Oncology & Hematology Coding Alert

In the day-in-day-out battle to stay compliant with reimbursement regulations, oncology practices best tool remains the routine chart audit. Nevertheless, many practices especially the small- and medium-sized ones still refuse to perform checks of their billing habits because of the time and effort.

The way I look at chart audits, its a method to identify weaknesses in your reimbursement processes and procedures. You can use it to educate your physicians and staff, says Mike Lewis, healthcare consultant with Wheaton, Ill.-based Mathieson Moyski Celer & Co. CPA, an accounting firm that provides reimbursement services.

The publication of compliance guidelines for physician practices is another compelling reason for oncology practices to implement chart audits, says Elaine Towle, practice administrator for New Hampshire Oncology and Hematology, an oncology practice in Hooksett.

Similar voluntary compliance guidelines published by the Office of Inspector General (OIG) for other segments of the healthcare industry have recommended that providers implement systems to ensure billing accuracy and the reporting of billing errors.

Performing a chart audit is a straightforward process. Just follow these four easy steps:

1. Senior staff randomly selects a sample (at least 10 to 15 records per coder) each week and reviews them for accuracy. The auditors request copies of payment information for these claims to ascertain how the primary codes crossover to the APC assignments. At the same time, they review physician documentation, which allows them to
select which doctors need orientation on the new
requirements for outpatient coding.

2. The business office makes copies of the pages in
the Medicare remittances that illustrate claims where coding problems exist, sends these back to the coders, and possibly, the providers to address errors or deficiencies.

3. The facility documents outcomes and error rates,
then advises coders of errors and asks them to
review coding policies relevant to the errors.

4. Focused audits also may be necessary on hot
coding spots i.e., critical care, modifiers,
observation, high-end procedures, etc.

For oncology practices, the bulk of the audits should focus on evaluation and management (E/M) services. Further scrutiny of charts should include a review of common procedures and their documentation.

Many practices will find billing deficiencies that either garnered payment for services that arent supported by available documentation or services that were undercoded, Lewis says. Errors cant be corrected until they are found. Typically, oncology practices will find the following errors in their billing and documentation:

level-four and level-five E/M service claims not
supported by documentation;

billed consults that dont meet the criteria;

deficiencies in the medical record, such as missing
notations that would support medical necessity;

billing for chemotherapy administration performed
in a hospital setting.

According to Towle, chart audits should be conducted routinely, randomly pulling five to 15 charts per month for each physician in the practice. Risk managers or practice administrators can act as in-house auditors. More important, however, practices should establish policies that outline how errors will be handled, including sanctions on physicians who continue to bill incorrectly despite repeated warnings and educational programs.

Audits can be done retrospectively or prospectively. Retrospective audits look back at a sample of each physicians charts after the claim has been sent. In addition, they must be accompanied by policies that outline how discovered errors are handled, such as self-reporting the error to payers and refunding money from an erroneous paid claim. If you find yourself having to self-report, you could be opening yourself up to a full audit, Lewis says.

On the other hand, a prospective audit looks at a sample of charts prior to claims being sent. If there are errors, they can be caught before the bill goes out, avoiding the potential of having to self-report an incorrectly coded claim.

Lewis says practices can use spreadsheet programs for random selection, and software is available to ensure the selected claim is suspended until the chart audit has been completed. By doing prospective audits, you can avoid sending out improper claims, he says.

In the charts themselves, Towle says, making sure documentation supports a claim should be the primary focus. Trouble areas in E/M service documentation likely will be in obtaining the proper histories, such as past family, social and medical history, to support level-four and level-five claims. Oncology practices also should concentrate on chemotherapy administration codes, including the documentation of start and stop times and proving medical necessity of ordered tests.

Practices also should pay close attention to the documentation of systems review and reason of visit. Its an easy thing that sometimes gets missed, she says.

To take the guesswork out of determining the proper level of documentation, Lewis recommends physicians use a paper template to prompt needed questions. For example, the template should include a checklist of histories history of present illness, family history, past history and social histories so the physician is reminded to ask the questions that are needed to fulfill each requirement.

As soon as a practice has a baseline from which to begin its improvement process, audits should be performed regularly to track whether physicians and staff are complying with newly implemented processes designed to eliminate billing errors.

Before routine chart audits are implemented in a practice, however, Lewis recommends that practices conduct a risk assessment to establish a baseline or snapshot of a practices current strengths and weaknesses.

Risk Assessment

A risk assessment is essentially an audit on a wider scale. The results of the risk assessment are formalized in a report that is used as a measuring stick against future progress. The risk assessment gives you a framework, says Lewis. You know what you have to think about in order to improve.

Lewis recommends that practices hire a third party ideally through an attorney to conduct the risk assessment. By using an attorney, the results of the risk assessment become protected under attorney-client privilege. Moreover, the use of a third-party auditor promotes the appearance of an independent review rather than an exercise with a hidden agenda.

The risk assessment should consist of randomly choosing 10 non-Medicare and non-Medicaid charts per physician and auditing five of them to review E/M service billing patterns. A separate 10 non-Medicare and non-Medicaid charts per physician should be randomly chosen with five audited to look at common procedure codes, such as 96400-96549 (chemotherapy administration) 88170 (fine needle aspiration with or without preparation of smears, superficial tissue) and 88171 (deep tissue under radiologic guidance). To decide which procedures to examine, Lewis says, practices should look at their latest procedure reports to find the most frequently billed procedure codes.

Because many oncology practices are using nurse practitioners and physician assistants, their work also should be part of any risk assessment and chart audit program, Towle adds.