Register Federal Register :: 2022 Federal Register Index :: Centers for Medicare & Medicaid Services can also be used to support audit findings, depending on the area of interest. Be sure to cite your resources correctly and validate that the most current versions are being used. In this way, you will provide not only excellent compliance feedback to your administration, but also provide the steps to take to implement the best operational solutions for your organization.