Coding audits 101: How physicians can prepare
by Abdul J. Roberts, Esq., and Jim Tudor, PCA, CPC Contributing Authors
You’ve received a request for medical records from a payer who is going to conduct an audit on your claims. Your electronic health record (EHR) system is excellent, the notes are voluminous and your providers are well-versed at coding. If anything, you undercode! You provide excellent care for your patients and achieve great outcomes. No one has ever given you any trouble before.
Nothing to worry about, right?
Several months pass, and you get a letter from the payer. It’s the results from your audit. You open it up and see:
“Medical necessity not supported.”
“Notes are cloned.”
“Records include conflicting data.”
It also says that you owe an astronomical amount of money due to “overpaid claims” and that they are putting you on prepayment review until things improve.
What just happened? Why are they doing this? Can they legally do this?
Welcome to the world of billing and coding — where black and white is often eclipsed by gray, where the “obvious” is rarely so and where sometimes less is more.
Below are recent trends in medical audits and what physicians can expect, especially after the Centers for Medicare & Medicaid Services’ (CMS) overhauled the documentation of evaluation and management (E/M) codes a year ago.
Most providers have an EHR system and fill in pertinent patient information as prompted by the system. Is there anything they need to be on the lookout for?
An EHR system is supposed to make your life easier. It provides accurate, up-to-date information about the patient. Its purpose is to facilitate coordinated access and information sharing among physicians. It helps providers more efficiently diagnose patients, reduces errors, provides safer care and facilitates quality. And, by the way, it does a bang-up job of capturing essential billing elements. Pop in the right template, maybe tweak it a little, and you’re good to go.
So where do things go astray? Well, to understand how something like the earlier scenario can happen, you first need to understand how the patient’s medical record influences medical necessity. Per CMS, medical necessity is the overarching criterion for payment.
Inaccurate information in the chart, especially when carried forward from a previous service date or entry without necessary editing, often does not afford an auditor the ability to understand if you needed to see that patient, perform that test, order that script, etc.
Often the information obtained from a patient has not changed from the prior
visit. So what is the potential problem with just carrying information forward?
Auditors across the nation, both private and public, love to deny claims based on allegations that the provider simply copied and pasted prior notes. A copy/paste-type operation that occurs without needed modifications to content is a process infamously known as “cloning.’’ And that doesn’t just refer to the entire progress note as a whole; it can refer to pieces of a progress note that are inaccurate. Those pieces could be integral to billing a distinct procedure or a crucial element associated with an office visit code. If one or more pieces never, or almost never, change from one visit to the next, the auditor doesn’t know if the information simply didn’t change or whether it may have changed but just wasn’t edited. Lately, auditors seem to assume the latter.
Is there anything else that auditors look for when they believe a note is cloned?
The presence of conflicting information is another giant red flag. If the history indicates the patient has severe dementia but the review of the systems template indicates that “all systems were reviewed and negative,” well, that could be a problem. One error of this nature can lead to a reviewer casting aspersions on the integrity of your note. “What else could be wrong with this chart?” thinks the auditor.
Truth be told, these are usually just innocuous mistakes that do not represent any intent to commit billing fraud. But the payers don’t see it that way. They don’t know if you forgot to revise that review of systems because you’re up until 11:30 p.m. signing off on your notes or if you’re trying to pad the record with billing elements. All they know is there is a conflict or redundancy that could represent something fraudulent.
Are there any other potential pitfalls that are low-hanging fruit for auditors?
Another pitfall that may come back to haunt you is the overstuff ed progress note. This occurs when the sheer quantity of the displayed items seems wildly disproportionate to the nature of the presenting problems. Taken at face value, a single, self-limiting medical condition would not normally warrant a complete review of past medical, family and social history; a full review of systems; and a comprehensive exam.
Although there may be times when circumstances do require a more intensive evaluation than meets the eye, the payers expect this to be the exception, not the norm.
All this leads to a presumption that the information in your charts is questionable. Once that notion is planted in an auditor’s head, it colors their perspective. If you happen to be a “high volume” provider with disproportionately more billing of any particular code or modifier, the notion that there must be something disingenuous going on becomes solidified. This thinly veiled ethical challenge can be insulting and infuriating to hard-working providers who would never, in a million years, intentionally submit an unsupported health claim.
Will providers have to completely change the way they document medical necessity?
A gift horse arrived a year ago in the form of the 2021 E/M guidelines. These are rules created by the American Medical Association and adapted by CMS and other payers for outpatient office visit codes (codes 99202-99215 only).
The guidelines effectively remove those preexisting requirements to “quantify” the history and physical examination; you no longer need to worry about having “enough” of that review of symptoms anymore. However, you should continue to document those aspects of history and exams that lend support to your clinical decision-making and any tests or treatments ordered. E/M coding has historically been associated with EHR misuse, in part due to the confusing and onerous documentation requirements imposed by the CMS.
The 2021 rules allow physicians to document the most salient points relevant to the medical decision-making or time spent. It is coding, so there are charting nuances you still need to know.
Is there anything else providers should keep in mind when documenting medical necessity?
Another very simple rule to bear in mind is: Change what changes. Your notes should always have an interval history of present illness (HPI). This is the history of the problem, but there is usually something unique to say about the patient’s status spanning the period between the last appointment and the current one.
Also, make a point to label it “interval HPI.” Don’t blend it in with the other history because that combination of new and old data sometimes doesn’t sit well together. You want unique documentation for each encounter, and it should stand out in your progress note. Taking the interval HPI concept one step further, you need to understand that encounter-specific charting is king. With the E/M changes comes a flexibility that has not existed in many years.
The rigidity of cookie-cutter, awkward-appearing templating is, from a billing standpoint, now inferior to an old-school, 1985-ish, free-text paragraph or two (yep, I remember those).
Everything has come full circle.
Less is more.
Do these documentation changes apply to all current procedural terminology (CPT) codes?
To be clear, the E/M documentation changes do not apply to all CPT codes. Certain services, such as wellness visits, chronic care, transitional care, etc., require more rigidity in capturing essential elements. However, you do want to infuse encounter/patient specificity into those templates too. Despite the redundancies, you still need to personalize those notes to render them unique to the patient. A little TLC goes a long way.
Any parting advice for physicians?
Spend an extra five to 10 minutes proofing those notes before you close them. As my mom once said, “An ounce of prevention is worth a pound of cure.” The immense benefits of such diligence can truly be worth its weight in gold.
In the unfortunate event that you do receive one of those nasty overpayment demand letters someday, don’t acquiesce without conducting an analysis first. Let’s face it: They call them “procedure” codes because there are commonalities. Certain things may not change, or change much, from one service date to another. If you’ve changed the things that change and still got dinged in an audit, you may have sufficient basis to challenge the results.
There is no requirement to rephrase verbiage in your charts just for the sake of making it look different. That’s a level of insanity we hope we’ll never reach.