It may be the Year of the Rabbit in the traditional Chinese calendar, but Rhode Island-based coding consultant Nancy Enos advises medical practices to think of 2011 as the "year of the audit." To stay safe and weed out the billing and collections problems stifling your practice's revenue stream, Enos recommends a "bottom-to-top" assessment of your entire billing operation. She says payer denials and under-performing accounts receivables can provide clues to cleaning up your entire revenue cycle and producing clean claims every time.
A billing operations assessment should include routine internal audits to spot coding and documentation errors so you can fix them promptly. We talked to experts in coding and billing to see where to get the process started — all recommended the bottom-to-top assessment approach. In other words, start with the outcomes and work backwards through the billing process to find the problems. The good news is that everything you do to keep physicians and other billing providers on the straight and narrow coding-wise will also aid your practice's entire billing operation — and, possibly, capture more of the revenue your physicians deserve.
First, about the audit landscape of 2011:
• The Recovery Audit Contractors (RACs) for the Medicare program continue nationwide;
• The Patient Protection and Affordable Care Act introduces the Medicaid Integrity Contractor (MIC) in all 50 states; and
• The Department of Health and Human Services, Office of the Inspector General's 2011 work plan sets its sights on Medicare physician E&M coding and medical necessity. The OIG will have a keen eye out for "EHR documentation practices associated with potentially improper payments." In particular, they're looking for medical records with identical documentation across different services and different patients — a pitfall of leaning too heavily on an EHR to help generate patient notes.
In the face of all this, Enos recommends a full-scale billing assessment.
Start your billing assessment with auditing — not just an audit but a program of routine annual or biannual audits of all providers who bill for services. Enos recommends auditing 10 to 20 charts per physician at least once a year — more often, if there are concerns about coding patterns, a history of sloppy documentation, or if it is a new physician.
"It's all about the documentation," Enos says. "With auditors from the government going around knocking on doors, documentation for medical necessity is more important than ever."
Audits and comparisons to coding frequency benchmarks, such as Medicare provides, can spot physicians who may be undercoding or overcoding, as well as those who don't document well.
"I just finished auditing a bunch of charts from a neurologist and they were the shortest notes I've ever seen," Enos says. "I think I write more on my grocery list."
The neurologist was coding at an extremely low level to play it safe, but that means he was leaving money on the table so to speak. In a proper note, the patient problem is reflected in the documentation and justifies the diagnosis and the level of code that is billed for the service, she says.
But beware. "Auditing is not an exact science and you certainly could give the provider erroneous feedback if you are not good at auditing and don't have some training," Enos says.
After an audit Enos does four things:
• Explain audit results to each provider — the one-on-one sessions can be in person or via Web linkup;
• Present each provider with a graphic summarizing major audit results, especially deviations from benchmarked coding patterns;
• Share with the provider patient records marked up to show concerns, such as where documentation of medical necessity was insufficient; and
• Provide specialty-specific educational tools, such as at-a-glance summaries of what to document for each level of history, exam, and medical decision making.
Melody Irvine, a Denver, Colo., coding consultant, says working with physicians is a critical success factor in resolving coding related problems.
"Whoever is doing the audit for the practice has to come at it as the doctor's friend and adviser," she says. "I start out by saying, 'I'm on your side. I'm here to help. You guys are doing a great job but ...' and then we work through the audit results together."