This article is more than 5 years old. Information may no longer be current.
Six steps for conducting an internal evaluation and management audit
Click Here to Manage Email Alerts
Evaluation and management coding patterns are under the microscope. CMS is monitoring evaluation and management code usage by specialty, state and nationally. The Recovery Audit Program of CMS aims to identify and correct improper Medicare payments through the detection and collection of overpayments. Commercial payers are using analytics to identify potentially inaccurate coding, too; take-backs may result.
An annual review of each provider’s evaluation and management (E/M) code usage is essential to effectively manage the audit risk of your practice. The process of reviewing documentation identifies coding pattern or usage anomalies — possible non-compliance. This, in turn, uncovers opportunities for educating physicians and staff on how to properly document, code and bill for services according to federal, state and payer guidelines.
Here are six steps that practices should take annually to assess and mitigate audit risk.
1. Revisit basic E/M documentation criteria.
E/M service levels are to be selected based on three key components: history, examination and medical decision-making. Medical necessity must support all three. Documentation must contain unique elements for each encounter. Although instances do exist in which time and counseling may be a contributing component, history, exam and medical decision-making are typically the determining factors for choosing the level of E/M service.
2. Generate a CPT frequency (usage) report.
This is a standard report from the practice management system (PMS) that indicates the number of times each provider billed each CPT code. Select a date range of 1 full year. Generate one report for each provider and one report for all providers combined. If you aren’t sure how to run this report, contact your PMS vendor.
3. Review your E/M usage against state and national peer data.
This is how CMS and other payers are reviewing the data. If your pattern differs significantly from state and national averages, pay particular attention to those coded visits, as these will attract auditors’ attention. State and national usage data are available from CMS. The raw data can be somewhat cumbersome to work with, however, using a tool such as the E/M Profile Analyzer will save your manager time. The tool auto-generates colored graphs that help easily compare patterns.
If your review identifies patterns that vary from peers, it does not necessarily indicate that there is a problem. Subspecialty is one factor that can drive the difference in E/M coding patterns. For example, pediatric and tumor subspecialists, often found in academic centers, may have different utilization patterns than private practice peers.
Regardless of the reason for the difference, if your patterns fall outside the norm of your peers, a CMS or payor audit is more likely. Engage the services of a health care attorney before you proceed with documentation review, so he or she can invoke attorney-client privilege if needed.
4. Audit 10 notes for each provider.
Select records that include some of the outlier codes identified in the previous step. Try to choose a mix of encounters that include more than just the E/M service; for example, visits that include an injection or procedure, or modifier 25. After choosing a date of service, look in the PMS to see which E/M code was billed. Review the note to determine whether it supports the billed code.
We typically recommend conducting baseline education at this point, targeted toward the potential compliance risks you find in your review. To measure the success of this education, conduct another record review in 90 days and establish a passing rate. Provide additional coaching for the providers who are still not hitting the mark.
As you review each record, look for instances of EHR auto-population or “cloning.” EHRs commonly generate multiple pages of the same rote text, making it difficult to identify the physician’s findings and causing some providers to code a higher level of E/M code than matches the medical necessity of the encounter. If your audit identifies these types of notes from your EHR, it indicates that physicians must improve their documentation of unique visit elements. To reiterate the documentation rule in step 1, documentation must contain unique elements for each encounter.
5. Discuss findings as a group.
Peer discussion allows you to review patterns, documentation and coding rules, and consider actions for improvement. If you’ve engaged a health care attorney as part of the audit process, invite him or her to participate.
6. Document everything in your compliance plan.
Summarize the process you used, results of the audit and actions being taken. Log all training hours. If you’ve engaged a health care attorney as part of the audit, work with him or her to ensure you thoroughly and accurately document activity.
No compliance program? Get to work! In an audit, a compliance program indicates the practice is making an effort to code, document and bill correctly.
Sarah Wiskerchen, MBA, CPC, is a senior consultant with KarenZupko & Associates Inc.(KZA) where she advises physicians about coding, reimbursement and operational systems. Wiskerchen has deep experience in orthopedics, neurosurgery, otolaryngology and physical therapy. She presents on CPT and ICD-10 coding nationally for the American Academy of Orthopaedic Surgeons (AAOS) national workshop series, and state societies, physical therapy firms and large musculoskeletal groups have invited Wiskerchen to educate physicians and staff. She is skilled at analyzing RVUs for compensation agreements, reimbursement and financial management.
Disclosure: Wiskerchen reports she is a consultant with KarenZupko & Associates Inc., which develops and delivers CPT Coding and Practice Management workshops presented by the AAOS in conjunction with KarenZupko & Associates Inc.