Wiki Auditing vs coding live

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jifnif

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I am currently auditing E/M charges for doctors. As of January 2010 I will be coding live from reports, not off of charge sheets. Does anyone have a process or any suggestions for getting the code every time? I don't have enough time to actually use an audit form for every charge and wow! what a waste of paper that would be. Any suggestions would be very much appreciated. Thank you. :D
 
I have debated whether or not to answer this but since no one else has I guess I will.

I rarely fill out an audit sheet, whether I'm auditing or just coding. When I audit I don't even look at what they coded, I treat it as if I am the first person to ever look at it. That way I am not influenced by what they did. It is really easy to waste a lot of time looking for info that isn't there if you are trying to support a code someone else assigned.

I have my audit cheat sheets handy but I have them memorized so it is rare that I look at them. If I am auditing/coding paper notes I usually mark them all up as I go and write out the level for each key component as I read it. If I am auditing/coding from EMR and not printing I do the same thing mentally. I have a co-worker that created a survey monkey form that she does on each note she audits or codes and only prints it for the audit piece or if she is sending it back to the provider.

I'm not sure how anyone else does it but for what its worth this is what I do.

Laura, CPC, CEMC
 
Mark up the document

Like Laura, if I have a hard copy I mark right on it. If I'm working off an EMR I just jot my notes on a piece of scratch paper. Once I've arrived at the correct type and level of service I mark the encounter form.

And don't worry, jifnif. You'll get faster with practice.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
Hi - I usually use an audit tool, since my work is used for education. However, when I have to do a quick review I usually write on the note. I write what it is and then make tally lines for HPI, ROS, exam. If there is anything PFSH I write the corresponding letter (P F S) down. I split MDM in 3 chunks and note the highest I find for each (Problem: 1-4, Data: 1-4, Risk SF, L, M, H). Then pull it all together. Describing it takes longer than actually doing it.
If you are new to this I would suggest be thorough when you start, over time you will speed up and get really efficient. It's just a matter of experience. You do want to be accurate and if in doubt about an item ask yourself if you can defend your opinion if challenged by an auditor (e.g. Medicare).
Use a pencil, just in case.
On a slow day (do they exist?) you may want to try the direct approach just to work up your speed to be ready for January.

Best of luck!:)
 
Thank you and one more question

Thanks to all of you. I will definitely be slow to start. Our manager says she has backbenched to see how many we should be doing and came up w/ 285 a day. Well, I have a problem with this b/c she got that number from the ED and i can only audit about 80 hospitalists claims a day. Either I am slow or ED is not comparible. Also, I used to code for radiology and my numbers were 450 a day. Shouldn't this be specific to the specialty? Is there anyone else out there that might have a more reasonable number for something close to what I would be doing?
 
Well I would think the of documentation would greatly affect productivity more so than the specialty.

Also the system speed you are working with plays a part.

I can audit/code fairly quickly and if I was looking at paper records (already printed) that were dictated, 285 would be no problem and I could probably do more since I know my doctors documentation so well.

Now, if it is handwritten and I have to go find it whole different story. Our system is never quick on a good day, on a bad day it can take more than 15 minutes to pull a chart up and find your note.

What type of documentation are you working with? Is that part of the productivity issue? I know in our ER they have the charts in front of them so the access to info is much greater than myself who has to go thru EMR.

I am assuming it is all E/M since you posted here. E/M is the same for all specialties, the only difference is how the key components are applied and that is based on code set. Another thing to help with productivity is once you know your providers style and the services they are providing you can audit from the weakest part of the note to the strongest which should save time. If you start from the first word and read/level everything in the note it takes awhile. If you know your provider is doing an admit and generally doesn't hit a comphrensive exam, start with the exam. If it is only detailed you only need to make sure the rest of the note supports that level since admits are 3 of 3. That way you aren't wasting time looking for 10 ROS or what not when it ultimately won't matter.

Hope this is helpful,

Laura, CPC, CEMC
 
Thanks, Laura. I will be coding from an EMR. The trouble is that the numbers came from the ED and not a hospitalists work day. Our hospitalists don't see more than 100 pts per day. I would just like to feel comfortable knowing that 80+ a day is a good number for coding hospitalists. Also, I am interupted much during the coarse of the day being the only coder in a group that has many specialties. Thanks for the tips, I will try to utilize them so I can be more efficient. Thank you for replying. :)
 
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