So that takes me to auditing best practices. So we are going to talk about auditing, and it's important to audit, whether you do it internally or you hire someone externally to do it, you got to know what you're doing. You can't, if a payer comes at you with an audit or request for multiple records and you fail, the first thing they're going to ask you is what's your compliance plan? Have you looked at your notes before? Has a coder looked at your notes? Have you, you know, do you have a compliance manager? And if, you know, ignorance is not an excuse. We can't say, oh, no, I didn't know how to, I didn't know we were supposed to do that. You want to do it first before the payer starts requesting many, many, many records. All right, so we're going to talk about GI-specific benchmarking and how important that is for your practice. We're going to talk about internal audit processes and compliance tools, types of payer audits that you can come, that can be thrown at you, and then how to respond to those types of audits. All right, so benchmarking. So it says, to minimize the risk of an audit, providers must be aware of and understand their utilization of E&M codes prone to audit review. Providers should know if their levels, their use of each level of service is in line or follows that bell curve for your specialty. When the benchmark or bell curve for a specialty has been determined, a physician's claims for E&M services can be compared to identify deviations from benchmarking. If the provider or practice is off the benchmark or bell curve, you will receive letters from payers and random audits. Okay, so if you are kind of closely in line with your peers, with all other GI practices in the United States, then you're probably doing okay. You are doing internal auditing, you're having someone look at these visits, but if you're all over the place, that is a red flag. You stick out to a payer. And guys, if you're in a practice with 10 physicians, 11, 12, 13, 14, more than anybody, anybody can cause a review for the entire practice, okay? So just because you might think, oh, we're safe, we only have one or two doctors that don't know how to select levels, we'll be fine. They're the ones that might throw you guys out of that bell curve, okay? So this next slide just shows you the percentages, the national average for the levels of visits. So when Dr. Littenberg was talking about, back in the day, we were billing 20, 30% level fives. Clearly, we are not now. It's 5%. But it's not zero. There's so many times I go into practices and do reviews and education, and I'll talk to them about documentation requirements for levels of services, and I always ask, have you ever billed a level five? And most of them will say, nope, I am not going to put myself out there. I don't want to get in trouble. I don't want to go to jail. It's like, that's not the purpose of the levels is to reflect that level of medical decision making that you provided to that patient. And if it supports a level five, you bill a level five, okay? And then you've got the providers that are like, I'm just going to bill a level three for everything. I'm not billing anything else but a level three. If I'm in the middle of the road, I'm not going to get in trouble. That's actually an error as well. Undercoding is not safe. Okay, so you have to know the requirements and making sure that you are running reports in your practice that gives you those percentages of all the levels that you guys bill for. And again, if one is deviated quite a bit from this bell curve, then you definitely start with that provider too. If you've got one provider that is all over the place, that's probably the one that you want to look at their documentation first and give them feedback and education. So internal audit process and compliance tools. Got a question. Your practice should have a copy of the current year CPT, ICD-10 and HCPCS coding books. True or false? Good job. Yes, true. Absolutely. And, you know, unfortunately, I've been in practices where they're like, what's that? Or practices that say, yeah, I have one from 1995. Well, now it definitely does not do you any good now. And then I've got practices that say, oh, yeah, they're right here and they're sitting on a shelf and the cellophane is still on them. You know, so take the wrappers off, shake them around, read them a little bit, but we have to have them. Okay. That's part of compliance. And I know we have coding programs, there's coding software, there's coding programs out there. You got to have the books. So keep them up to date and keep them to where everybody knows where they're at as well. You know, if you've got a huge practice and you're in multiple areas, you should have one for the ASC, one for your clinic, one for the, you know, you got to have, you know, them available. All right. So compliance tools. Assign an appropriate member of your staff to review your billing process and develop the compliance plan. Okay. Include policies and step-by-step processes for responding to audits. Review internal billing data to identify patterns that may trigger an audit. Conduct coder training provider education. So this is part of your provider education and coding training is this class today. Okay. This is one of those things. So make sure you're documenting that you attended. Again, perform regular internal coding audits if you can. Again, if you don't have the manpower, get someone from the outside to do it. Reviews should be conducted by someone that's certified, someone that knows coding and billing. They should be credentialed coding certifications, whether it's through AAPC or AHIMA, you know, it really doesn't matter, it's your preference, but definitely should be credentialed. Determine how frequent you're going to do your audits. Best practices, do them on a quarterly basis. And then you can focus on either a specific provider, you can focus on a specific service, or you can just do a random sample. And that's typically when we do reviews, a lot of practices will say, well, we want you to look at kind of everything. So they'll send us a few visits, a few procedures, some infusions, et cetera. Define the scope of your review. So are you going to do a retrospective review or a prospective? So prospective is the best. Okay. Prospective is before billing, retrospective is after billing. And the thing is, with a retrospective, if errors are identified, then you're correcting claims and or refunding money accordingly. Okay. So there's a lot more work on that retrospective. So prospective is something that I would do, educate the providers, and then hopefully when you do another one, things will improve. Create a spreadsheet of findings. So this is what we looked at. This is what we found. Here's our comments. Whether you're reviewing a coder or whether you're reviewing a provider, if the provider's responsible for coding, and many practices they are, especially like office visits. You know, we don't have the manpower to look at every single office visit that goes out the door. So who's responsible for it? The physician, the provider whose name is on that claim is responsible. And then efforts to improve coding and billing processes. So again, ongoing training. You can't just learn coding and then go on your own and pretend like it doesn't change. We all know it changes all the time. So it's got to be ongoing. And you have to communicate this with the providers. That's my biggest pet peeve is, you know, I've gone into practices where the coders are experts, they know a lot of information, and they go to all these seminars. And then you get to the doctors and you're educating them. And they're like, well, I didn't know that. Nobody told me. Oh, what's that modifier used for? What are we going to do? You know, and we got to give them feedback. We have to know, they have to know if they have documentation errors or if they are, you know, assigning the incorrect diagnosis code, et cetera. We have to communicate that information back to them. Track and research denials. Keep up to date with CMS policies and your local Medicare contractor. You all should know who your Medicare contractor is. You should be familiar with their websites. Most of them, believe it or not, are easy to navigate. They've got modifier fact sheets. They've got local coverage determination, which tells you the diagnosis codes that are approved for the services that we do. They're very helpful. Print those LCDs out and provide it. Everybody should see what's covered, what's not covered, okay? If I've got a provider continually ordering scopes for anemia and we are not getting paid for that, and I'm not giving them the feedback on this, how are they going to fix it? They're not going to fix it because they're not going to know. See the Office of Inspector General's work plan and identify potential audit areas, monitor your RACs, your recovery audit contractors, and see what they are looking at. They've got it on their websites what they look at. Communication is key. I can't stress it enough. All right, types of audits. The Office of Inspector General provides independent and objective oversight that promotes economy, efficiency, and effectiveness in the programs and operations of the HHS. OIG program integrity and oversight activities are shaped by legislative and budgetary requirements that adhere to professional standards established by the Government Accountability Office. The Department of Justice and the Inspector General community, OIG carries out its mission to protect the integrity of those programs. So the task list, so the things that they focus on, services in the hospital, services in home health, physicians, everybody, we, all of us, anybody that accepts federal money is subject to a review. So for GI, some of these things that we deal with, we've already talked about a lot of these, split shared services, modifier 25, new versus established patient, knowing the three-year rule and if you are considered a subspecialty, et cetera. Use of modifier 59, reckless use, I'm just going to put a 59 on everything and hope it gets paid. Medicare 60-day rule, if you become aware of an overpayment, you are compelled by Medicare law to refund that money within 60 days of the identified overpayment. Failure to do so may result in false claims and civil monetary penalties, and that sounds scary, guys, and I would not want to be involved in that. Cloned records, okay, and I know I've got a talk on cloning later on. So auditors are being trained on quality, not the quantity of your record. Just because you gave me an eight-page progress note does not mean it's worth anything if it's cloned. Okay, got to have customization. Place of service errors, you've got to know what place of service your patient had that service done in. Recovery audit contractors, so they recover improper Medicare payments. They are contracted by Medicare to recoup all that money, okay, so they've got their own task list, okay, so you should know who your RAC is. We've got performant recovery in Region 1 and we list the states. I've went to every single one of these websites. They are all still legit. There was one that changed, and it's Region 4. It's now Cotivity GOV Services, okay, so I updated that information. It used to be HSN Federal Solutions or something like that, but it's now Cotivity GOV Services. So know who your RAC is. If you get some feedback, a letter or anything, or your providers get information audits back from the RACs, and you're looking at, what's Cotivity? Oh, that's junk mail. I'm going to throw it away. No, it's an audit letter. It's a request for records. CERTs, Certified Error Rate Testing, okay, so this is established by CMS to monitor the accuracy of claim payments for Medicare fee-for-services. The intent of CERT is to protect Medicare's trust fund by identifying errors and assessing error rates at both the national and regional levels. Claims are randomly selected for CERT reviews. When a claim is selected for review, the provider will receive a letter via fax or U.S. mail from CMS requesting the medical documentation be submitted for a CERT review. To ensure your letter is a valid CERT request, the first page contains a CMS logo, a bar code, and it's been designed by the CMS CERT government task leader. All right, here's something that came from a CERT update, and this was quite a while ago, but it had something to do, and they still have it on their website, actually. It has something. It has to deal with amendments and corrections to the medical record, okay? So what they said is, we did a random sampling from our CERTs, and we found that this was an issue, so we're reminding you that this is the appropriate way to amend a record. So they say late entries, addendums, or corrections to a medical record are legitimate occurrences in documentation of clinical services. A late entry, an addendum, or a correction in the medical record bears the current date of that entry and is signed by the person making the addition or change. So late entry, when we refer to a late entry or when Medicare refers to something as a late entry, it supplies additional information that was omitted from the original entry. So it bears the current date that it was added, okay? So it said, for example, a late entry following treatment of multiple trauma might add abdomen soft with no masses or organomegaly, okay? So if that was truly left out, he did it, he added it. Addendum. Addendum is used to provide information that was not available at the time of the original entry. So, you know, if you request, if you order a procedure or something on the patient, and you sign your note that day, but you want to come back just to have that information in the note for next time they come in, you're going to do an addendum and add that information. Correction, okay? This is, this means, oops, okay? Never write over or otherwise obliterate the passage when an entry to the medical record is made in error. We have to know what was the original document said. Draw a single line through it, keeping the original entry legible, sign or initial and date the deletion, state the reason for the correction, document the correct information with the current date and time. Obviously, electronic records should follow the same principles, but again, it's going to look like an addendum type format, okay? Don't unlock your note and fix it, that's a no-no. You got to sign your notes, if there's something wrong with it or a delay in something that you need to add, you add an addendum. And they said falsified documentation, providers are reminded that deliberate falsification of medical records is a felony offense and is reviewed, is viewed seriously when encountered. Examples are creation of new records when records are requested, backdating, postdating, predating, writing over or adding to existing documentation except in a form of an addendum late entry correction, okay? Remember, that's just what I said, unlocking your note, don't do that. Individual payer reviews, they can be worse than Medicare. We have been into practices where they can't keep up with the record requests from commercial payers, okay, so it can be anybody. ZPICs, you don't want to mess with the ZPICs, Zone Program Integrity Contractors. The primary goal of them is to investigate suspected fraud, waste, and abuse. So if you've got ZPICs coming after you, that means they've got a very good clue indication that you guys are doing something very bad, okay? Investigating potential fraud and abuse from CMS administrative action or referral to law enforcements, they often work with the FBI, it's not a random review, they can just come up and come in and look at your records, look at your computers, it's like a raid. So anyway, you don't want to get, we don't like that. Responding to an audit, okay, I got an audit, now what do I, I've got a request for records, I've got an audit, what do I do? Routine audits, those that do not involve some suspicious or false information, whatever, but we should treat them seriously, okay? Your physicians, your providers should know who's auditing the records too, okay? Because a lot of times, you know, we'll, you know, we'll hear, oh, well, we have all these records requests because Dr. so-and-so, blah, blah, blah, blah, blah, it's like, did you tell Dr. so-and-so? You got to tell him, got to let him know. So again, if it's a ZPIC, this would come in a form of a subpoena, okay? Routine audits, given the possible consequences, we recommend a healthcare attorney, you know, just, or auditors experienced. All correspondence should be taken seriously again, and most of these, when you get reviews or when you get random audits, most of the time, there's a time, there's a 30-day, 60-day window, okay? So you got to read the letter carefully, look, provide all the information requested in the letter, okay? Include anything to help you. If you, you know, for example, this is one example, a lot of practices, when they bill for endoscopy procedures, they also review pathology for the most accurate diagnosis code, that's great. But when, if a payer requests your coding on an endoscopy, you're going to send the endoscopy report and the pathology report, because that's going to support the diagnosis code you billed. So just send things that will help through the process, don't send the entire medical record, though. Because then they might find something else and go after you for something else. Make sure that all the records are legible and good copies, clear. Never, ever alter your medical record after a notice of an audit, okay? So if you get audited for a consult, coder goes to print the consult off and like, oh my gosh, there is no exam on here. Unfortunately, we cannot alter that. You have to send in what you did. You have to send in what you did. Now, if you want to add it for patient care purposes, that's fine, but not for billing purposes. Copy each page of the medical record correctly and completely. Make color copies if you can. Include a brief summary that provides kind of what you did and how you did what you did. Include any kind of explanatory notes, LCDs, journals, etc. Keep legible copies in your office as well and give a copy to your provider. Consult, again, an experienced healthcare attorney. Never accept values or findings at face value. Contest the audit results if you're correct. Don't back down.

auditing best practices

compliance plan

payer audits

accurate coding

types of audits

responding to audits