Pediatric Coding Alert

Local analysis and education provide valuable lessons … literally.

In last month’s Pediatric Coding Alert, we discussed the financial and compliance benefits of self-audits. We also provided guidance on the first steps you should take to perform an audit, including discussing whether you should compare the data you gather from your own practice with national data.

In this second part of our series, we continue to look at the methodology of your analysis before providing suggestions about what you should do with your findings once you have them.

Step 3 Continued: Keep the Analysis Local …

If you are performing an internal audit for your practice’s benefit only, Jan Blanchard, CPC, CPMA, pediatric solutions consultant at Vermont-based PCC recommends a pretty simple approach that involves using internal data only. “I compare what’s billed to what’s documented and educate the practice/clinicians on the gaps I see between,” Blanchard says. “As such, I do not recommend a comparison to an outside data source. If the peds practice down the street does not see a lot of time-intensive behavior/psych conditions and your practice does, for example, you are not going to have comparable code curves,” Blanchard goes on.

“What’s material, in my opinion, is the relationship between your coding to your services and documentation. As long as your codes match your encounter and match your documentation, you’re in good shape to defend against any review,” Blanchard believes.

… Know Your Medical Terminology …

One important factor in making sure your codes, encounters, and documentation all line up is understanding how medical decision making (MDM) factors into the equation.

“Determining MDM is the most subjective part of auditing as far as I am concerned,” says Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana. “Having a medical background is extremely helpful in helping you understanding what a provider is looking for when ordering tests. This helps in determining the complexity of the MDM. So, having a provider/clinical staff helping with the audits is extremely helpful in the MDM process,” Holle suggests.  

… and Look to the 1995 E/M Guidelines

Why? “Primary care will differ from a specialty audit, and the 1997 guidelines are much better suited to specialty care,” Blanchard argues. “Even though the two are very similar, the 1995 guidelines credit the physical exam requirements according to body systems, while the 1997 guidelines credit exams according to body areas and total bullets per area,” Blanchard reminds coders.

The bottom line: “I compare the visit level documented to the visit billed, but I also compare element by element to discover which of the three key elements departed from the level billed,” Blanchard notes. This means developing a check list to make sure your documentation incorporates the right level of history, examination, and medical decision making to justify the appropriate E/M level.

Step 4: Share the Findings

Once you’ve completed the analysis, you’ll want to pass on your conclusion to the rest of your practice. “Educational sessions are vital after doing an audit so that you don’t continue to make errors and providers continue to understand what is required in documentation for each level of care,” argues Holle.

This means identifying “patterns, pitfalls, and opportunities,” according to Blanchard.

Patterns: “I paint a picture of what sorts of repeat omissions or ambiguities I saw in the selected records. These can be anything from ‘When you note the physical exam for eyes, there’s no description of normal in these 14 records,’ to ‘zero of these encounters has a chief complaint documented,’” Blanchard notes.

Pitfalls: “I make certain to share little known but common errors to avoid,” Blanchard continues. “A frequent recommendation I make is to fine-tune statements required for leveling based on time, for example. Also, I visually compare which of the three components — history, exam, or MDM — departed from the level billed. That helps practices understand whether the visit contained more that could have been documented to convey greater risk or work, or if the code selected was simply different than the visit warranted and why.”

Opportunities: Finally, Blanchard uses financial motivation to educate practices about correct coding. “In a recent audit, I identified a few hundred dollars in additional payment for just one clinician’s notes had they known they could bill a pre-op as a consult in one and bill an ortho procedure for reducing a nursemaid’s elbow in another,” Blanchard notes.