Minimize the risk of a major audit with a self-audit and monitoring program

The Office of Inspector General (OIG) recommends that individual providers develop a compliance system, such as self-auditing and monitoring programs, which can help minimize third-party payor reviews and avoid one of the compliance risks as identified by the OIG.

Since hiring a practice management firm or consultant can be expensive, you and your staff can easily administer self-monitoring programs by following a few basic steps and filing a simple report. By performing these audits on a routine basis, your practice can avoid costly mistakes and prevent a major audit.

Perpetual Training
The first line of defense is knowledge. The worst mistake is to think that experience is the necessary skill for insurance matters. What may have been true yesterday is no longer true today, and that could change again tomorrow. CAs who believe they know all because of their years in the field may be making errors. All insurance personnel should attend training courses a minimum of once per year. Doctors should attend insurance classes with the staff to stay informed on the latest changes.

Doctors must also be trained on proper diagnosing and documentation protocol. Patient records must be complete and legible. Avoid prescripted formats that have a tendency to appear canned. Evaluation and management (E/M) coding requires special documentation to determine the level of service. Medicare has promulgated PART (pain, asymmetry/alignment, range of motion abnormality, tenderness/tissue tone) documentation, and some states require extensive documentation for workers’ compensation cases.

Paid in Full
The formula for payment is simple:
ICD-9 = CPT = Payment

The diagnosis (ICD-9) must equal the procedures (CPT) in order to have what the carrier deems to be a "medical necessity" or "clinical rationale." A patient’s major complaint is usually reflected by the primary diagnosis code. Complaints or conditions added following the consultation with the doctor should also be included in the patient’s confidential history form. Otherwise, diagnoses that patients have not listed in initial complaints appear "doctored."

1. Each procedure billed (CPT codes) must be supported by a diagnosis (ICD-9) code.
Services rendered = Treated condition/illness/symptom

2. The treatment plan should state the reasons for each service provided (rationale). This is based on the diagnosis and patient’s chief complaint.
Treatment plan = ICD-9 = CPT

3. Documentation shows services provided and proves a legitimate claim. Do not use shorthand notes or hieroglyphics that cannot be easily translated. The patient’s progress, response to, and changes in treatment and revisions of diagnosis should be documented.
Documentation = Payment

Clean Bill of Practice
To avoid a major audit because of billing or coding errors, a common sense approach should be implemented in your practice:

• Cookie-cutter treatment plans should be avoided. Offices that routinely schedule all patients with the same treatment plan have difficulty maintaining rationale.

• Steer clear of pattern billing. Similar to treatment plans, pattern billing is determined when every patient receives the same care: heat or ice with interferential, neuromuscular reeducation, and therapeutic activities. Even worse is when all patients have the same treatment from the first to last visit. The treatment should change as the patient progresses.

• Avoid reports that are computer-generated or canned with regard to style and content because they are easily spotted in reviews. Reports should be individual and personalized.

• Upcoding and unbundling should be avoided. Upcoding is when documentation does not justify the level of services billed. Unbundling happens whenever a comprehensive service code is broken down into several different codes such as coding X-rays by region as opposed to using the entire spine code.

• Avoid billing for services not rendered or documented. Billing for services such as a 15-minute massage, when it was only a 3-minute genie-rub is fraudulent and unethical.

• Steer clear of billing for services under another CPT code. Services are sometimes "recoded" in payment-friendly language or coded for maximum reimbursement. A service that may be denied, such as a massage (97124), is sometimes listed as neuromuscular reeducation (97112). Or a supervised modality, such as interferential (97014), which has no time units, is coded as a manual stim (97032) to maximize reimbursement by billing multiple units. These practices are fraudulent.

• Make sure paid claims are not due to an error. At times, claims that are paid in error are assumed clean claims by the offices that filed them. Unfortunately, some incorrect claims still get paid. Either the carrier has missed the error or is unaware of the true service. The errors and offenses are repeated because there are no denials. In some cases, carriers actually pay incorrect claims to set bait for an audit.

• Review denials and reductions to detect errors. When a claim is not paid as expected, the office should investigate the denial. The insurance CA should read the explanation carefully and review previous payments from the carrier and/or patients’ policy limits. If errors occurred due to filing mistakes, corrected claims may be filed. If the denial is due to lack of documentation, a narrative report may be necessary to clarify the need for care.

• Monitor outside billing services as you would in-house audits. Outside billing companies are also required to abide by strict compliance issues. Keep a close account of billing company filing methods and errors made. Perform routine monthly audits to ensure that all services are billed properly and strict adherence to CPT and ICD-9 coding rules is maintained.

• Be aware of your billing profile. Carriers, especially Medicare ones, maintain utilization profiles on providers. These reports can determine if a provider is billing with "usual and customary" rates. The report can also show overuse of particular codes. Do your own in-house billing profile. If your computer system can produce a utilization report by CPT codes, you can see how the practice appears on paper.

The Internal Audit
At regular, intermittent intervals, conduct random audits but do not plan on when to have them. Audits done at predetermined times are less likely to expose errors.

First, take five patient folders from each financial class—cash, personal injury, workers’ comp, Medicare, etc). It is best to have two new patients, two mid-treatment, and one patient close to finishing care. Examine five critical visits recorded in each folder: first, second, reevaluation, 12th, and 24th (if applicable).

To reconstruct the visits you will need copies of patients’ fee or routing slips, daily notes, and Centers for Medicare and Medicaid Services forms that match the visits and explanation of benefits (EOB) from carriers. Items that should be highlighted include: initial complaint, examination and X-ray findings, diagnosis, treatment plan, and outcome response.

An ongoing evaluation process will ensure compliance procedures in your office, while auditing your own files will prevent serious and costly mistakes.

About the Author
Ces Soyring, CA, is a cofounder of the National Academy of Chiropractic Assistants (www.naca-online.com) and a chiropractic consultant. She can be reached at: 888-218-7757 or via email: naca_csoyring@yahoo.com.