Urology Coding Alert

Audits:

Handle Common Audit Issues by Developing Robust Audit Program

Published on Tue Oct 12, 2021

Hint: See which barriers you must overcome.

During the 2021 RISKCON session, “Effective Audit Program for Risk Adjustment,” Donna Malone, CPC, CRC, AAPC Approved Instructor, shared helpful information you can apply when you are developing an audit program in your practice. For example, you can learn the best way to educate your providers to improve documentation.

Here’s how to apply Malone’s insights to your urology practice — today.

Tip 1: Observe Common Barriers to Developing an Audit Program

You may encounter certain barriers when you work on developing your audit program, according to Malone. These barriers include the following:

Barrier 1: Not enough staff: Rethink who you have on board, Malone said. You must make sure your change with the times and are not just continuing the norm of what you have done for years and years.

Value-based care is not going away, and it’s expanding quite rapidly, according to Malone.

The key, Malone said, is training people across the board.

We must train our coders and billers we have on staff holistically, Malone explained. We cannot keep the same mindset of a of fee-for-service driven perspective.

Barrier 2: Potential financial impact: Correcting errors could result in a financial loss, Malone said. We must also understand that not all “deletes” constitute a revenue adjustment. However, this should never be a reason why you don’t perform audits.

“We have a responsibility to the patients we manage,” Malone said. The patient complexity we are messaging to the government programs must be accurate. We don’t want it to be underrepresented, and we don’t want it to be overrepresented.

Barrier 3: Lack of focus on all contracts and contract components: It’s really challenging working with organizations, Malone said.

There is still a high focus on fee-for-service, which we still need to do because that doesn’t go away, but we also need to understand that the organizations we work for are dependent on all the contracts we are involved in to be utilized as robustly as possible, according to Malone. When that doesn’t happen, we are not getting the adequate reimbursement to help us manage our patient population.

Barrier 4: Coder and/or biller training: “We focus a lot on provider training, which we will continue to do, but we also need to make sure we are educating our coders and billers across the continuum and aren’t just focused on one component,” Malone said. We may hear people say something like “That’s not my job.” We may focus a lot on making sure that medical necessity is taken care of, and that’s important, but understanding the whole picture is also important.

Tip 2: Know How to Choose Cases to Audit

When you are developing a strong audit program, you will choose cases to look at, Malone said. You should include a mixed case selection based on both a random and targeted approach.

Random review: So, you can do a true random selection where you randomly choose 10-25 encounters per physician. But you can also do a random selection of an identified cohort. Examples of cohorts you can select include the following:

High-complexity visits
Annual wellness visits
Preventative medicine visits
Telehealth/telemedicine

Then from the cohort, you decide how many cases you should sample based on what is best for your organization and your people, Malone explained.

Targeted review: When it comes to a targeted review, you will look at specific targeted high-risk conditions such as:

1. History/resolved versus active conditions. Note: Cancer is a particularly high-risk condition, Malone said.

2. Stroke and pulmonary embolism in the office setting. You need to ask — Is it the right diagnosis for that place of service? Stroke in office will not pass audit, Malone said.

The provider might be absolutely spot-on, but where is the diagnosis confirmed? Malone added. It is confirmed in the emergency department (ED) if that person really has a stroke, so it’s going to be captured there.

3. Conditions appropriate for mother’s chart versus baby’s chart

4. Fracture coding. Note that seventh character use is always challenging, Malone said.

5. Drug dependence versus long-term use

On the other hand, when you perform a targeted audit, you should also look at common unspecified and under-documented conditions such as: depression, chronic kidney disease (CKD), diabetes, amputations, ostomies, and HIV-positive.

Finally, you can perform targeted review based on the on Officer of Inspector General (OIG) work plan, payer audit results, and internal chart reviews, Malone said.

Tip 3: Base Protocols on This Information

When you develop the protocols for your audit program, you should include guidance from ICD-10-CM coding, AHA Coding Clinic, Centers for Medicare & Medicaid Services (CMS), and The U.S. Department of Health and Human Services Risk Adjustment Data Validation (HHS RADV) protocols, Malone said.

Know what CMS is looking for in a RADV checklist. Be proactive, Malone added. Look at the updates and use these resources to make the most robust audit program you can.

Tip 4: Apply These Best Ways to Educate Providers

When you educate providers, you want to make sure you are speaking their language, Malone said.

“Focus on patient complexity. Does this have a revenue impact? Yes, it does,” according to Malone. “But your audience is providers, and they care about taking care of patients. Talk about patient complexity and the importance of stating the true complexity of the patient.”

Your provider’s assessment and plan are the gospel, Malone added. So, when you are educating your providers, give them this acronym and tell them you need this information in their assessment and plan: DSP. Each letter stands for the following:

D — Diagnosis. To the highest level of complexity known

S — Status. Is the patient stable, worsening, improving, etc.?

P — Plan. What are you doing about it? Steer clear from blanket statements like “Continue current treatment.”

Don’t miss: Working with your payers is vital, according to Malone. Ask for data and get that information. Build relationships with the appropriate people to make sure you can share information back and forth.

Editor’s note: Want more great coding info like this? You can register for the upcoming educational events here: https://www.aapc.com/resources/events.aspx.