2021 coding-and-documentation-audit-focus-areas webinar
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Join HRG audit expert Vanessa Brumfield as she reviews new and continued areas to focus on in 2021 when it comes to coding and documentation audits. Vanessa will also go over recommended strategies to prioritize these areas in this 30 minute complimentary HRG webinar.
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2021 coding-and-documentation-audit-focus-areas webinar
- 1. © 2021 Healthcare Resource Group, Inc. ALL RIGHTS RESERVED. hrgpros.com Presented by Vanessa Brumfield HRG Director of Audit Services February 10, 2021 2021 Coding & Documentation Audit Focus Areas
- 2. © 2021 Healthcare Resource Group, Inc. ALL RIGHTS RESERVED. hrgpros.com Objectives Discuss recommended strategy to prioritize areas of focus Review new and continued areas of focus for regulatory audits
- 3. © 2021 Healthcare Resource Group, Inc. ALL RIGHTS RESERVED. hrgpros.com Intent of Audit Compliance • Assess compliance with regulatory and coding compliance • Routine – (monthly, quarterly, bi-annual, annually) • Education & follow-up review Focused • Targeted reviews based on the concerns/needs of the organization • Education & follow-up review Provider Documentation • Assess for documentation improvement opportunities • Education & follow-up review
- 4. © 2021 Healthcare Resource Group, Inc. ALL RIGHTS RESERVED. hrgpros.com Recommendations Review CMS site for reporting on monitoring program findings Review OIG’s work plan Review state and regulatory program requirements (e.g. RHC) Review your compliance audit plan/program annually • Routine audits – random sample • Consistency for trending and identifying continued areas of opportunity and improvements • Focused audits – Targeted (not included with routine reviews) • Pick at a minimum 1 area of focus annually • Monitoring programs relevant to your organization • Relevant areas from OIG’s work plan • Highest risk areas based on your facility data • Provide education and submit claim corrections for significant findings
- 5. © 2021 Healthcare Resource Group, Inc. ALL RIGHTS RESERVED. hrgpros.com Regulatory Audits • Comprehensive Error Rate Testing (CERT) • Medicare PART C Improper Payment Measurement (Part C IPM) • Payment Error Rate Measurement (PERM) Improper Payments • Targeted Probe and Educate Program • Recovery Audit Contractors Medicare Fee-for- Service Compliance
- 6. © 2021 Healthcare Resource Group, Inc. ALL RIGHTS RESERVED. hrgpros.com Improper Payments Measurement Programs
- 7. © 2021 Healthcare Resource Group, Inc. ALL RIGHTS RESERVED. hrgpros.com Comprehensive Error Rate Testing Measures improper payments for Medicare Fee-for-Service Statistically valid stratified random sample of all FFS claims Coverage, coding, and payment rules PHE – Temporarily suspended activities for reporting year 2020 • Resumed CERT program activities effective 8/11/20 • Sending documentation request letters & conducting phone calls (RY 2021 and 2022) • 2021 – July, 2019 through June, 2020 • 2022 – July, 2020 through June 2021
- 8. © 2021 Healthcare Resource Group, Inc. ALL RIGHTS RESERVED. hrgpros.com CERT – 2020 Top 3 Error Findings • Missing/Inadequate Orders • Missing/Inadequate Plan of Care • Missing/Inadequate records • Certification/Recertification requirements not met Insufficient Documentation Medical Necessity Incorrect Coding
- 9. © 2021 Healthcare Resource Group, Inc. ALL RIGHTS RESERVED. hrgpros.com CERT – Claim Type Type Insufficient Documentation Medical Necessity Incorrect Coding DMEPOS 7% 0.6% 0.1% Part A (excluding hospital IPPS) 28.9% 8.9% 1.2% Part A (hospital IPPS) 4% 6% 2.6% Part B 22% 0.6% 7.1%
- 10. © 2021 Healthcare Resource Group, Inc. ALL RIGHTS RESERVED. hrgpros.com CERT Root Cause Part A (excluding Hospital IPPS) Findings Inadequate Certification/Recertification Missing provider’s intent to order Missing/Inadequate order Missing documentation to support medical necessity Inadequate plan of care content
- 11. © 2021 Healthcare Resource Group, Inc. ALL RIGHTS RESERVED. hrgpros.com CERT Root Cause Part B Findings Inadequate/Missing documentation to support medical necessity Inadequate/Missing documentation to support services were provided or the code submitted Missing provider intent to order Missing order
- 12. © 2021 Healthcare Resource Group, Inc. ALL RIGHTS RESERVED. hrgpros.com CERT Root Cause DMEPOS Findings Inadequate or missing order Inadequate or missing documentation to support coverage criteria Inadequate or missing proof of delivery
- 13. © 2021 Healthcare Resource Group, Inc. ALL RIGHTS RESERVED. hrgpros.com Payment Error Rate Measurement • Medicaid and CHIP • Activities resuming as of 8/11/2020 • Determines the appropriateness of the service provided and whether the documentation supports the service. • Service requirements may include a state’s documented policies, federal regulations, and any other contractual or legal requirement. PERM Findings Medicaid FFS CHIP Documentation not in the record Documentation not in the record No Documentation No Documentation Improperly Completed Documentation Procedure Coding Error
- 14. © 2021 Healthcare Resource Group, Inc. ALL RIGHTS RESERVED. hrgpros.com Medicare Fee-for-Service Compliance
- 15. © 2021 Healthcare Resource Group, Inc. ALL RIGHTS RESERVED. hrgpros.com Targeted Probe and Educate • Intended to quickly increase accuracy in very specific areas. • Providers and suppliers who have high claim error rates or unusual billing practices • items and services that have high national error rates and are a financial risk to Medicare. Common Claim Findings Certifying physician signature not present Encounter notes did not support all elements of eligibility Documentation does not meet medical necessity Missing or incomplete initial certification or recertification
- 16. © 2021 Healthcare Resource Group, Inc. ALL RIGHTS RESERVED. hrgpros.com Recovery Audit Contractor • Identify and correct improper payments to prevent future errors • Post-payment review process Approved Issues 2021 Medical necessity & documentation requirements for Vagus Nerve Stimulation Incorrect coding of anesthesia with multiple surgeries Ambulance Transport subject to SNF consolidated billing Medical necessity & documentation requirements for Hospice Continuous Home Care 2020 Incorrect coding of Distal claviculectomy Excessive units of Nerve Conduction Studies Incorrect coding of procedures that include ultrasounds and imaging
- 17. © 2021 Healthcare Resource Group, Inc. ALL RIGHTS RESERVED. hrgpros.com OIG Work Plan
- 18. © 2021 Healthcare Resource Group, Inc. ALL RIGHTS RESERVED. hrgpros.com OIG Work Plan OIG Work Plan Part B Psychotherapy Services Payments Part B Laboratory Services Payments MA Risk Adjustment Data – Targeted Diagnosis Review of Documentation Facet Joint Procedures Part B claims review for Intravitreal Injections of Eylea and Lucentis Telehealth requirements https://oig.hhs.gov/reports-and-publications/workplan/active-item-table.asp
- 19. © 2021 Healthcare Resource Group, Inc. ALL RIGHTS RESERVED. hrgpros.com References • CMS Research, Statistics, Data & Systems, Monitoring Programs • https://www.cms.gov/Research-Statistics-Data-and-Systems/Research- Statistics-Data-and-Systems • Office of Inspector General, Active Work Plan Items • https://oig.hhs.gov/reports-and-publications/workplan/active-item-table.asp
- 20. © 2021 Healthcare Resource Group, Inc. ALL RIGHTS RESERVED. hrgpros.com
Editor's Notes
- Why resumed? Improper payment measurements cannot be paused for an extended period w/o missing statutorily required due dates Not sending documentation request for RY 2020, claims submitted 7/1/18 through 6/30/19 2020 data – collected from providers and suppliers that voluntarily submitted and from information they had RY 2021 & 2022 adjusted data collection Sample size reduction to account for provider/supplier difficulties during the pandemic
- Claim Type Part A, excluding hospital IPPS highest rate of improper payments for insufficient documentation and medical necessity with Part A(Hospital IPPs) showing the highest rate for incorrect coding. Provider Type
- Effective August 11, 2020, the Centers for Medicare & Medicaid Services (CMS) resumed Comprehensive Error Rate Testing (CERT) program activities that were temporarily suspended in response to the public health emergency (PHE) for the 2019-Novel Coronavirus (COVID-19) pandemic. Specifically, the CERT program resumed sending documentation request letters to and conducting phone calls with providers or suppliers to request medical documentation for claims in Reporting Year (RY) 2021 (claims submitted 7/1/2019 through 6/30/2020) and RY 2022 (claims submitted 7/1/2020 through 6/30/2021).
- Verification of Documentation Sufficiency The RC determines whether the submitted documentation is appropriate and sufficient to complete the MR by evaluating if: ■ The documentation received supports the service billed ■ The documentation supports the requested sampling unit ■ The documentation supports the DOS ■ The documentation includes signed physician orders ■ The documentation includes approved certifications/re-certifications required by state policy The original MRR lists the specific supporting documentation that providers should send for each claim category. b. Verification of Service Provision in Accordance with State Policy The policy review includes review of the applicable state-specific Medicaid or CHIP policy related to the service on the claim. The procedure or service documented in the medical record is reviewed to determine if the service was covered under the state’s policy, if there were any applicable limitations (e.g., units, quantities), and if the provider’s service fell within those limitations. Source documentation for the review will include documented state policies, including non-covered benefit limitations, provider manuals, and the CFR. c. Confirmation of Medical Necessity of Service The medical necessity review includes review of the record to determine if the service provided was consistent with the symptoms or diagnosis under treatment. In addition, the review may also involve a contextual claim review of other services provided to determine the pattern and feasibility of the sampled service. This may include an entire MR to determine if the sampled service was medically necessary. Source documentation includes documented state policies, including medical necessity documentation guidelines the state used, provider manuals, and the CFR. d. Determination that the Service Rendered Matches the Service Codes Billed and Paid The coding validation involves confirming the diagnosis recorded by the provider and its relevance to the billed procedure code. The coding review includes reading the medical record documentation and applying applicable ICD-10 coding guidelines to ensure the code the provider Payment Error Rate Measurement Manual 48 billed and the payer paid is the most appropriate code and level of code for the service rendered and that the provider did not assign multiple codes when only one code is appropriate (unbundling). The RC does not perform coding reviews for long-term care payments since claims for these services are not paid based on ICD-10 codes. For the RC to determine whether it received appropriate and sufficient documentation, it evaluates if: ■ The medical record documentation is consistent with the code billed by the provider ■ The procedure codes are unbundled ■ The billed code is consistent with the provider’s diagnosis The diagnosis code is appropriate (if relevant to the payment) ■ The diagnosis is included in the DRG (if relevant to the payment) ■ Another procedure code would be more appropriate e. Verification of Appropriate Physician Certification For long-term care, inpatient hospital services, and home health care, the review verifies the documentation contained a signed physician certification, if required by state policy.
- Phase one audits will focus on making an early assessment of whether services such as evaluation and management, opioid use order, end-stage renal disease, and psychotherapy (Work Plan number W-00-21-35801) meet Medicare requirements. Phase two audits will include additional audits of Medicare Part B telehealth services related to distant and originating site locations, virtual check-in services, electronic visits, remote patient monitoring, use of telehealth technology, and annual wellness visits to determine whether Medicare requirements are met.