June 6, 2011

Upon Closer Inspection…
By Annie Macios
For The Record
Vol. 23 No. 11 P. 14

By implementing a chart auditing program, healthcare organizations can rest easier knowing their documentation is receiving the once-over.

Lately, many healthcare facilities and physician practices are borrowing a mantra from the Boy Scouts handbook: Be prepared.

Chart auditing programs have become more important in light of an increase in federal payer audits. As a result, many physicians and health systems want assurance their documentation will withstand scrutiny, while others seek a refresher in best practices. A strong internal chart auditing program can help ensure sound documentation, making it easier for healthcare organizations to capture missed revenue and improve patient care.

Audrey Howard, RHIA, a senior consultant with 3M Health Information Systems, believes chart auditing is important on several levels. “It used to be that chart auditing was done to evaluate DRG [diagnosis-related group] issues that could lead to incorrect coding and reimbursement, but now audits are used to make sure everyone is in compliance and that records are coded in a way that can withstand an external audit,” she says.

Likening coding to the tale of “Goldilocks and the Three Bears,” Howard says the results should be “not too much [overcoding], not too little [undercoding], but just right,” adding that a successful chart auditing program incorporates consistency, accountability, and the ability to track information.

For Hospitals
One major goal of an internal audit is to educate coders on performance levels, Howard says. The results can offer coding managers clues to areas where the department may be falling short.

“For an internal audit, audit a consistent sample of each coder’s work. Then you can review the audit results on a monthly basis and track and trend findings. Sometimes you might find problems with a particular coder or the same mistakes occurring across the board for one particular DRG. By knowing what the problem is, it makes it easier to tailor education and provide support to correct those problems,” says Howard.

In addition to a sampling of each coder’s work, facilities can perform focused reviews of specific DRGs. During this process, internal auditors focus on a specific DRG on a prebill basis, search for inconsistencies, and track and trend results. Howard says an audit should also contain random DRGs, records, length of stay, and patient types for review.

Kathy Johnson, RHIA, vice president of coding quality and compliance services at Care Communications, says chart auditing examines not only coding practices but also interface issues associated with the interoperability of a facility’s software application, which impacts quality of care, patient satisfaction, and revenue. Being receptive to reviewing areas beyond coding helps a facility receive a better return on investment from its chart auditing program, she adds.

For example, attending physicians may visit patients twice in the hospital. Plus, hospitalists may see the patient a couple times. “That is four visits for stable patients. Something like that may be identified in a review process with an impact on patient care as well as revenue,” Johnson says.

She adds that it is important to examine the consistency of medical records for not only what information is included but also to ensure they are filed in the same place so they are accessible across the continuum of care. For example, patient care can be affected if diagnostic test results are not recorded in a timely manner and kept in a location that offers clinicians easy access.

When Johnson conducts an inpatient client review, it features a full chart audit, including documentation and coding, plus a check on the present-on-admission indicator. The accuracy of that indicator, she says, will often determine whether the chart accurately reflects the patient story as well as proper reimbursement.

Physician education is another key to success. Howard suggests physician querying should be a part of the chart auditing process. “Having a query process in place is very important, and it should include a retrospective query process and possibly a concurrent query as well. Getting the query to the physician to obtain clarification prior to final coding is key,” she notes.

Howard also recommends creating a set of audit policies and procedures to help ensure compliance. “That way you can track information, making everyone accountable for the work they do, which will ensure consistency throughout the process,” she says.

In regard to improving patient care via chart audits, Howard believes a concurrent review program makes the most sense. Anyone reviewing the record across the continuum of care can recommend and address issues that surface while the patient is still in the hospital.

While maximizing reimbursement remains the main driver behind the implementation of chart auditing programs, many facilities are becoming increasingly concerned with compliance issues and whether physician documentation supports a DRG.

One advantage of having an internal review process is that it allows a facility or a physician to self-report and correct any documentation that might be lacking. On the other hand, an external review boasts the objectivity of a third-party evaluation. “Having both allows for greater preparedness for when an external payer auditor comes in. The expectation is that the review must be thorough,” says Johnson.

The arrival of recovery audit contractors (RACs) has put more emphasis on preparedness as the frequency of reviews has intensified, with greater attention being paid to chart audits. “The breadth of the [RAC] review is pretty expansive, but it also allows people to say, ‘We have been able to rectify ourselves.’ It isn’t a matter of if a RAC will review but when. It’s just a part of the way we conduct business today,” Johnson says, adding that external auditors are looking at not only whether a facility has a program in place but also how effective it is.

For Physician Practices
Johnson says chart auditing is approached differently in a physician practice compared with a hospital setting. In a physician office, reviewers work more closely with the provider whereas in a hospital they are also working with other departments that support the clinician. For example, a hospital coding department will receive feedback as will HIM staff if it involves an interoperability issue.

Feedback is an essential element of the audit process in physician practices, Johnson says. “In a physician’s office, you can interact directly with the provider and have the opportunity to look at things very objectively and share that with the physician,” she notes. “It is always nice if you do a review where you discover they’re doing a good job and you can really reinforce their practices and make sure they are maintaining that performance.”

Peggy Stilley, CPC, CPMA, director of audit services with AAPC Physician Services, an affiliation of AAPC, works with physicians and other providers to analyze whether the documentation of evaluation and management (E/M) services, and surgical and office procedures meets established guidelines, including those of Medicare and Medicaid.

“I compare what the practice billed with what the provider has in the record, looking at documentation guidelines and the nature of the patient’s presenting problem compared to what should have been billed by the provider,” she says.

Stilley says an audit can determine where the physician is falling short in terms of documentation or whether cases are being overdocumented based on the complexity of a patient’s condition. “For example, if a patient presented with a problem with low complexity, you could not support the service with a high level of documentation because it is not considered medically necessary,” she explains. “Conversely, if there is moderate complexity and the physician fails to document adequate history and/or exam, he’s not able to bill the higher level of service.”

The key components of E/M services are history, exam, and complexity of decision making. “Providers have an idea going into the encounter of its complexity and must capture adequate details in the documentation to bill appropriately,” says Stilley. “If it isn’t documented, you cannot prove the service was provided.”

A chart audit can have implications for patient care standards. Examining the patient based on how he or she presents, whether the encounter was dated and signed by a physician, adequate documentation of the procedure, identifying the location of service, and the patient’s status when sent to recovery are all important chart elements that can affect care.

After conducting an audit, Stilley provides a detailed report based on CPT guidelines and documentation standards. She also schedules a review to evaluate the findings and discuss the results with the provider. “Most physicians understand and want to be accurate in their documentation and are receptive to it and will say, ‘I did x, y, z for the patient’ and I will tell them I have no doubt they did that, but they didn’t write it down. What you document is critical to the clinical story you are telling,” Stilley says.

Being descriptive is no crime when it comes to patient records, Stilley says. “Detail—using adjectives, descriptors—is invaluable to the record, including giving a description of a patient’s presenting problems and then examining the patient and describing your findings and your plan of care,” she says. “Payers want you to support what you do with documentation.” Because physicians need to see more patients to make up for lower reimbursement levels, it is critical they develop efficient documentation methods.

Stilley recommends physician practices perform annual audits. If issues are identified, more frequent audits could be warranted, depending on the compliance level. Training or shadowing sessions for the provider can also be helpful to more accurately capture the clinical story.

Federal auditors are on the lookout for outliers—physician practices that are consistently billing at higher or lower levels than their peers—or those for whom they receive patient complaints.

“I sometimes find physicians bill at lower levels to stay under the radar,” Stilley says. “This also sends a message to peers by resulting in a loss of revenue. Overbilling is more frequent, possibly because they were taught incorrectly regarding documentation or they might have an EHR that creates a higher level of service than what is actually performed. But I believe that most are trying to document correctly.”

There are instances, however, where, because of specialty (ie, cardiology, rheumatology), physicians simply have sicker patients, resulting in higher levels of service.

No matter the circumstances, Stilley says good documentation is always the best defense. If medical records are accurate, physicians can feel confident they have the necessary “evidence” to support the services they are providing and being compensated for.

Because establishing an auditing program can be overwhelming, Johnson recommends approaching it incrementally by focusing on high-dollar areas or areas where the practice might be most vulnerable due to case mix or the complexity of patients’ care. Many organizations have success with auditing programs by recognizing their problem areas and targeting them for improvement.

Johnson believes EHRs, which impact workflow and how information is shared, are changing the machinations of documentation, but the objective remains the same: to clearly reflect a patient’s history and the level of service provided.

“There have been a lot of changes in guidelines recently and as the changes occur, facilities must make sure all the systems that various departments are using enable data to flow across the system,” she says. “If there is just one area causing the data not to flow, it is important to find that and fix it. Sometimes you might catch an interface problem because of an increased incidence of denials for a particular type of claim. It’s always better, though, to catch them before they are denied.”

— Annie Macios is a freelance writer based in Calgary, Alberta, Canada.