CPMA Exam
Current False Claims Act penalties
$5,500-$11,000 per claim
How many sampling units are selected for review in a Discovery Sample under a CIA?
50
How many sets of administration codes are there?
2 sets
How many sets of NCCI edits are there?
2, one for the provider and one for the facility
How long can FFS Recovery Auditors go back and request claims after the date the claim is paid?
3 years
How many elements has the OIG identified that should be present in every compliance plan?
7
How many elements of HPI can be included in the documentation?
8
Administration codes 90460-60461
Auditor must verify that counseling was performed and that the patient is 18 years old, or younger; reported per component, not per vaccine administered; when combination codes are given, code for each component
History of present illness
A chronological description of the development of the patient's present illness from the first sign or symptom, or from the previous encounter, to the present
A comprehensive audit is:
A large number of claims are selected for review that might be focused on specific procedure and/or diagnosis codes.
QX modifier
A medically directed CRNA
Why is it important for an auditor to be familiar with both sets of guidelines?
A provider can choose either the 1995 or the 1997 guidelines and they must determine which will be more advantageous to the provider
The sample is usually created from:
A report generated within the billing system for retrospective audits
What is required to bill a consultation?
A request by a provider or other appropriate source, a recommendation of care for a specific condition, and a written report from the consulting provider to the requesting provider/appropriate source
How should a paper medical record be corrected?
A single line strike through should be used so the original content is still readable; the person altering the medical record must sign and date the revision, amendment, or addenda
Advance Beneficiary Notice (ABN)
A standardized form that explains to the patient why Medicare may deny the particular service or procedure; protects the provider's financial interest by creating a paper trail that CMS requires before the provider can bill the patient for payment if Medicare denies coverage for the stated service or procedure
What is the civil monetary penalty for covered entities that fail to comply and cooperate with any investigation initiated by OCR?
Between $100-$50,000 or more per violation with a calendar year cap of $1,500,000
Utilization review and data mining provide insight into:
Billing patterns and can uncover areas of risk
Chemotherapy and therapeutic drug administration requires codes for:
Both the administration and the supply
Proportional sampling
Built around high frequency items or those items that are considered proportionally significant
According to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), an outside auditor must sign which of the following agreements prior to reviewing and auditing any medical records?
Business Associate Agreement
How are most test results reported?
By a number value on a computer printout
How does a physician "sign" an electronic record?
By entering his or her unique code into the system
How is the amount and complexity of data to be reviewed measured?
By the need to order and review tests and the need to gather information and data
CLIA number
Certifies the complexity of tests to be performed in the testing location
What recordkeeping principles apply when a modification is made to the medical record?
Clearly and permanently identify any amendments, corrections, or addenda; clearly indicate the date and author of any amendments, corrections, or addenda; and clearly identify all original content (do not delete)
CMS transmittals
Communicate new or changed policies or procedures that will be incorporated into the CMS Online Manual System; each one has a transmittal number, an issue date, an implementation date, a Change Request number, and a subject name
When auditing an ENT practice, you discover the practice uses an EMR. Which of the following options would you look for when reviewing documents created in the electronic medical record or notes created using templates that may be indicators of misuse?
Complete medical histories on each visit, diagnosis driven by clinical picture, repetitious notes not relevant to presenting problem.
What is the most common type of audit?
Compliance audit
What systems meet the authentication requirements for medical record entries?
Computerized systems that require the physician to review the document on-line and indicate that it has been approved by entering a computer code; a system in which the physician signs off against a list of entries that must be verified in the individual record; and a mail system in which transcripts are sent to the physician for review, and the he/she signs and returns a postcard identifying the record and verifying its accuracy
An annual audit is the minimum requirement an IRO must conduct under what agreement?
Corporate Integrity Agreement
What could be the result of auditing too many records?
Could hurt productivity and is not any more effective
Category III codes
Created to report new and emerging technologies
First D in CHEDDAR
Details
If a pattern of medically unnecessary claims submitted to Medicare can be shown-and the physician knows or should know that the services are not medically necessary-the physician may face:
Large monetary penalties, exclusion from Medicare program, and criminal prosecution
Left anterior oblique (LAO)
Left front angled view
Who should an auditor consult with to resolve any issues of confusion in regards to an audit involving improper payments?
Legal counsel
Issues in an audit report should be presented in a ______ sequence.
Logical
In many cases, the audit identifies a specific error or cause of error, after which it is common to:
Look at this issue more closely in subsequent audits
Second D in CHEDDAR
Drugs and dosages
Objectives of an audit report
Effective means of communicating the audit results, effective educational tool, and can serve as a roadmap for achieving compliance
Documentation requirements for therapy services include:
Evaluation and Plan of Care; certification and recertification; progress reports which provide justification for the medical necessity of treatment information; and treatment encounter notes for each treatment day
What should providers list on the ABN?
Every recommended procedure or service that might not be covered
E in CHEDDAR
Exam
A physician asks you, her auditor, what is the specific difference between 1995 and 1997 versions of documentation guidelines. Your response would be:
Exam elements
How is time defined in the office and outpatient setting?
Face-to-face time
How far in advance must the ABN be presented by the patient, according to CMS?
Far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice
A monitoring system may be based on:
Findings from the baseline audit
Patients can request copies of disclosure of PHI under HIPAA:
For a six (6) year period of time
Anteroposterior (AP)
Front to back
Patient registration form
Gathers information needed to identify the patient and process claims and typically includes the date, patient demographic information (age, DOB, address, SSN), insurance and financial information, and an emergency contact
A useful audit tool:
Guides the auditor through all the compliance issues that should be addressed, based on the scope and objective
H in CHEDDAR
History of present illness
You are preparing to perform a surgical chart audit. What resources would you need in order to accurately conduct the audit?
ICD-9-CM, CPT®, HCPCS Level II code books, NCCI edits, medical terminology book, global days, surgery audit tool, rules of insurance carriers
Entries included in a medical record
Identification information, a patient's health history, medical examination documentation and findings, and test results, among other information
An IRO should not engage in:
Implementation of any necessary corrective action, or otherwise consult with or advise the auditee
Modifier 22
Increased procedural services; documentation must clearly indicate why the procedure was more extensive, requiring more time or effort than is typically required
The IRO must remain:
Independent
If the tie to a federal healthcare program is not obvious and an audit results in error that causes an apparent overpayment, the auditor should:
Make a recommendation that the practice engage legal counsel (where counsel has not already been engaged) for analysis of the entity's legal duty to disclose and refund any any identified overpayment, or to perform additional auditing necessary to identify the totality of the potential overpayment; where counsel is already engaged, the auditor has usually been engaged by counsel and must therefore simply report any concerns to the entity's appointed counsel
Auditing psychotherapy codes
Make sure the time documented supports the codes reported
CMS Fraud Definition
Making false statements or misrepresenting facts to obtain an undeserved benefit or payment from a federal healthcare program
Why should you review MAC guidance when auditing E/M services?
Many have audit tools, FAQs, and online E/M education; you must review the provider based on the standard he or she will be measured against
Audit report: audit objectives
May be to assess compliance with a pending change in a carrier's documentation standards, to assess the effectiveness of prior education efforts, to identify and assess potential post-payment risk, or to determine the veracity of compliance concerns reported by an employee, patient, or carrier, etc.
The electronic audit tool software does not have the capability to analyze:
Medical necessity
What element should drive the level of a visit?
Medical necessity
What needs to be the overarching factor when selecting a code?
Medical necessity
When performing a retrospective audit, the auditor will need to have what materials?
Medical record, audit form, coding manuals, EOB or Medicare RA, payer policies and CMS-1500 form.
In reviewing claims for an ENT provider, you identify that he is consistently billing Medicaid for four units of 69641. Which of the following resources would support your findings that this provider is billing too many units?
Medically Unlikely Edits
For what insurance provider must you follow the documentation rules to be properly reimbursed when an anesthesiologist performs monitored supervision?
Medicare
When the sample is designed, the auditor must:
Merely audit the sampled claims
Global surgery status indicator: 000
Minor procedures with preoperative and postoperative relative values on the day of the procedure only are reimbursable. E/M services on the same day of the procedure are generally not payable.
QS modifier
Monitored anesthesia care service
Where the propriety of the coding is at issue, the auditor often helps to identify the ______ _______, especially where the nature of the error or errors creates a _____ and _____ universe of potentially suspect claims.
Sampling frame; large; diverse. In such a case, it may not be feasible to audit 100% of the potentially suspect claims and the input of the auditor may be necessary for the statistician to define the appropriate sampling approach. Such input might involve identifying any available data elements or group of elements within the billing data that might be used to identify potentially suspect claims
The practice manager has requested an audit of all E/M services for all the providers. The practice manager has determined the:
Scope
If approved for the primary care exception, the resident can:
See patients on his or her own and discuss the case with the teaching physician
When responding to a subpoena for medical records, what document would likely not be required to be copied and submitted:
Signed authorization for release of information
Informed consent
Signed by the patient to verify that the patient understands procedures, outcomes, and options; consists of the patient's diagnosis (if known), the nature and purpose of a proposed treatment/procedure, alternative treatments/procedures, the associated risks and benefits, and the risk and benefits of not receiving the treatment/procedure. The patient can withdraw this consent of the procedure at any time.
Confirmation of Receipt of Privacy Notice
Signed documentation from the patient that he/she received the entity's privacy notice
Modifier 25
Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service
Anti-Kickback Law
Similar to the Stark Law but imposes more severe penalties; states that whoever knowingly or willfully solicits or receives any remuneration in return for referring an individual to a person for the furnishing or arranging of any item or service for which payment may be made in whole or in part under a federal healthcare program or in return for purchasing, leasing, ordering, or arranging for or recommending purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in whole or in part under a federal healthcare program is guilty of a felony
Purposed of including a patient's medical history in the record
So healthcare providers can make assessments about a past, current, or future state of an illness
Why is it important to include the time of service in every medical record entry?
So that the events of a patient's medical treatment may be reconstructed at a later time. If the time of the service is significantly different from the time of the chart entry, both times should be documented with an explanation for the delayed entry.
Why should an auditor concentrate on visits that took place during a specific period?
So that trends can be observed
Add-on code definition
Some of the procedures listed in CPT are carried out "in addition to" the primary procedure performed. Add-on codes are never reported alone. They always accompany specific primary procedure codes. There usually is a parenthetical note following the add-on code to indicate the appropriate primary code(s) for the add-on code.
What is a drawback of using an electronic audit tool?
Sometimes, the level selected by the audit software affords a higher level of service based on documentation alone and the medical necessity element cannot be incorporated into the software.
Modifier 58
Staged or related procedure or service by the same physician or other qualified healthcare professional during the postoperative period; applies when the physician planned a supplementary service during the global period of another procedure, or when the patient required the supplementary service to complete treatment begun at an earlier date
Conditions of Participation (CoP) and Conditions for Coverage (CfC)
Standards set forth in the Federal Register that must be met to participate in Medicare and Medicaid Programs; they include Ambulatory Surgical Centers (ASCs), Critical Access Hospitals (CAHs), and hospitals
S in SOAP
Subjective
Evaluation and Management documentation is often captured in SOAP format, which is the acronym for:
Subjective, Objective, Assessment, Plan
How do you determine how the audit results will be reported?
Summarize results, analyze and apply results, meet with the practitioner to discuss results and offer solutions for improvement, and refund overpayments and submit claims for missed charges (if applicable)
Types of history often involved in the medical record
Surgical history, obstetric history, medications and allergies, family history, social history, immunization history, developmental history
PC/TC indicator: 3
Technical Component Only Codes: This indicator identifies the codes describe the technical component only. Modifiers 26 and TC cannot be reported.
Risk areas of EHRs
Templates might cause a provider to document more than is medically necessary for that visit, EHRs allow copying or cloning medical records which can cause many records to look the same and cause information to be recorded that did not apply to that visit
What organization is responsible for criminal prosecutions under the Privacy Rule?
The Department of Justice
What organization is responsible for administering and enforcing the standards set forth in the Privacy Rule?
The HHS OCR
What organization has published a standard for the appropriate use of abbreviations as well as a "minimum list" of dangerous abbreviations, acronyms, and symbols?
The Joint Commission (JC)
What is included in each section of the operative report?
The header, indications for surgery, the detail or body of the procedure, and the findings
Assessment
The healthcare provider makes a determination (also known as a diagnosis) about the cause of the symptoms, which is the provider's assessment of the problem. Based on that assessment, the provider creates a plan to relieve or resolve the patient's symptoms.
An IRO report must specifically address:
The issues (and only those issue) detailed in the CIA
How is risk determined?
The item in the column that best describes the patient is selected
Who should bill the service when a specimen is sent to an outside facility for testing?
The lab performing the test
Where errors are identified in an annual audit, they should be added to:
The list of issues evaluated in subsequent internal audits
Diagnosis codes identify:
The medical necessity of services provided by describing the circumstances of the patient's condition.
CMS has the power under the Social Security Act to determine on a case-by-case basis if:
The method of treating a patient is reasonable and necessary
What is the auditor's best guide regarding the number of diagnoses and management options?
The nature of the presenting problem and the medical necessity of the encounter
A problem is finding an auditor with:
The necessary training and expertise in auditing medical records for coding and compliance
The codes used to report a nerve block is selected based on:
The nerve injected
Monitoring
The ongoing process of reviewing coding practices and the adequacy of the documentation and code selection; should be conducted regularly
What should be included in the informed consent for treatment?
The patient's diagnosis (if known), the nature and purpose of the treatment, risks and benefits of the treatment, alternative treatment options, risks and benefits of alternative treatment options, risks and benefits of not receiving any treatment
Timing
The patient's statements regarding a measurement of when or at what frequency they noticed the complaint
Modifying factors
The patient's statements regarding anything that makes the problem better or worse
Context
The patient's statements regarding what the patient was doing, their environmental factors, the circumstances surrounding the complaint
What should be reviewed when auditing a provider who performs consultations?
The payer policies
CPT codes for epidurals are determined based on:
Whether a single injection is performed or if it is a continuous infusion, and the section of the spine in which the epidural is inserted.
Where the propriety of the coding is at issue and the statistician identifies the sample, the auditor would determine:
Whether the sampled claims were reported appropriately and if not, identify the financial impact of the non-compliance; in some cases, the auditor may recommend a different code
Where the knowledge of a potential overpayment is obtained based on an audit of a limited sample of claims, the cause of the error usually indicates:
Whether there is a significant likelihood that similar error exists outside the claims included in the sample; if such an error involves improper payments from federal healthcare programs, the entity may be obligated to initiate one of a variety of self-disclosure processes
Audit parameters
Whole chart or just 1 record from the chart, multiple patients with the same diagnosis, and multiple patients seen on same date of service
Can the elements of the ROS and PSFH be taken from a previous encounter?
Yes, if there is documentation that the provider reviewed and updated the previous information; the provider must include any new information or comment that there has been no change and indicate the date and location of the previous ROS or PFSH
Is the number of radiological views the same as the number of digital images or films?
No
Is there a quantifiable number of body area(s) or organ system requirements when using the 1995 guidelines?
No, because of this, some practices choose to follow the 1997 guidelines
O in SOAP
Objective
When was the CPG for individual and small group physician practices issued?
October 5, 2000 in the Federal Register
Audit findings are of little value unless the findings are shared with the provider to:
Offer recommendations for improvement, illustrate compliant documentation, and address problem areas.
With the elimination of payment for consultations, what codes does Medicare direct providers to use?
Office and other outpatient and hospital care E/M codes
Medicare conducts an in-depth analysis of medical necessity for:
Office visits, hospital visits, nursing home visits, and procedures and services provided by physicians
Example: Column 1 Code/Column 2 Code 45385/45380 CPT Code 45385 - Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique CPT Code 45380 - Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple Policy: More extensive procedure Modifier -59 is:
Only appropriate if the two procedures are performed on separate lesions or at separate patient encounters.
Ears, nose, and throat
Patient's answers about signs or symptoms including sensitivity to noise, ear pain, ringing in the ears, vertigo, feeling of fullness in the ears, ear wax, and abnormalities. Other possible conditions include nosebleed, postnasal drip, sneezing, nasal drainage, impaired ability to smell, sinus pain, difficulty breathing, and history of sinus infection and treatment. For the throat and mouth: sore throat, current/recurrent mouth lesions, teeth sensitivity, bleeding gums, history of hoarseness, change in voice quality, and difficulty in swallowing or inability to taste
Endocrine
Patient's answers about signs or symptoms of the endocrine system such as blood sugar readings at home, sudden changes in height and/or weight, increased appetite or thirst, intolerance to heat or cold, or changes in hair distribution or skin pigment
Neurological
Patient's answers about signs or symptoms of the neurologic system such as numbness, tingling, dizziness, fainting or unconsciouness, seizures or convulsions, memory loss, attention difficulties, hallucinations, disorientation, speech or language dysfunction, inability to concentrate, sensory disturbances, motor disturbances including the gat, balance, and coordination, tremor, or paralysis
Business Associates
Perform certain functions or activities which involve the use or disclosure of individually identifiable health information on behalf of another person or organization
External audit
Performed by an individual or group not part of the organization or the practice
Internal audit
Performed by members of the organization
Retrospective audit
Performed on claims that have already been submitted for payment
Prospective audit
Performed prior to claim submission so that variances in the coding may be corrected prior to claim submission; if the documentation does not support the CPT/HCPCS code or ICD-9 code that was to be billed, the coding should be corrected based on the audit findings
What services are included in the definition of outpatient therapy?
Physical therapy, occupational therapy, and speech-language pathology services
Which type of case is not prosecuted under the federal false claims act?
Physician tax issues
What is proper protocol for making a correction to a paper medical record?
Place a single line strike through the original statement, signing and dating the revision
P in SOAP
Plan
Diagnostic test systems are placed into 1 of 3 CLIA regulatory categories based on:
Potential for risk to public health
The global fee includes:
Preoperative visits beginning with the day before the day of surgery; intraoperative services that are a usual and necessary part of a surgical procedure; all additional medical or surgical services required of the physician within 90 days of the surgery due to complications that do not require additional trips to the operating room; related follow-up visits made within the 90-day postoperative period; post-surgical pain management by the surgeon; any related supplies, services, procedures normally required for the particular surgery
When conducting a compliance audit your findings identify that one of the providers is signing chart entries in the EMR three days after seeing patients. What steps should be taken to address this finding?
Prepare a summary of findings that include number or percentages of compliant vs. non-compliant charting; discuss with the provider, including recommendations for improvement; re-audit according to criteria established by the practice.
QK modifier
Qualified Individual who is medically directing 2-4 concurrent procedures
Test may be identified as:
Quantitative or qualitative
Compliance Plan
Represents comprehensive documentation that a provider, practice, facility, or other healthcare entity is taking steps to adhere to the federal and state laws that affect it
Audit universe
Represents the potential range of all audit activities
HIPAA Administrative Simplification provisions
Required that sections of the law be publicized to explain the standards for the electronic exchange, privacy, and security of health information
Component of the audit report: report attachments
Resources/reference list and service-specific results
Social history
Review of the past and current activities that the patient is undergoing; should be age appropriate
Right anterior oblique (RAO)
Right front angled view
Right posterior oblique (RPO)
Right rear angled view
Surgical CPT codes are assigned global surgery status indicators based on:
Risk factors associated with medical procedures
Payment for minor procedures includes:
Same-day services (either preoperative or postoperative care), intraoperative care, and care within the defined global period
Cardiovascular
Answers by the patient regarding signs and symptoms which may include chest pain, tightness, numbness, palpitations, heart murmurs, irregular pulse, color changes in the fingers and toes, edema, or leg pain when walking
Non-statistical or judgmental sampling
Can be applied to a focused audit; sample based on unique services that were defined in the objective and the scope; could be used if the audit is being performed to look only at high levels of service
What is an example of a scenario that would support medical necessity for critical care services?
Care given to a patient in renal and respiratory failure
Which set of guidelines do carriers use when auditing medical records?
Carriers will review both sets of guidelines and give the provider credit for using either set that is most advantageous for the provider for the visit
Decubitus (DEC)
Patient lying on their side
In what situations might it be the auditor's responsibility to develop a corrective action plan?
In the case of routine or annual compliance audits conducted on behalf of providers that do not have formal compliance programs or staff
What year should an auditor use for a codebook to audit a chart?
The year the services being audited were rendered
Many payers will follow NCCI in addition to:
Their own bundling edits
Global surgery status indicator: YYY
These are unlisted codes, and subject to individual pricing.
Why are templates often adopted for medical records?
To ensure consistency and accuracy
What is the purpose of National Safety Goals?
To help institutions identify areas where safety can be improved through medication safety and hospital acquired infections
Purpose of a contract between business associates
To impose specified written safeguards on the individually identifiable health information used or disclosed by the business associate
How is time defined in the inpatient setting?
Unit/floor time
What do payers use to determine the expected reimbursement?
Units; units may vary from payer to payer
What is the only option to report an encounter without a chief complaint?
Unlisted code 99499
How do you determine the scope of an audit?
Select type of services to review, select patient population based on payer type, determine the time frame to be used to select claims
For potential or actual Stark law violations, HHS provides a separate disclosure process called the:
Self-Referral Disclosure Protocol (SDRP)
To support medical necessity, the assessment and plan must define clearly the following:
1. All diagnoses the provider is managing during the visit 2. For an established diagnosis, whether the patient's condition is stable, improved, worsening, etc 3. When diagnostic tests are ordered, the rationale for ordering the tests are either documented or easily inferred 4. Management of the patient is documented clearly
Steps to determine medical necessity
1. List the principal diagnosis, condition, problem, or other reason for the medical service/procedure. 2. Assign the code to the highest level of specificity. 3. For office and/or outpatient services, never use a "rule-out" statement (a suspected but not confirmed diagnosis). 4. Be specific in describing the patient's condition, illness, or disease. 5. Distinguish between acute and chronic conditions, when appropriate. 6. Identify the acute condition of an emergency situation. 7. Identify chronic complaints or secondary diagnoses, only when treatment is provided or when they affect the overall management of the patient's care. 8. Identify how injuries occur.
Based on the 1995 and 1997 guidelines, how many components are required for established patients to determine the correct code?
2/3
When were National Safety Goals established?
2002
An external audit will typically conduct what type of audit to measure the coding compliance for each practitioner?
A baseline audit
For how long does CMS require hospitals to retain all patient records?
At least 5 yrs after the submission of their closed cost reports
Radiology
A branch of medicine using radiation-including ionizing radiation, radionuclides, nuclear magnetic resonance, and ultrasound-to diagnose and treat disease
The final audit selection should include:
A certain percentage of patient encounters to ensure a representative sample.
CCM indicator 1
A CCM is allowed and will bypass the edits
CCM indicator 0
A CCM is not allowed and will not bypass the edits
When should appropriate risk analysis occur?
At the beginning of the audit
When should information be entered in the patient's chart?
At the time of service or immediately following the service
QY modifier
An anesthesiologist that medically directed a CRNA in a single case
When was HIPAA enacted?
August 21, 1996
How can an auditor make their report understandable?
Be mindful of the intended reader and his/her level of expertise, be cautious of tone, present options objectively, do not overstate potential risks and/or render legal conclusions, stick to the conclusion justified by the objective comparison of the facts and the rule, and keep the report as brief as possible while making the points that need to be made
Modifier QW definition
CLIA waived test: This modifier is reported with any test on the CMS list of CLIA waived tests
Posteroanterior (PA)
Back to front
QZ modifier
CRNA who is performing anesthesia services without medical direction by a physician
Most reported codes for insertion of a central venous line
36555 and 36556
Codes for insertion of arterial catheters
36620 and 36625
HIPAA electronic transaction content and format requirement
ASC X12N or NCPDP (used for certain pharmacy transactions)
A in CHEDDAR
Assessment
A focused audit may concentrate on one type of service to:
Determine compliance
Coronal plane
Divides the body in half from front to back
A provider knows that an evaluation and management service they provide on the same date as a major procedure will be bundled, so submits the claim for the E/M with a different date of service. This is an example of:
Fraud
When does the False Claims Act allow for reduced penalties?
If the person committing the violation self-discloses and provides all known info within 30 days, fully cooperates with the investigation, and there is no criminal prosecution, civil action, or administrative action regarding the violation
When can services provided by teaching physicians with resident services can be billed to Medicare?
If the physician is involved in the key or critical portions of the services performed by the resident, and if the physician participates in the patient's management
Where can base units be found?
In the Crosswalk or RVG Guide
Medicine section
Includes therapeutic and diagnostic services
Why is it important that the scope also defines what will not be part of the audit?
It is important so that the outcomes do not reflect misleading information
Do all payers follow CPT coding guidelines?
No
If the patient chooses to proceed with a procedure after signing an ABN, he or she may request:
The charge be submitted to Medicare for consideration (with the understanding that it will probably be denied)
Who is required to certify the care or re-certify the plan of care if significant modifications are made?
The physician or NPP
Indication
Typically gives a brief history outlining the reasons for or medical necessity for the procedure
When can outpatient therapy start?
When the initial plan of care has been established
In what circumstances is the importance of timely medical records entries more critical?
When the patient is undergoing a complicated set of services by different healthcare providers
When does anesthesia time end?
When the personal attendance of the anesthesia provider is no longer required
When are acronyms acceptable in the medical record?
When they are commonly recognized
Novitas Solutions guidance for distinguishing between expanded problem focused and detailed exam using the 1995 Documentation Guidelines
"By providing a tool we call 4x4 (4 elements examined in 4 body areas or 4 organ systems satisfies a detailed examination; however, less than such can be a detailed exam based on the reviewers clinical judgment) our reviewers and physicians have a clinically derived tool to assist in implementing the E/M guidelines and decreasing one area of ambiguity."
Medicare defines medical necessity as:
"Services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member."
Qualifying circumstances codes
+99100, +99116, +99135, and +99140
Audit steps for E/M
1. Determine the scope of the audit 2. Make sure the documentation is complete and legible, signed properly, and the DOS is correct. When an EMR/EHR was used to create the documentation, make sure the records haven't been cloned. Look for inconsistencies in the documentation. 3. Determine whether to follow CMS 1995 or 1997 Documentation Guidelines. Review MAC guidance for the provider being audited to determine if there is further guidance or an audit tool that is MAC specific. Inquire if the practice has a policy to use one set of documentation guidelines over another. 4. Verify the provider of service has been appropriately reported on the claim for post payment audits or encounter form/superbill for prepayment audits. 5. Review the medical record using an audit tool to capture elements that are given credit. 6. Determine the correct E/M category and level using the 3 key components or time if properly documented. 7. Verify the service provided is medically necessary. 8. Run a utilization comparison of the provider against peers in the same specialty to see how the provider compares. 9. Compile a report to communicate the findings. 10. Determine ongoing monitoring and education targeted at the provider's specific deficiencies.
The history component consists of:
A chief complaint (CC), history of present illness (HPI), review of systems (ROS), and past, family and social history (PFSH)
What must be included in the privacy practice notice?
A clear explanation of the covered entity's obligation to protect privacy, provide a notice of privacy practices, and abide by the terms of the current notice; the covered entity must also inform the patient of his or her individual rights, and the steps to follow (including a point of contact for further information) if an individual feels his or her privacy rights have been violated
Rules applicable to federally-regulated health plans are found primarily in:
A federal statute. The auditor must look to federal regulations for the administrative agency responsible for the interpretation of those statutory requirements.
Procedure definition
A manner of effecting change through the application of clinical skills that attempt to improve function; codes require direct patient contact from a physician or therapist
What are assigned to some of the physical status modifiers that are recognized by some payers?
Additional base units; when P3-P5 are reported and supported by documentation, additional units may be factored into the calculation for total anesthesia units; P3 is assigned one unit, P4 is assigned 2 units, and P5 is assigned 3 units
Review of systems
An account of body systems obtained through a series of questions seeking to spot signs and/or symptoms that the patient may be experiencing, or has experienced; the physician and/or staff make this query verbally or via the patient intake form; may be about the systems directly related to the problems identified in the HPI and/or additional body systems; commonly interspersed with elements of the HPI
CMS Abuse Definition
An action that results in unnecessary costs to a federal healthcare program, either directly or indirectly
What do most CIA's require?
An annual audit and will define the specific number of claims to analyze, how to sample, and the issues to evaluate
Baseline audit
An audit (usually random) of all possible services provided within a specific time frame, and is normally performed if documentation from various types of services needs to be reviewed
What is the most critical step in the audit process?
An auditor's ability to effectively communicate the audit results and recommendations
Chart audit
An examination of claims data and medical records to determine if the documentation for a particular claim is compliant, if the claim is correctly coded, and if all charges are captured.
A in SOAP
Assessment
Medicare calculation to determine total anesthesia units
Base Units + Time Units = Total Units
What components of the compliance plan should be adopted by the practice?
Based on the practice's specific history with billing problems and other issues, the practice should begin by adopting only those components most likely to provide an identifiable benefit
Organ systems
Constitutional; eyes, ears, nose, mouth, and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; skin; neurologic; psychiatric; hematologic; lymphatic; and immunologic
What should be included in the documentation of a finding of non-compliant conduct?
Date of incident, name of reporting party, name of the person responsible for taking action, and the follow-up action taken
Outpatient therapy treatment encounter notes for each treatment day should include:
Date of treatment; treatment, intervention, or activity; total timed treatment by individual modality and total treatment time in minutes (includes timed codes and untimed codes); signature and professional identity of the qualified professional furnishing the treatment; and additional information may include response to treatment or changes
Medically Unlikely Edits
Define the maximum units of service that a provider would report, under most circumstances, for a single beneficiary, on a single date of service, for a specific HCPCS/CPT code
Audit scope
Defines the specific concerns to be addressed with an audit
Semi-quantitative tests
Describe an amount within a specified range or over a certain threshold, but do not identify a specific quantity
Physical Status modifiers
Describe the condition of the patient receiving anesthesia services; append to the 5 digit anesthesia CPT code
Qualitative testing
Determines the presence or absence of a drug only
Psychiatric services include:
Diagnostic evaluations, psychotherapy, and other procedures
What was included in the OIG Work Plans for 2013 and 2014?
Direction to review EMR/EHR systems due to concerns over system up code selection, cloning of patient data on subsequent visits, and auto population or auto fill features
What is the appropriate way to dispose of PHI that is no longer needed?
Discard it in a locked shredding receptacle
Privacy Rule exceptions to the business associate standard
Disclosures by a covered entity to a healthcare provider for the treatment of the individual; disclosures to a health plan sponsor, such as an employer, by a group health plan that provides the health insurance benefits or coverage for the group health plan; and the collection and sharing of PHI by a health plan that is a public benefits program, such as Medicare
Modifier 59
Distinct procedural service. This modifier is used to indicate that a procedure is distinct or independent from another procedure performed on the same day. The documentation must support a different session, different procedure, different site, or separate incision/excision.
What should the provider do if the beneficiary refuses to sign a properly presented ABN but still requests the service/procedure?
Document the patient's refusal and sign the form, along with a witness
The decision to perform the audits internally or externally is determined by:
Each individual practice
How much information should be included in a written summary of the services rendered on the DOS?
Enough information about the patient encounter so that it could be used in place of the transcription in case of loss, misfiling, or inaccuracies
Examples of fraud/misconduct subject to the False Claims Act
Falsifying a medical chart notation; submitting claims for services not performed, not requested, or unnecessary; submitting claims for expired drugs; upcoding and/or unbundling services; submitting claims for physician services performed by a non-physician provider without regard to Incident-to guidelines
When must ABN's must be signed?
Far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice
Reverse False Claims section of the False Claims Act
Final section that provides liability where a person acts improperly to avoid paying money owed to the government
When monitored anesthesia care (MAC) is performed, what modifiers may apply?
GS, G8, and G9
Exceptions to the Stark Law
General exceptions to both ownership and compensation arrangement prohibitions (in-office ancillary services); general exceptions related only to ownership or investment prohibition for ownership in publicly traded securities and mutual funds (services furnished by a rural provider); exceptions related to other compensation arrangements (personal services arrangements and rental of office space and equipment)
PC/TC indicator: 4
Global Test Only Codes: This indicator identifies stand-alone codes that describe selected diagnostic tests that have professional component only codes and technical component only codes. Modifiers 26 and TC cannot be reported.
What codes are used to report chemotherapy and therapeutic drug supplies?
HCPCS Level II
Forms of medical record documentation
Handwritten, dictated, templates, or electronic
Major surgical procedure Medicare definition
Having a one-day preoperative period and a 90-day postoperative period
What must the provider do is he or she cannot obtain the history from the patient or other source?
He or she must document the patient's condition or other circumstance that prevented him or her from obtaining the history
How should the provider obtain a history about a patient if the patient presents unconscious or has dementia?
He or she must make an effort to obtain history from another source such as a family member, EMS bringing the patient to the emergency room, or the patient's primary care physician
How should a physician indicate that an abnormal result was seen?
He or she should circle and sign the abnormal result
Body areas
Head and face; neck; chest including the breast and axilla; the abdomen; genitalia; groin; buttocks; back including spine; and each extremity
HIPAA covered entities
Health plans, healthcare clearinghouses, and any healthcare provider who transmits health information in an electronic format
Knowing your client's risk tolerance will:
Help you to provide the appropriate corrective action options
Core requirements in CIAs
Hiring a compliance officer/appointing a compliance committee; developing written standards and policies; implementing a comprehensive employee training program; retaining an independent review organization (IRO) to conduct annual reviews; establishing a confidential disclosure program; restricting employment of ineligible persons; reporting overpayments, reportable events, and ongoing investigations/legal proceedings; providing an implementation report and annual reports to the OIG on the status of the entity's compliance activities
Both sets of guidelines are determined by what 3 key components?
History, exam, and medical decision-making (MDM)
History of present illness (HPI)
How the patient describes the symptoms he or she is experiencing, and which have prompted the patient to seek medical attention
Where the OIG identifies an issue and imposes a CIA, those issues will be the specific focus of the:
IRO in the annual audit required by the OIG, as part of the CIA
A lines
Intra-arterial catheters; allow the physician to monitor arterial blood pressure and to have easy access to collect specimens to measure arterial blood gases
Component of the audit report: background
Introductory section in which the identity of the entity, physician(s) being audited, the audit objectives, the type of audit, the scope of the audit, and identity and qualifications of the auditor are detailed
All potential overpayments must be ______ and where overpayments are discovered, they must be ______ and ______.
Investigated; disclosed; refunded
Why should an auditor know what is in the OIG Work Plan for the current year?
It allows an auditor to inform providers and facilities of services or issues of which to be especially mindful in the coming year; may be helpful in forming the scope of an audit for a provider or facility or may influence recommendations given to a practice
CMS rules for time based physical therapy and rehabilitation codes
It has 2 parts: you look at each code separately and total time; time is based on 15 min increments and is reported to the nearest 15 min based on the 8-minute rule (applies only to time based codes); time bundling will occur when services are not provided for the full 8 minutes; 2 services can be performed under 8 min each but the total units will allow you to bill for at last 1 unit. In that case, lower RUV codes bundle to higher RVU codes and lower time will bundle to higher time
Why is the CERT program beneficial to auditors?
It identifies errors causing improper payments by the Medicare program. The errors found can identify areas for providers to improve documentation.
CMS advice to prepare providers for RAC audit
Know where previous improper payments have been found and look to see what improper payments were found by the Recovery Auditors and in OIG and Comprehensive Error Rate Testing (CERT) reports; know if you are submitting claims with improper payments and conduct an internal assessment to identify if you are in compliance with Medicare rules and identify corrective actions; appeal when necessary (the appeal process for a Recovery Audit denial is the same as the appeal process for MAC denials)
A provider receives a denial on a Medicare claim due to lack of medical necessity. What resource is a valuable tool for providers to limit denials for medical necessity?
LCDs
A common audit finding for teaching physician services is:
Lack of documentation of a face-to-face encounter with the patient and teaching physician
Is accreditation by an AO mandatory?
No, it is voluntary
If there are elements missing in an operative note, does it always mean that something wasn't done?
No, it may be that the physician believes the missing element would be inherently "built into" the note by another physician reading that note
Is it necessary to have a separate operative report for a minor office procedure that is performed during an E/M service?
No, the documentation for that procedure can be included in the notes for the E/M service
If a controlling standard does not exist for the service you are evaluating, you should not declare error but can use:
Persuasive standards (with appropriate citations and qualifications) to identify potential post-payment risk
PC/TC indicator: 0
Physician Service Codes: The PC/TC concept does not apply.
What are indications of data collected?
Planning, scheduling, performing, and reviewing clinical labs and tests from the medicine section and radiology sections; reviewing history from a family member or caregiver
Electronic audit tool
Prints audit reports and analyzes the data after the detail of the E/M level is entered
National Physician Fee Schedule Relative Value File, meaning of 2 in the Multiple Procedure column
Procedure is subjected to the multiple procedure payment reduction
A sample is gathered of the CPT®/HCPCS codes that have the highest dollar charges. This would be considered which type of sampling?
Proportional
Keep the focus on the ______ ______, and be prepared to present ______ where implementation of the recommended course of corrective action is not feasible.
Proposed solutions; alternatives
How often may additional audits be performed, after the baseline audit is conducted?
Quarterly, biannually, or annually, depending on the results of the baseline audit
What is the name of the statistical sampling program provided by the OIG to randomly select and determine the size of the Discovery Sample?
RAT-STATS
What are the only elements that can be recorded by someone other than the provider performing the E/M service?
ROS and PFSH; there must be documentation in the note that the provider reviewed the information obtained by someone else
Amount of civil monetary penalties
Range from $10,000-$50,000 per violation and an assessment of up to 3 times the amount of the over-payments
What is a good reminder to give the auditee when communicating their audit results to them?
Remind the auditee that no one is perfect and that the purpose of auditing is less to put a seal of approval on the practice's compliance efforts, and more to identify what the practice needs to work on
Sarah Smith works for an emergency physician group. She has been given the responsibility to perform a baseline E/M audit for the physicians in the group. What is the first step she should take to begin this process?
Run a utilization report of E/M services
Sandra Keller works for an internal medicine practice. As part of the practice's compliance plan, she has been given the responsibility to perform an audit of the top five surgeries performed by the group at Hill Dale Hospital in the past year. How will Ms. Keller determine what types of services to review for this physician group?
Run a utilization report of all surgeries performed by the group's physicians during the past year at Hill Dale Hospital.
SOAP and CHEDDAR are two formats of medical record documentation. Which section of each format would you find the patient's history?
S in SOAP and H in CHEDDAR
What is RAT-STATS used for by an auditor?
Software used in performing statistical random samples and evaluating results
Hiring a full-time internal auditor may be cost prohibitive for what types of practices?
Solo or small group practices
When an auditor is seeking more information than what is available in the CPT codebook, what resource can be helpful?
Specialty societies' websites and publications that provide layperson descriptions for surgical CPT codes
Where the cause of error is a misunderstanding on the part of the entity's coding/billing personnel, education of those individuals usually involves:
Specific policy requirements
The CPT codebook describes the surgery package as including:
Subsequent to the decision for surgery, 1 E/M visit on the date immediately prior to or on the date of the procedure (including history and physical); local anesthesia: defined as local infiltration, metacarpal/digital block, or topical anesthesia; operation itself; immediate post-operative care, including dictation of operative notes, talking with family and other physicians; writing orders; evaluation of patient in post-anesthesia recovery; normal, uncomplicated follow-up care
What does a signature alongside the note indicate?
That the provider has read the transcription and approved the information
What is the most important component of medical records retention?
That the record is protected, to ensure the security and integrity of the records; they should be accurately written, promptly completed, filed, and readily accessible
For payers allowing payment for the consultation codes, what guidelines should be followed?
The CPT coding guidelines
How should an electronic health record (EHR) be corrected?
The amendment, correction, or delayed entry must be distinctly identified; there must be a way to provide a reliable means to clearly identify the original content and the modified content; the person altering the record and the date of the revision, amendment, or addenda must be documented
To justify an allegation of error, auditors are limited to:
The application of controlling standards
Who should help determine the appropriate number of medical records to review?
The compliance officer, office manager, and/or practitioner
Conditions of participation for medical record services
The conditions include that each patient should have a medical record; medical records must be organized to allow for prompt completion, filing, and retrieval; medical records must be retained for at least 5 years; and patient confidentiality should be protected
Why is it important to read the entire operative note slowly and carefully?
The details in the body of the note do not always match the procedure that is documented in the header or indicate additional procedures not reported in the title
What determines the CPT code used to convey surgical services performed?
The details in the body of the notes
What should happen if any information within the radiology report is unclear or conflicting?
The documenting provider should be queried for verification and correction, as necessary
Although the report is addressed to the OIG, it is usually submitted to:
The entity (usually to the compliance officer of the entity), which in turn submits it along with the entity's annual report
Who must maintain the orders for radiologic services?
The facility
Total units are used to determine:
The fee for anesthesia services
What is the minimum requirement for the signature of the author of an entry in the medical record?
The first initial, last name and credentials
Global surgery status indicator: XXX
The global concept does not apply to this code.
Indications of risk
The nature of the presenting problem and the urgency of the visit, comorbid conditions, and diagnostic tests for surgery
Severity
The patient's statements regarding a degree or measurement of how bad it is
Associated signs and symptoms
The patient's statements regarding associated secondary complaints
Location
The patient's statements regarding the anatomical place, position, or site of the chief complaint
A family physician requests that you perform a post payment audit on claims from a particular commercial payer he is receiving denials from. Whenever the provider performs a minor procedure with an E/M service, the minor surgery is reimbursed but the E/M service is denied. You review 10 charts and all cases are documented and coded correctly. What could be the reason for the denial?
The payer contract may bundle the E/M service when performed on the same day as the minor surgery.
The False Claims Act allows for reduction of penalties to two times the amount of damages (as opposed to three times) under what condition(s)?
The person committing the violation self discloses within 30 days of violation notification and the person fully cooperates with the investigation of the violation.
Who must sign the plan of care for outpatient therapy services?
The person who established the plan of care (physician, NPP, clinical nurse specialist, or physician assistant)
The communication should be tailored to:
The person(s) responsible for any detected errors (coders, ancillary staff, physicians)
How must test results be documented when they are a computerized number value?
The physician must note the type of test; the methodology used, the normal range for the test, and then comment on whether the finding is abnormal or normal in relation to that range
Sample frame
The subset of all claims that possess the variable that is attributable to the potential error
To audit the surgical medical record accurately, the auditor must have a good understanding of surgical terminology and anatomy, and must also understand:
The surgery coding guidelines, insurance carrier rules, CCI edits, and how to code an operative report
When chemotherapy medication requires pre- and post-hydration, what amount of time must the total time exceed to report hydration?
The total time must exceed 31 minutes
What must a provider document when selecting an E/M code based on time?
The total time spent, as well as that more than 50% of the time was spent counseling or coordinating care and a description of the content of conversation
Psychotherapy
The treatment of mental illness and behavioral disturbances; codes are time based
What do anesthesia modifiers report?
The type of anesthesia provider(s) as well as type of anesthesia or special circumstances that arise during anesthesia
CCM indicator 9
The used of modifiers is not specified; this indicator is used for all code pairs that have a deletion date that is the same as the effective date; created so that no blank spaces would be in the indicator field
How are medical records requirements generally enforced?
Through licensing, the certification process, or credentialing with insurance carriers
Purpose of a medical directive
To allow the patient to communicate his/her wishes to the healthcare community prior to any event in which he/she may become incapacitated to speak, or to make his/her wishes known in certain medical emergencies
Why must a prospective audit be completed in a timely manner?
To avoid delays in claims submission
Purpose of the personal identification number assigned to each medical record?
To ensure accuracy of the details contained within the record and it adds a layer of security to prevent unauthorized use
Purpose of the medically unlikely edits
To help reduce the paid claims error rate for Medicare Part B claims
Exclusion Statute
Under the Exclusion Statute, a physician who is convicted of a criminal offense—such as Medicare fraud (both misdemeanor and felony convictions), patient abuse and neglect, or illegal distribution of controlled substances—can be banned from participating in Medicare by the OIG. Physicians who are excluded may not directly or indirectly bill the federal government for the services they provide to Medicare patients.
To understand how much to focus on potential risk:
Understand the provider's compliance objectives
Monitoring may include auditing and reviewing:
Utilization patterns, computerized reports, and reimbursement
Definition of the 1997 guidelines regarding single organ system examinations
Variations among these examinations in the organ systems and body areas and in the elements of the examinations reflect differing emphases among specialties. To qualify for a given level of single organ system examination, the following content and documentation requirements should be met: Problem Focused Examination-should include performance and documentation of 1-5 elements identified by a bullet, whether in a box with a shaded or unshaded border; Expanded Problem Focused Examination-should include performance and documentation of at least 6 elements identified by a bullet, whether in a box with a shaded or unshaded border; Detailed Examination-examinations other than the eye and psychiatric examinations should include performance and documentation of at least 12 elements identified by a bullet, whether in a box or unshaded border. Eye and psychiatric examinations should include the performance and documentation of at least 9 elements identified by a bullet, whether in a box with a shaded or unshaded border; Comprehensive Examination-should include performance of all elements identified by a bullet, whether in a shaded or unshaded box. Documentation of every element in each box with a shaded border and at least one element in a box with an unshaded border is expected.
Purpose of codebooks in an audit
Verify correct CPT, HCPCS Level II, and ICD-9-CM use
When auditing any diagnostic service:
Verify that documentation supports the codes reported, medical necessity is met, an order for the service is documented, and an interpretation and report are included, when required.
Forms of patient contact for the application of a modality
Visual, verbal, or manual
3 CLIA regulatory categories
Waived tests, tests of moderate complexity, and tests of high complexity
The provider either:
Wants to maintain compliance with express binding standards and is unconcerned with potential audit risk; or, he is extremely concerned about becoming an audit target and more receptive to conservatively structured recommendations
The reader of an audit report should be able to clearly understand:
What was audited, why it was audited, the standards that were applied, how those standards were applied, what was found, and what the auditee should do going forward
When should providers use an ABN?
When a Medicare beneficiary requests or agrees to receive a procedure or service that Medicare may not cover
When are criminal penalties imposed for individuals who have violated the Privacy Rule?
When a person knowingly obtains or discloses individually identifiable health information in a way that violates the Privacy Rule; penalties may be as much as $250,000 and up to 10 years imprisonment if the conduct involves the intent to sell, transfer, or use identifiable health information for commercial advantage, personal gain, or malicious harm
When may contrast administration be reported in addition to the actual procedure?
When contrast is not considered an integral part of the study
When will Medicare cover postoperative complications?
When they require a return to the operating room (procedure rooms and minor treatment rooms are not operating rooms)
Component of the audit report: summary of audit findings
Where the most common findings, aggregate conclusions, and key recommendations are found; should provide the auditee a preview of what is to be found in the report
Subjective
Where the patient provides information about his/her symptoms and what, if anything, he/she has done to relieve the symptoms
Suggested questions to narrow the scope
Will the audit be limited to government payers only? If no, will self-pay also be included in the scope? Will the audit be limited to E/M codes only? Will the audit include surgical procedures? For E/M codes, will both established and new patient visits be included? Will the audit include outpatient and inpatient records? Are all providers to be included in the audit?
Are all add-on codes exempt from the multiple procedure concept?
Yes
Are auto and workers' compensation exempt from the HIPAA mandated code set rules?
Yes
Are base units assigned to each anesthesia code?
Yes
Can a provider choose from either 1995 or 1997 guidelines for each E/M service?
Yes
Can residency programs qualify for a primary care exception for services performed in the primary care office setting?
Yes
Does CERT identify undercoding as well?
Yes
If a patient is returning for a follow up, does the provider have to document the reason for the follow up?
Yes
Is elaboration on abnormal findings required?
Yes
Is a signature required on the ABN for unassigned claims (claims submitted by the provider but the payment is sent to the patient who then reimburses the physician)?
Yes, to hold the patient financially liable
Is it beyond an auditor's scope and training to identify an entity's legal duty to disclose an overpayment or refund?
Yes, unless you are a licensed attorney representing the auditee
Can you use elements of the HPI for a chief complaint?
Yes. According to the CMS E/M Guide: "the CC, ROS, and PFSH may be listed as separate elements of history or they may be included in the description of the history of present illness."
Outpatient physical therapy services cannot be initiated until:
an initial plan of care has been established.
Semi-automated review
claims review using data and potential human review of a medical record or other documentation; medical records supplied at the discretion of the provider to support a claim identified by data analysis as an improper payment
An auditor identifies claims for services provided by a non-physician provider as Incident-to during the month the physician was on vacation. This would be considered:
fraud.
P6 modifier
patient that is declared brain dead, but whose organs are being removed for donor purposes
P5 modifier
patient who is not expected to survive without the operation
P2 modifier
patient with a mild systemic disease
You audit a provider who performs and bills for an arthroscopic rotator cuff repair, 29827, and for an arthroscopic debridement, 29822. The payer contract specifies NCCI edit rules will be applied. There is an NCCI edit against reporting both procedures during the same operative session; in reviewing the surgeon's documentation, you find that the debridement was performed in a different site supporting the 59 modifier, which is allowed under NCCI. This is an example of:
proper coding and billing practice.
An auditor identifies a procedure that has a modifier appended. This is an indication that:
the procedure performed was altered, but the definition of the code has not changed.
During an audit of a paper medical record, the auditor finds a correction was made using white-out and initialed by the nurse. This method of correction is:
unacceptable because the original content is not readable.
What is often the most effective way to motivate the auditee to follow your recommendation?
Focusing on the solution rather than the problem
The provider must present the patient with a cost estimate for the proposed procedure or service that is within how much of the actual costs?
$100 or 25 percent, whichever is greater
Minimum necessary
A covered entity may not use, disclose, or request the entire medical record for a particular purpose, unless it can specifically justify the whole record as the amount reasonably needed for that purpose
Chief complaint
A description of why the patient is presenting for healthcare services.
Additional units assigned to qualifying circumstances codes
+99100 is assigned 1 unit, +99116 is assigned 5 units, +99135 is assigned 5 units, and +99140 is assigned 2 units
Oblique (OBL)
Angled view
What will be one of the focuses of OIG audits in 2014?
Evaluation and Management New Patient Visits
If the physician's documentation is inadequate, education usually involves:
Identification of the specific error or omissions
Utilization review
Provides data about how frequently certain services are billed
5 practical tips provided by CMS for creating a culture of compliance
Make compliance plans a priority now; know your fraud and abuse risk areas; manage your financial relationships; just because your competitor is doing something doesn't mean you can or should; and when in doubt, ask for help
Constitutional
Patient's answers about general constitutional signs or symptoms
The scope of the audit is closely tied to:
The audit objectives
Swimmers
Thoracic X-ray with one or both arms overhead
Complex review
medical record required
Automated review
no medical record needed; improper payments are determined based solely on the submitted claims and regulatory guidelines such as National Coverage Determinations, Local Coverage Determinations, and the CMS Manuals
P1 modifier
normal healthy payment
The penalties for violation of the Stark law include program exclusion for knowing violations and:
potential $15,000CMP for each service.
An auditor must be a _____ _____ to effectively convey the reasons behind any error.
skilled writer
What organization is one of the most commonly known accrediting organizations?
the JC
A shared/split visit occurs when:
An NPP and physician are involved in the same patient case
Corporate Integrity Agreement (CIA)
An imposed compliance program usually in force for 5 years; during this time, the entity must demonstrate on-going compliance relative to specifically-identified issues, and report annually to the HHS OIG
General scope
Analysis of all relevant carrier coding and documentation rules
Limited scope
Analysis of the claims of a specific provider, to a specific carrier, pertaining to a specific CPT code
AA modifier
Anesthesia personally performed by an anesthesiologist
What providers usually place the central venous catheter lines percutaneously for immediate use?
Anesthesia providers; they do not usually tunnel the catheter
Who can provide anesthesia services?
Anesthesiologists, CRNAs, and residents medically directed by the teaching physician
The OIG CIA agreement states that the IRO's minimum requirement to perform an audit is:
Annually
How often should an internal audit be conducted?
Annually, at minimum
An SDP may be submitted in response to a detected violation of the:
Anti-Kickback Statute (AKS)
Stark Law vs. Anti-Kickback Law
Anti-Kickback applies to anyone, not just physicians; the Anti-Kickback Law requires proof of intention and states that the person must "knowingly and willfully" violate the law.
When providers use templates, how should abnormal findings be documented?
Any findings that are abnormal must have elaboration as to what is abnormal
False Claims Act
Any person is liable if they knowingly present or cause to be presented a false or fraudulent claim for payment or approval; knowingly makes, uses, or causes to be made or used, a false record or material to a false or fraudulent claims
Modality
Any physical agent applied to produce therapeutic change to biologic tissue; techniques involved include thermal, acoustic, light, mechanical, or electric energy; 2 subcategories, based on the level of supervision
Regardless of the nature of the state regulated plan, you must identify:
Any regulatory provision or administrative agency guidance that provides a standard for how services are to be reported
An infectious disease provider has been notified by the MAC (Medicare Administrative Contractor) in his region that their data shows he is billing level 99214 more frequent than any other provider in the same specialty and same geographic region. The provider requests that you audit a sample of his claims that were coded as 99214 to determine if he is coding appropriately. What supporting references will you need to conduct the audit?
1995 and 1997 CMS Documentation Guidelines
A provider performs two procedures that NCCI edits state should not be reported together. However if the NCCI edit does not allow use of NCCI-associated modifiers to bypass it and the documentation supports and qualifies as an unusual procedure, the physician may report the column one HCPCS/CPT® procedure code of the NCCI edit with what modifier?
22
What must be included in an operative report?
A detailed summary of the findings throughout the surgery, the procedure performed, any specimens removed, the pre- and postoperative diagnoses, and the names of the primary performing surgeon and any assistants
When reporting 90762, the documentation must include:
A medical assessment in addition to history, mental status, other physical exam elements as indicated, and recommendations.
Data mining
A method that many payers use to compare billing frequencies of one provider against other, or similar, providers of the same specialty
The decision to conduct an audit can be based on:
A request from someone w/in the organization or medical practice, or because the organization's compliance plan requires annual audits.
Modifier 76 and 77 are reported when:
A service is repeated on the same date of service
Minor surgical procedure Medicare definition
A service that has 0- or 10-day postoperative period
Imposition of a commonly accepted, but not binding, standard may expose the entity to:
A substantially higher overpayment than it is legally obligated to repay
When old records are reviewed, what should an auditor expect to see?
A summary of findings based on the review and discussions with the performing physician about unusual or unexpected patient results
The time, effort, and services required to complete a procedure are bundled together to form:
A surgery package
Apical
A view of the chest to include the apex of the lung
Dr. Jones performed a femoral-femoral bypass graft in the morning on June 1, 20xx. Later that day, the graft clotted and the entire procedure was repeated. Dr. Jones was not available so Dr. Martin who is with a different group repeated the procedure in the evening. The auditor reviewed the documentation for Dr. Martin. The following was reported by Dr. Martin: Date of Service Procedure 06/01/20xx 35556-76 What procedure should Dr. Martin report?
35558-77
How many sections is the operative report divided into?
4
How many Recovery Audit Contractors does Medicare currently have?
4, divided by region
How many add-on codes describe qualifying circumstances that make delivery of anesthesia more difficult?
4; the qualifying circumstances codes are reported in addition to the anesthesia code
A full sample must be reviewed and a systems review must be conducted when the net financial error rate of the sampling equals or exceeds what percent?
5%
How many charts does the OIG recommend per physician when conducting an annual compliance audit?
5-10 random charts
For how long does HIPAA require privacy records to be maintained?
6 years of the date of its creation, or the date from which it was last in effect (whichever is later)
What codes should you report when the epidural is used for pain management?
62310, 62311, 62318, or 62319
An action that resulting in unnecessary costs, whether directly or indirectly, to a federal healthcare plan is the definition of
Abuse
Independent review organization (IRO)
Acts as a 3rd party medical review resource that provides objective, unbiased audits and reports
Privacy Rule standards
Address how an individual's protected health information (PHI) may be used
Chart audits may measure:
Adherence to clinical protocols; patient adherence with medication regimens; and provider compliance with coding and documentation requirements for E/M services, office procedures, modifier use, diagnosis code(s) supporting medical necessity, and/or surgical procedures
Medicare Administrative Contractor (MAC)
Adjusts a claim and sends a demand letter to the provider for the amount of the overpayment
What medical record requirements must be in place to be accredited by the Department of Health and Human Services for Medicare and the JC?
Admission report, consent to treatment form, attestation statement, medical history, physician's orders, report of physical examination, progress notes, pathology reports, radiology reports, consultation reports, anesthesia record, operative report, nurse's notes, vital signs graphics, medication sheet, laboratory report, physical therapy evaluation, respiratory therapy evaluation, special reports (obstetrics, nursery), and discharge reports
Authentication of a report by a physician or other practitioner must take place:
After the document has been transcribed and reviewed
To identify patterns of undercoding and upcoding among physicians in a practice as compared to another practice of the same specialty would best be identified through which type of analysis?
Aggregate analysis
What are the administrative requirements of the Privacy Rule?
All covered entities must have written privacy policies that comply with the privacy rule; a privacy official must be designated to be responsible for developing and implementing privacy policies and procedures; all members of a covered entity's workforce must be trained on the privacy policies; covered entities are required to mitigate any harmful effect that may have been caused by inappropriate use or disclosure of PHI by its workforce or business associates; procedures must be in place to allow an individual to complain about a covered entity's compliance with their privacy policies; a covered entity may not retaliate against a person for exercising his/her rights provided by the Privacy Rule; privacy policies must be maintained by covered entities for 6 yrs, after the later of the date of their creation, or last effective date; fully insured group health plans have only 2 obligations: banned from retaliatory acts and waiver of individual rights and to provide documentation for the disclosure of PHI through documentation
Random selection
All items in the total sample have an equal chance of being selected for an audit
The sample for prospective audits is:
All the claims that are being held, pending the audit findings
A chart audit may be performed on:
Almost any aspect of medicine and medical care, and may even be used to review the prevalence of symptoms and disease. The data being reviewed should be accurate and must be available in the chart or in the electronic medical record.
Modifier 92 definition
Alternative laboratory platform testing: This modifier is reported when the test is performed using kits and transportable instruments.
Prior to undergoing a specific medical intervention, law requires the provider to obtain an informed consent for treatment signed by the patient. In addition to the nature or purpose of the treatment and risks and benefits involved, the informed consent must include what information?
Alternative treatment options and the risks and benefits of alternative treatment options.
Failure to have which form in the medical record will result in payment being sent to the beneficiary?
Assignment of benefits form
The role of an auditor relative to a self-disclosure of improper payments is to:
Assist with identification of the sample frame
Institute of Internal Auditors definition of the objective and the scope
Audit objectives represent high-level goals and anticipated accomplishments of the review and address controls and risks associated with the client's activity. The audit's scope defines the parameters to be used toward achieving those objectives
Component of the audit report: standard of review
Auditor identifies the specific binding standards or criteria applied during the course of the audit; in many cases, each subject code is identified with appropriate sub-headings; important to cite the specific contractual or regulatory basis behind each cited standard and if no standard exists, this should be identified
Component of the audit report: discussion
Auditor should address the cause of any identified error, or any issue that increases the auditee's potential post-payment risk; auditor should concisely address the specific non-conformances found to include the basis for the allegation of error; if the lack of a binding rule or ambiguity in the binding rule precludes a declaration of error, identify any concerns regarding the potential for post-payment risk; if the audit is part of evaluating the auditee's level of compliance, each error or risk area should be delineated to include the basis for the delineation, and within each delineation the auditor should provide the specific basis for the error or concern by citation to the appropriate binding or persuasive standard
Assignment of benefits
Authorization form signed by the patient that allows their insurance carrier to pay the provider directly. Without this, the payment will go to the beneficiary and the provider will be required to collect payment from the beneficiary.
3 types of review performed by FFS Recovery Auditors
Automated, semi-automated, and complex
In most cases, the _____ _______ is the only means by which the IRO communicates with the OIG.
Written report
Is every Medicaid plan subject to state-specific requirements?
Yes
Is it common to identify non-standard coding and reimbursement rules when auditing claims for state regulated plans?
Yes
May various audits be combined?
Yes
Do administrative law judges usually follow subordinate sources such as LCDs or MedLearn Matters, even though they are not law?
Yes unless there is a conflict between the guidance in secondary publications and the binding regulations or statute. In such a case, the regulatory/statutory provisions control.
In preparation for a high volume of patients coming in for chemotherapy, the nurse documents the chemotherapy treatments in advance. The purpose is to speed up the treatment process so that patients do not have to wait long. Would this cause concern in an audit?
Yes, chart entry should not be made in advance of the treatment.
When does HHS require a covered healthcare provider to distribute the privacy notice to individuals?
Not later than the first service encounter by personal delivery of patient services, electronically or through mail; by posting the notice in a clear and prominent place that can easily be seen by people seeking services; in emergent situations, the notice must be furnished when the emergency has abated
For which healthcare entities are CPGs listed on the OIG website?
Nursing facilities; hospitals; recipients of PHS research awards; pharmaceutical manufacturers; ambulance suppliers; Medicare+Choice organizations; hospices; durable medical equipment; prosthetics, orthotics, and supply industry (DMEPOS); third-party medical billing companies; clinical laboratories; and home health agencies
Where are the status indicators found?
On the National Physician Fee Schedule Relative Value File
Where are physical status modifiers reported?
On the anesthesia record
How many initial chemotherapy or therapeutic drug administration codes can be reported for each date of service?
Only 1
When multiple procedures are performed during a surgical session, how many anesthesia codes are reported?
Only 1, based on the anesthesia code with the highest assigned base value
When should you see 90863 reported?
Only if the state where you are auditing allows a psychologist to prescribe medication; because psychiatrists most commonly prescribe medication, this service should be reported with the appropriate E/M code, based on medical necessity and documentation
According to CPT® coding guidelines for inpatient consultation services, how should consults be reported?
Only one consultation is reported per hospital admission.
The Stark Statute applies to:
Only physicians who refer Medicare and Medicaid patients to entities for designated health care services with which the provider or immediate family member has a financial relationship
Odontoid
Open-mouth cervical spine view to identify joint space C1
Health plan covered entities
Organizations that pay providers on behalf of an individual receiving medical care; exceptions include an employer who solely establishes and maintains the plan with fewer than 50 participants, food stamps, community health centers, insurers providing only worker's compensation, automobile insurance, and property and casualty insurance
To accomplish the objectives of an audit report, the report must be:
Organized, succinct, and well written
Karen has reviewed denials from payers. Out of the 25 denials reviewed, 23 of them were found to be denied in error based on NCCI guidelines. Karen is preparing her appeal for the erroneous denials. In addition to her appeal letter, she should include in the appeal package:
Original claim forms, copies of documentation and copies of EOBs and supporting documentation from NCCI
In what setting is the chemotherapy and therapeutic drug administration code hierarchy defined?
Outpatient facility setting
Where there are multiple issues, the total _____ (or ______) should be delineated for each type of error.
Overpayment; underpayment. These results, when validated, would be submitted to the statistician who would statistically estimate the error for all the claims in the sampling frame as a means of determining the appropriate re-payment amount
Some payers will allow for additional units for physical status modifiers:
P3-P5
Limited data set
PHI from which certain specified direct identifiers have been removed
Clinical Laboratory Improvement Amendments (CLIA)
Passed in 1988; establishes quality standards for all laboratory testing; ensures the accuracy, reliability, and timeliness of patient test results, regardless of where the test is performed
You are performing an audit of evaluation and management services for a family practice office. In the encounter, you read the physician ordered and reviewed a differential WBC. Which of the following best describes what you would expect to see in the medical record?
Patient identification, assignment of benefits, patient's medical history, immunizations, physical examination, lab report, clinical impression, and physician orders.
What should be included in the lab report?
Patient name and identification number, name of laboratory, name of physician or practitioner ordering the test, date and time of the collected specimen and date and time of receipt, reason for an unsatisfactory specimen if applicable, test or evaluation performed, result, and date and time of report
What is the header of the operative note designed to identify?
Patient name, date of surgery, preoperative diagnosis, postoperative diagnosis, the procedure performed, primary surgeon, assistant surgeon(s), anesthesia administered, anesthesiologist
What is included in a complete radiology report?
Patient name; referring physician; date and time of study; patient history; reason for study; diagnostic and procedural statement; extent of exam (limited, complete); number and type of views taken (bilateral, left, right); contrast material used, as appropriate, including type, amount, and method of administration; separate description of each study performed on the patient; recommendations for follow-up exam or additional studies needed; comparison of prior studies, as appropriate; indication of any limitations in study, such as poor image quality or poor patient prep; summary of conversations with other healthcare providers; findings, results, impressions, conclusions; signature of radiologist
Psychiatric
Patient's answers about signs and symptoms of the psychiatric system such as depression, excessive worrying, stress, suicidal thoughts, persistent sadness, anxiety, loss of pleasure from usual activities, loss of energy, physical problems that do not respond to treatment, restlessness, irritability, and excessive mood swings
Gastrointestinal
Patient's answers about signs or symptoms of the GI system and include such things as indigestion or pain associated with eating, burning sensation in the esophagus, frequent nausea and/or vomiting, abdominal swelling, and changes in bowel habits or stool characteristics, such as diarrhea or constipation
Genitourinary
Patient's answers about signs or symptoms of the genitourinary system such as painful urination, urine characteristics, urinary patterns, hesitance, flank pain, decreased/increased output, dribbling, incontinence, frequency at night, genital sores, erectile dysfunction, irregular menses, toilet training, or bed wetting
Musculoskeletal
Patient's answers about signs or symptoms of the musculoskeletal system, including joints, such as muscle cramps, twitching or pain, limitations on walking, running or participation in sports, joint swelling, redness or pain, joint deformities, and stiffness, and noise with joint movement
Respiratory
Patient's answers about signs or symptoms of the respiratory system such as cough, phlegm, chest pain on deep inhalation, wheezing, shortness of breath, or difficulty breathing
Integumentary
Patient's answers about signs or symptoms of the skin such as itching, rash, skin reactions to hot and cold, changes of scars, moles, sores, lesion, nail color or texture, breast pain, tenderness or swelling, breast lumps, and history of nipple discharge or changes
Eyes
Patient's answers about signs or symptoms that may include the use of glasses, eye discharge, eyes itching, tearing or pain, spots or floaters, blurred or doubled vision, twitching, light sensitivity, swelling around the eyes or lids, and visual disturbances
Past history
Patient's experiences with childhood diseases, illnesses, operations, injuries, treatments, and medications
To code for medical direction to Medicare, the anesthesiologist must meet the following requirements:
Perform pre-anesthetic exam and evaluation; prescribe the anesthesia plan; personally participates in the most demanding procedures in the anesthesia plan; ensure any procedures that are not personally performed are performed by a qualified individual; monitor the course of anesthesia in frequent intervals; and remains physically present and available for emergencies; and provides indicated postoperative care
Physical examination
Performed by the healthcare provider through a series of assessments and observations, focused around the symptoms described by the patient
Pharmacologic management can be reported only as an add-on code when:
Performed with psychotherapy; providers authorized to code E/M codes are directed to report E/M
Based on JCAHO accreditation guidance for personal data, what two elements must be evident in the medical record:
Personal biographical data and consent for treatment or authorization for treatment form
The writing style of an audit report should be:
Persuasive rather than purely scientific or argumentative
What type of service is frequently audited?
Physical therapy services
You may consider modifier 58 for a procedure or service during the postoperative period if the procedure or service is:
Planned prospectively at the time of the original procedure (staged); more extensive than the original procedure; or for therapy following a diagnostic surgical procedure
What are some common indicators used to measure the relative level of difficulty in making a diagnosis and the status of the problem?
Problems that are new to the patient or that the physician is seeing in this patient for the first time; seeking additional workup, such as a consultant's opinion; ordering additional workup, such as diagnostic tests to confirm or to rule out the suspected diagnosis and/or differential diagnosis with which the patient will leave the office; and established problems for which the patient shows no improvement or for which he or she has not responded as expected
National Physician Fee Schedule Relative Value File meaning of 0 in the Multiple Procedure column
Procedure not subjected to the multiple procedure payment reduction
List of Excluded Individuals/Entities (LEIE)
Produced and updated by the OIG; provides information regarding individuals and entities currently excluded from participation in Medicare, Medicaid, and all other federal healthcare programs; sorts excluded individuals or entities by the legal basis for the exclusion, the types of individuals and entities that have been excluded, and the states where the excluded individual resided at the time they were excluded or the state in which the entity was doing business
PC/TC indicator: 2
Professional Component Only Codes: This indicator identifies the codes describe the physician work only. Modifiers 26 and TC cannot be reported.
For what types of service is the primary chemotherapy or therapeutic drug administration procedure code the reason for the encounter?
Professional services
Benefits of external audits
Provide a framework for developing a remedy for isolated issues; may be more objective than internal audits; and when a practice pays for an outside service, the feedback is usually taken seriously
RAT-STATS
Provided by the OIG; statistical software program that is recommended and commonly used to perform a sample size estimate and to generate a random number printout to support its sampling methodology
Who may retrospectively review claims submission and payment trends to ensure correct coding and billing practices?
Providers and payers
Medicare Learning Network (MLN)
Provides education, information, and resources for the healthcare professional community; offers educational products, national provider calls, provider association partnerships, provider eNews, and provider electronic mailing lists
OIG Self Disclosure Protocol (SDP)
Provides the ability to self-disclose potential instances of fraud involving federal healthcare programs for which liability arises under the OIG's civil monetary penalty authorities; not for reporting of potential or actual Stark (self-referral) violation and is not a means to obtain an advisory opinion to determine if the suspected conduct is unlawful
In most cases, individuals have the right to review and obtain copies of their PHI. What areas are excluded from the rights of access?
Psychotherapy notes, information related to legal proceedings, and certain lab results or information held by research laboratories
OIG Work Plan
Published annually; lists the various projects that will be addressed during the fiscal year by the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General; summarizes new and ongoing reviews and activities that OIG plans to pursue during the next fiscal year and beyond
For an audit, always state a clear ____ and indicate the _____.
Purpose; scope
Development or modification of existing policies, practice forms, etc. will always involve:
Re-training of existing staff as well as training of all subsequently hired new staff
Additional risk area for physicians listed in the appendix at the end of the CPG
Reasonable and necessary services; physician relationships with hospitals; physician billing practices; and other risk areas (rental of space in physician offices by persons or entities to which physicians refer and unlawful advertising)
What changes will be effective within the next Recovery Audit Program contracts?
Recovery Auditors must wait 30 days to allow for a discussion before sending the claim to the MAC for adjustment and providers will not have to choose between initiating a discussion and an appeal; Recovery Auditors must confirm receipt of a discussion request within 3 days; Recovery Auditors must wait until the second level of appeal is exhausted before they receive their contingency fee; CMS is establishing revised ADR limits that will be diversified across different claim types; and CMS will require Recovery Auditors to adjust the ADR limits in accordance with a provider's denial rate. Providers with low denial rates will have lower ADR limits while providers with high denial rates will have higher ADR limits
Modifier 90 definition
Reference (outside) laboratory: This modifier is reported when the laboratory procedures are performed by a provider/lab other than the treating or reporting physicians
What falls under the responsibility or oversight of an organization's compliance committee?
Regularly reviewing and updating policies and procedures, assisting with the development of standards of conduct and policies and procedures, and determining the appropriate strategy to promote compliance
Modifier 91 definition
Repeat clinical diagnostic laboratory test: This modifier is reported when laboratory tests are repeated for clinical reasons.
Modifier 77
Repeat procedure by another physician or other qualified healthcare professional
Modifier 76
Repeat procedure or service by same physician or other qualified healthcare professional
The NCCI manual also states that if the NCCI edit does not allow the use of an NCCI-associated modifier to bypass the edit, and the procedure qualifies as an unusual procedural service that requires additional work, the provider may:
Report the column 1 code of the NCCI edit with modifier 22 to indicate additional work was required. The documentation would need to support the additional work required above and beyond the usual work of that procedure.
Unlisted procedure codes
Reported when an existing CPT category I or category III code does not describe the procedure. Report the appropriate unlisted code for the category/type of procedure performed.
Global surgery status indicator: ZZZ
Represents add-on codes. They are related to another service and are always included in the global period of the primary service.
Dr. Black receives a demand letter from the OIG stating the sanctions that are sought under CMP for claims submitted by Dr Black. He asks you, his auditor, to review the letter and the claims that are under scrutiny. It is determined that Dr. Black should not agree with the demand letter. You recommend that Dr. Black:
Request a hearing before an HHS administrative court judge
Certificate of Compliance Agreement (CCA)
Require the provider to certify that is will continue to operate its existing compliance programs and to report to OIG for a lesser period of time (usually 3 years); introduced in Inspector General Janet Rehnquist's An Open Letter to Healthcare Providers in November 2011
Medicare Modernization Act
Required a 3-year Recovery Audit demonstration, which ran between 2005 and 2008; during the demonstration, Medicare employed Recovery Auditors to identify overpayments and underpayments made to healthcare providers and suppliers in randomly selected states
Privacy Rules national priority purposes
Required by law; public health activities; victims of abuse, neglect or domestic violence; health oversight activities; judicial and administrative proceedings; law enforcement purposes; decedents (funeral directors or medical examiners); cadaveric organ, eye, or tissue donation; research; serious threat to health or safety; essential government functions; workers' compensation
Corporate Integrity Agreements
Required by the OIG s a condition of not seeking exclusion from participation when an individual or entity seeks to settle civil healthcare fraud cases; typically last 5 yrs but can be longer; most have the same core requirements along with specific steps for the individual or entity that are related to the conduct that led to the settlement
Tax Relief and Healthcare Act of 2006
Requires a permanent and nationwide Recovery Audit program by 2010
Rebuttal audit
Response to a payer audit where the auditor is tasked with validating or refuting the conclusions of the payer; work centers on determining whether the appropriate binding standards were applied correctly or whether the information provided to the payer was complete and/or properly interpreted
R in CHEDDAR
Return visit information or referral
Recovery Audit Contractors (RACs)
Review claims on a post-payment basis and use the same CMS regulations that providers are required to follow
Family history
Review of medical events in the patient's family, including the age of death and diseases that may be hereditary, or that place the patient at an increased risk
What is often performed prior to the issuance of a formal and final audit report?
Review of the audit results with the auditee and legal counsel
Additional optional, but recommended, elements for a plan of care include:
Short term goals; goals and duration for the current episode of care; specific treatment interventions, procedures, modalities, or techniques and the amount of each; and the beginning date for the plan
Medical decision-making
Takes into account the work involved to determine a diagnosis and treatment options for the patient, and the amount of data collected and reviewed; also factored into MDM is the level of risk to the patient, either due to the diagnosis or the management options to treat the diagnosis
Without a valid ABN:
The Medicare beneficiary cannot be held responsible for denied charges
What resource is useful to determine if procedures are subject to the multiple procedure payment reduction?
The National Physician Fee Schedule Relative Value File
If a covered entity identifies material breach of a contract agreement with a business associate and the contract is terminated the problem is reported to:
The Office for Civil Rights (OCR)
What permits providers and suppliers "accredited" by an approved national accreditation organization (AO) to be exempt from routine surveys by state survey agencies to determine compliance with Medicare conditions?
The Social Security Act
Definition from the 1995 guidelines regarding types of exam
The levels of E/M services are based on 4 types of examination that are defined as follows: Problem-Focused-a limited examination of the affected body area or organ system; Expanded Problem Focused-a limited examination of the affected body area or organ system and other symptomatic or related organ system(s); Detailed-an extended examination of the affected body area(s) and other symptomatic or related organ system(s); Comprehensive-a general multi-system examination or complete examination of a single organ system
To perform a retrospective audit, an auditor reviews:
The medical record documentation, encounter form, claim form, explanation of benefits (EOB) or Remittance Advice (RA), and the payer policies to determine if and where there are errors in the process
Quality
The patient's statements regarding characteristics about the problem, such as how it looks or feels
Duration
The patient's statements regarding how long the complaint has been occurring, or the time when the complaint first occurred
What system do the majority of audit tools follow for the number of diagnoses and treatment options?
The point system
What should an auditor focus on if coding and reimbursement policies are ambiguous?
The potential risks associated with the method of reporting, specifically the likelihood that the payer would declare the codes/modifiers used to be erroneous, the reasons why, and the corrective action recommended (to include an alternative method of reporting) to mitigate that risk
How should a primary physician document the help of a surgical assistant?
The primary surgeon should clearly explain in the indications section of the note why an assistant was necessary and what the assistant surgeon performed that required the assistance
Auditing
The process of examining the medical record, verifying information, and gathering baseline information to identify risk areas
Supervision of a modality
The provider must be in the office
How must pathology and laboratory services be documented?
The provider needs to document medical necessity for the services in the patient's medical record and must indicate that he or she ordered the tests. The ordering physician must also note in the patient's record how the findings were used in determining a diagnosis and selecting a treatment plan.
Assessment
The provider's assessment of the patient's condition, and where the provider indicates either a definitive or working diagnosis. In absence of a diagnosis, signs and symptoms may be documented until furhter testing can be performed
Plan
The provider's plan is documented in direct relation to the assessment above. In cases where a definitive diagnosis has not been reached, the documentation should reflect tests that are being ordered, with an indication of the provider's thought process.
The scope of the audit determines:
The range of the activities and the period (months or years) of records subjected to examination; also determines what will not be part of the audit
Chief Complaint
The reason for the encounter
The number of diagnosis and management options is based on:
The relative level of difficulty in making a diagnosis and the status of the problem, such as whether it is controlled versus worsening
What must a properly sourced audit result cite and properly apply?
The relevant, applicable statutory and regulatory provisions and any potential conflict between these provisions and the secondary guidance materials published by the agency or its contractors
For claims processing, what must be reported as the referring provider?
The requesting provider and NPI
To communicate a clear recommendation for mandated or suggested corrective action, the successful auditor must identify:
The resources and tools used to conduct the audit. Where no binding standard exists, any persuasive resource used to identify potential risk must be identified, as such.
What is usually the first Appendix attached to the audit report?
The resources/reference list
What could be the result of auditing too few records?
The results may be distorted
Pharmacologic management includes:
The review of the patient's medication, responses to the medication, management of side effects, and ongoing monitoring and maintenance.
Components of the audit report
Background, summary of audit findings, standard of review, issue oriented findings, discussion, recommendations, and report attachments
Stark or Physician Self-Referral Law
Bans physicians from referring patients for certain services to entities in which the physician or an immediate family member has a direct or indirect financial relationship; bans the entity from billing Medicare or Medicaid for the services provided as a result of the self-referral
Calculation used by all other payers to determine total anesthesia units
Base Units + Time Units + Modifying Units=Total Units
How are outpatient hospital laboratories reimbursed?
Based on a fee schedule for Medicare
Numerical sampling
Based on all possible services within the chosen time frame; lends itself well to a random final selection
What is another way to calculate the HPI besides using the 8 elements?
Based on documentation of the status of 3 chronic or inactive conditions (documented in the 1997 guidelines), or based on the documentation of three chronic or inactive conditions as an extended HPI when using the 1995 guidelines (as of September 2013)
How is risk measured?
Based on the physician's documentation of the patient's probability of becoming ill or diseased, having complications, or dying between this encounter and the next planned encounter
As an auditor you are tasked with performing a random selection of the medical and surgical services performed by the three new providers who joined the practice six months ago. This would be considered what type of audit?
Baseline audit
If an legally definable error is discovered after an audit, the auditor must:
Be very clear in detailing the rationale for any error or change in code, as well as to detail the financial impact associated with the auditor's conclusions (usually on a service-specific basis)
Why must concurrency for anesthesia cases be monitored?
Because anesthesia is time based
When should corrections be made to dictations?
Before it becomes part of the record
According to Medicare guidelines, when must the physician sign dictated notes?
Before they are placed in the patient's chart
An effective compliance plan attributes to which of the following:
Better informed employees and reduced risk of criminal sanctions or civil penalties
CMS Examples of Fraud
Billing for services and/or supplies that you know were not furnished or provided, altering claim forms and/or receipts to receive a higher payment amount, billing a Medicare patient above the allowed amount for services, billing for services at a higher level than provided or necessary, misrepresenting the diagnosis to justify payment
Healthcare clearinghouses
Billing services, repricing companies, and community health management information systems that process nonstandard information, received from another entity, into a standard (or vice versa)
How can a provider verify that a written report was provided to the requesting provider/appropriate source?
By indicating who was copied on the report; if in the inpatient setting, a separate report is not needed because providers share the record
How should the provider document body areas and organ systems that are normal?
By notating "normal" or "negative"
Where can you access the National Physician Fee Schedule Relative Value File?
cms.gov
The manager of a small physician's practice who also is the compliance officer, contacts you an auditor, stating that a coding and billing violation has been identified by the billing department manager. What should you advise the compliance officer to document in the practice's compliance file:
date of incident, name of reporting party, name of person responsible for taking action, follow-up action taken
When auditing operative reports, the header describing the procedure:
may not fully support the procedure documented in the body of the report.
Communication usually occurs in 2 phases:
The written communication via the audit report and the oral communication to address questions or concerns with the reported findings, conclusions, and recommendations
Minor procedures as defined by Medicare have a zero or 10-day postop period. How should minor and endoscopic procedures be billed if an office visit takes place prior to the procedure?
There is no preoperative period and an office visit is billable if a significant and separately identifiable service is performed in addition to the procedure.
What is the purpose of "best practice" standards relating to the contents of a medical record provided by allied health professional organizations?
They are a tool to help guide health information managers, to ensure accurate and compliant medical records
Risk areas of handwritten records
They are often illegible and abbreviated, some information may be left off the medical record to reduce the amount of time it takes to write the note
What must a practice do if they use abbreviations that are not industry standard?
They must maintain a list of the abbreviations with definitions and how they are used, and should understand that documentation should be submitted anytime an audit is done.
If Medicare or other payers determine that services were medically unnecessary after payment has been made:
They treat it as an overpayment and demand that the money be refunded, with interest.
Why is it beneficial for an auditor to review the Recovery Auditors' websites for issues currently being reviewed?
This info can be used to target reviews to help providers determine if they are in compliance
What documentation format used in medical records is less commonly used?
CHEDDAR
No diagnostic tests should be performed without a:
CLIA certificate
Any lab or clinic performing any diagnostic test must have a:
CLIA number
All bills for tests must include the:
CLIA number of the testing location
Which E/M guidelines should you use?
CMS, local contractors, and commercial carriers have all supported the use of either the 1995 or 1997 E/M documentation guidelines
Other helpful audit tools
CPT Assistant, AHA Coding Clinic, frequency reports by physician, utilization based on specialty (can be obtained by insurance carrier), physician's fee schedule by insurance carrier, medical dictionary, medical terminology reference book, OIG work plan
What should be reviewed as you prepare to perform an audit?
CPT coding guidelines, federal guidelines, and payer guidelines for the types of services ad the payers included in the audit
C in CHEDDAR
Chief complaint
What elements are generally included in an evaluation and management encounter?
Chief complaint, history of present illness (HPI), physical examination, and assessment
What systems are recognized for purposed of ROS?
Constitutional; eyes; ears, nose, and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary; neurological; psychiatric; endocrine; hematologic/lymphatic; allergic/immunologic
The most common commercial insurance plans are:
Contract based; i.e. benefits arise primarily under a contract between the insurance company and the subscriber/patient
Fee-For-Service (FFS) Recovery Auditors
Contract with CMS to identify Medicare FFS improper payments; if an improper payment is identified, a review results letter is sent to the provider that includes the decision and rationale for that decision
What are the options in the event that the patient refuses to sign an ABN for an unassigned claim?
To not provide the service or procedure (which might raise potential negligence issues), or to provide the service with the understanding the provider may not be able to recoup payment from either Medicare or the beneficiary
Purpose of the National Correct Coding Initiative (NCCI)
To promote correct coding methodologies and to control improper assignment of codes that results in inappropriate reimbursement; identifies Column I/Column 2 edits that are edits for code pairs that should not be billed together because one service inherently includes the other, unless an appropriate modifier is used and allowed
Purpose of the Privacy Rule
To protect individual privacy, while promoting high quality healthcare and public health and well-being
What was the original intent of HIPAA?
To provide rights and protections for participants and beneficiaries of group health plans; limited exclusions for pre-existing conditions and prohibited discrimination against employees and dependents based on their health status
Stereo
Two views of a structure taken at different angles
Sampling
Type of sample, how the universe from which the same was drawn was defined, and method of selecting the sampling frame should be disclosed
Common surgical coding errors
Unbundling of procedures; missing charges, when multiple procedures are performed; coding from the operative note headers; failure to support medical necessity; incorrect use of modifiers; failure to report imaging guidance, when appropriate; incorrect reporting of units
Although an adverse audit result can create a significant emotional response, the auditor should remain _________ and ________ when discussing audit results.
Unemotional; objective
Modifier 78
Unplanned return to the operating room by the same physician or other qualified healthcare professional following initial procedure for a related procedure during the postoperative period; requires a return to the operating room; does not extend the global period
Modifier 24
Unrelated E/M by the same physician or other qualified healthcare professional during a postoperative period
Modifier 79
Unrelated procedure or service by the same physician or other qualified healthcare professional during the postoperative period; applies to any procedure within the postoperative period; will begin a new global period for the unrelated procedure
Modifier 23
Unusual anesthesia. This modifier is used when administering anesthesia for a service or a procedure that does not typically require anesthesia.
What are the civil monetary penalties for false or fraudulent claims?
Up to $11,000 per claim and three times the amount improperly claimed
Penalty for violating the Anti-Kickback Law
Up to $25,000 fine and/or imprisonment of up to 5 years
Top E/M coding errors
Upcoding; downcoding; chief complaint or reason for the visit is missing; assessment is not documented clearly; documentation is not initialed or signed; tests ordered are not listed in the documentation, but are billed on the encounter form/superbill; a clear assessment and plan is not documented; diagnosis is not referenced correctly; documentation is missing; lost dictation; superbill/encounter form and/or charge (fee) ticket are not available; superbill/encounter is incomplete or incorrect; and documentation is illegible
When does HHS require health plans to distribute their privacy policy notices to members?
Upon new member enrollment; they are also required to send a reminder to their enrollees every 3 years and upon request
P3 modifier
patient with a severe systemic disease
P4 modifier
patient with severe systemic disease that is a constant threat to life
What happens if variances are found between the codes supported and the codes submitted?
Decisions must be made concerning potential corrections, including refunding of overpayments
What must be included in a contract between business associates?
Description of the permitted and required uses of PHI by the business associate, limit the business associate from using or further disclosing the PHI (except where permitted by contract or required by law), and a requirement for the business associate to follow appropriate safeguards to prevent use or disclosure of the PHI, except as expressly defined in the contract
To provide legal counsel with the necessary information, the auditor should:
Detail how the error(s) was/were discovered, the cause of the error(s), the approach taken to determine the totality of the potentially suspect claims, the approach taken to determine the total overpayment amount being disclosed (100% audit or sampling), the specific law(s) or standard(s) violated, and the amount of overpayment implicated by the conduct
Office of the Inspector General (OIG)
Detects and prevents fraud, waste, and abuse and improves efficiency of HHS programs; most resources are directed toward the oversight of Medicare and Medicaid, but also extend to the Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), and the Food and Drug Administration (FDA)
Correct Coding Modifier (CCM) indicator
Determines whether a CCM causes the code pair to bypass the edit; will be either "0", "1", or "9"
Comprehensive Error Rate Testing (CERT) program
Developed by CMS to determine national, contractor specific, provider compliance error rates, paid claims error rates, and claims processing error rates
Voluntary compliance plan guidance (CPG) documents
Developed by the OIG for a variety of healthcare settings; indicate the comprehensive framework, standards, and principles by which an effective internal compliance program may be established and maintained
What must be included in the plan of care?
Diagnoses; long term treatment goals; type of rehabilitation therapy services (physical therapy, occupational therapy, or speech-language pathology) identifies each specific intervention, procedure, or modality, to support billing and verify correct coding; amount of therapy (number of treatment sessions in a day); duration of therapy (number of weeks or number of treatment sessions); and frequency of therapy (number of treatment sessions in a week)
PC/TC indicator: 1
Diagnostic Tests for Radiology Services: Modifiers 26 and TC can be reported with these codes.
Types of radiologic services
Diagnostic, radiation oncology, nuclear medicine, and radiologic guidance
Proper use of modifier 59 include:
Different surgical session, different procedure or surgery, different site or organ system, separate excision or incision, and separate lesion or injury
What is one of the biggest problem areas for the exam component?
Differentiating an expanded problem focused exam and detailed exam using the 1995 guidelines; both levels require 2-7 body areas/organ systems and the distinction is where the exam is limited or extended
Education and training to reinforce recommendations regarding a physician's deficiencies and problematic areas is best addressed through:
Direct follow-up with the physician.
Modifier 53
Discontinued procedure. If during a procedure, the surgeon decides to terminate the surgery due to the patient's condition, report modifier 53 for a discontinued procedure.
Sagittal plane
Divides the body from left to right
Transverse plane
Divides the body from top to bottom
Appropriate modifier use with NCCI
Documentation indicates 2 separate procedures performed on the same day, by the same physician; represented by a different session or patient encounter, different procedure or surgery, different site, or separate injury (or area of injury); use modifier 59 with the secondary, additional or lesser procedure of combinations listed in NCCI edits; use modifier 59 when there is NO other appropriate modifier; use modifier 59 on the second initial injection procedure code when the IV protocol requires 2 separate IV sites, or when the patient has to come back for a separately identifiable service
Health Care Fraud and Abuse Control Program
Established by HIPAA to combat fraud and abuse in healthcare, including both public and private health plans
Health Care Financing Administration (HCFA)/Centers for Medicare and Medicaid Services (CMS)
Established in 1977 to administer the Medicare and Medicaid programs; renamed the Centers for Medicare and Medicaid Services (CMS) in 2001; largest agency within the Department of Health and Human Services; administers Medicare, Medicaid, and the Children's Health Insurance Program
Retrospective audit
Evaluates whether services that were previously reported to a particular carrier were reported appropriately and consistent with that carrier's binding rules
What is the most significant difference between the 1995 and 1997 documentation guidelines?
Examination
Microscopy
Examination of a specimen under a microscope; most codes for microscopic examination also include gross inspection
Gross examination
Examination of the entire specimen without sectioning of the specimen into slides for examination under a microscope
Allergic/immunologic
Examples include answers about allergies to medication, foods or other substances, hives and/or itching, sneezing, chronic or clear postnasal drip, conjunctivitis, and history of chronic infection
Hematologic/lymphatic
Examples include easy bruising, fevers that come and go, swollen glands, night sweats, or unusual bleeding
State regulated insurance plans are most commonly associated with:
First party medical claims in an auto insurance case (where the state law requires or provides for such coverage) or workers' compensation claims
An audit performed on one provider would be considered a:
Focused audit
The HIPAA Privacy Rule defines "minimum necessary" as typically requiring healthcare employees to:
Follow policies and procedures developed by the covered entity which limit use and disclosure of PHI to that which is needed to accomplish the intended purpose to perform the duties of their job.
How may limited data sets be used?
For research, healthcare operations, and public health purposes, as long as there is an agreement with promised safeguards in place for the PHI
Release of Information
Form signed by patient allowing the release of their medical records
A deliberate misrepresentation of facts to gain unauthorized benefits is the definition of:
Fraud
Be _____ and _______ when discussing the auditee's options and recommendations for corrective action.
Helpful; supportive
Diagnostic services are reviewed that have:
High audit error rates and are commonly audited by government and private payers
"Forbidden" symbol meaning in the CPT codebook
Identifies codes that are modifier 51 exempt (see CPT Appendix E) and exempt from the multiple procedure payment reduction
"Bulls-eye" symbol meaning in the CPT codebook
Identifies codes that include moderate sedation. When this symbol appears next to a CPT code, moderate sedation is not reported separately (see CPT Appendix G). If moderate sedation is performed in a facility setting by a different physician (other than the physician performing the procedure), that provider may bill for moderate sedation.
Quantitative testing
Identifies not only the presence of a drug, but the exact amount present
Service-Specific Results attached to the audit report
Identifies the specific audit findings for each service evaluated as well as comments detailing the rationale supporting the audit conclusion; often presented in a spreadsheet format with column headings such as claim number, sample control number (where a SVRS Audit is performed), patient name, provider of service (where the services of multiple providers are included in the audit sample), date of service, CPT/HCPCS reported (for concurrent and retrospective audits and where accuracy of CPT/HCPCS coding is within the audit scope), ICD code reported (where ICD reporting accuracy is within the audit scope), correct CPT/HCPCS code (where accuracy of CPT/HCPCS coding is within the audit scope), correct ICD code (where ICD reporting accuracy is within the audit scope), other audit result, and comments/rationale
Although changes in the substantive conclusions are not usually necessary, a review is often effective to:
Identify any ambiguous or confusing portions of the audit report
How do you determine the sample that will be used for the final selection?
Identify measures (e.g. just new patient visits, all services, just one provider) and determine sample size (usually 10-15 charts per provider)
In addition to identifying the appropriate binding standards, where a change in code is the result, the auditor may be asked to:
Identify the appropriate fee schedule allowance in effect at the time, so that the specific financial impact associated with any detected error can be identified and refunded
Using RAT-STATS to create a Discovery Sample for a CIA Claims Review serves what purpose?
Identify the financial error rate of the selected sample
The audit report should:
Identify the key findings and present the analysis, rationale and recommendations in a format that is easy for the auditee to read, understand, and apply
Although an auditor is unlikely to be responsible for managing self-disclosures, an auditor may need to be involved in:
Identifying the scope of the error (sampling frame)
State law will take precedence over HIPAA under which of the following circumstances:
If HIPAA is less restrictive than state law.
After the sampling frame is identified, the auditor determines:
If a 100% audit was feasible or whether statistical sampling should be employed
When can a RAC extrapolate the overpayment(s) on claims?
If a RAC can demonstrate a high level of error, the RAC can then extrapolate the findings and request a refund.
Qui Tam or "Whistleblower" provision
If an individual (known as a "relator") knows of a violation of the False Claims Act, he or she may bring a civil action on behalf of him or herself and on behalf of the U.S. government; the relator may be awarded 15-25% of the dollar amount recovered
When can the physician bill a shared/split visit?
If performed in the office setting and incident-to requirements are met. If not, it is billed by the NPP. In the hospital setting, if the physician performs a face-to-face encounter, the service can be billed by the physician or the NPP. If the physician only reviews the chart and discusses the case with the NPP, the service is billed by the NPP.
What is 1 issue a smaller medical office may have with conducting an internal audit?
If staff conducting the audit has other responsibilities, the audit could pose productivity issues.
Component of the audit report: recommendations
If the audit is part of evaluating the auditee's level of compliance, include recommendations for resolving any detected errors; the auditor should make specific recommendations relative to each identified issue; usually included is a recommendation for follow-up analysis at a heightened frequency to evaluate the effectiveness of the corrective action; present recommendations in the same order as presented in the summary, findings, and discussion sections or in order of priority; continuity should be established
When can penalties be reduced at the discretion of the OCR?
If the failure to comply was due to reasonable cause and the penalty would be excessive based on the nature and extent of the noncompliance
When will a covered entity not receive a civil monetary penalty for failing to comply and cooperate with an investigation initiated by OCR?
If the failure to comply was not due to willful neglect and was corrected within 30 days of identification that the error occurred; or, if a criminal penalty was imposed by the Department of Justice
What happens after the provider receives the demand letter during a RAC audit?
If the provider agrees with the letter, he/she may submit payment; ask for a recoupment of future payments; or ask for an extended payment plan. If the provider disagrees with the demand letter, he/she may submit a discussion period request to the Recovery Auditor within 15 days from the date of the demand letter; submit a rebuttal to the MAC within 15 days from the date of the demand letter; or submit a redetermination request to the MAC within 120 days from the date of the demand letter (first level of appeal)
When is a code for a vaccine not reported?
If the vaccine is given to the provider for free, the patient brings the supply, or if the supply s provided as part of a clinical trial.
Component of the audit report: issue oriented findings
If there were consistent findings attributable to a specific CPT/HCPCS Level II code or a particular provider, it is appropriate to report these findings in an issue-oriented format; if the audit results do not lend themselves to reporting in this fashion, it is not necessary to include this section
When must an operative report be dictated?
Immediately after the procedure was performed
Elements identified by the OIG that should be present in every compliance plan (except for individual or small group practices)
Implementing written policies, procedures and standards of conduct; designating a compliance officer and/or compliance committee; conducting effective training and education; developing effective lines of communication; enforcing standards through well-publicized disciplinary guidelines; conducting internal monitoring and auditing; and responding promptly to detected offenses and developing corrective action
When are ABNs never required?
In emergency or urgent care situations; CMS policy prohibits giving an ABN to a patient who is "under duress" including patients who need Emergency Department (ED) services before stabilization
Where are the anesthesia start and stop times documented?
In the anesthesia record
In what setting is the electronic signature recognized as sufficient to meet documentation requirements?
In the hospital setting
Who established National Safety Goals?
the JC
Where can you find a list of AOs online?
the Medicare website for accreditation
What is the most common format used in medical records?
the SOAP format
Under the Office of the Inspector General CIA, an Independent Review Organization (IRO) reports audit results to:
the compliance officer in the organization under the CIA
PC/TC indicator: 5
Incident-to Codes: This indicator identifies services that can be covered incident to when provided by auxiliary staff employed by the physician working under his or her direct personal supervision. Modifiers 26 and TC cannot be reported.
To facilitate claims adjudication for unlisted codes:
Include the operative report (if you can attach records) and provide a suggested fee by comparing the procedure to the type of work required for a similar procedure with an assigned fee schedule
X-ray technology
Includes a variety of advanced applications, such as computerized axial tomography (CAT or CT scan), magnetic resonance imaging (MRI), ultrasound technology, nuclear medicine, radiation oncology, and positron emission tomography (PET)
Potential benefits of a compliance program for individual and small group practices
Increasing accuracy of documentation; increasing the speed and optimization of proper payment of claims; minimizing billing mistakes; reducing the chances that an audit will be conducted by CMS or the OIG; and avoiding conflicts with the self-referral and anti-kickback statutes
Anatomic modifiers may be used to:
Indicate different sites
Opposing horizontal triangle symbol meaning in the CPT codebook
Indicate new and revised text, other than in procedure descriptors. The codes may not change, but there was a need to clarify code use to prevent unbundling or to alert the coder that additional services may also be reported.
Modifiers
Indicate that the service or procedure performed has been altered, but the definition of the code has not changed; can affect reimbursement and, used properly, can break the global package
Modifiers 78 and 79 are reported during the global period to:
Indicate the patient required either an unplanned procedure (usually a complication) or an unrelated procedure
Bullet symbol meaning in the CPT codebook
Indicates new procedures and services added to the CPT codebook
Triangle symbol meaning in the CPT codebook
Indicates that the description of the code has been revised (details of the revision found in Appendix B)
Objective
Indicates the physical exam findings of the provider
Who generally governs medical record retention times?
Individual states
PHI
Individually identifiable health information that includes many common identifiers such as demographic data, name, address, birth date, and social security number; also includes information that relates to an individual's past, present, or future physical or mental health or condition, the provision of health care to the individual, or the past, present, or future payment for the provision of healthcare to the individual, which reasonably may be used to identify the individual
Certificates for more complex testing require:
Inspections, calibration of equipment, and other tests to assure the quality and accuracy of tests performed
What is included in the CPT codebook?
Instructions, coding guidelines, parenthetical notes, and symbols to provide guidance for proper coding
Prospective audit
Intercepts claims coded prior to reporting to ensure the coding and associated documentation is compliant with binding carrier standards; another type involves analysis of current claims against a pending standard to determine if changes are necessary to maintain compliance
Many practices use a combination of what 2 types of audits to maintain compliance?
Internal and external
What requirements must radiology reports meet to accurately assign a CPT code for services performed?
It is necessary to retain the actual images of radiologic services, as well as a written report, to describe the indication for the study and to summarize the findings. An order or request for the study must also be retained.
Risk areas of dictations
It may take several days for the transcriptionist to transcribe the recorded information and return it to the physician,
What must happen before the patient signs the ABN?
It must be verbally reviewed with the beneficiary or his/her representative and any questions raised during that review must be answered
When providing a prescription for a patient, the education of the patient, including side effects and supporting documentation in the medical record that the information was reviewed is based on which of the following standards?
Joint Commission standards
Concerns raised by the Recovery Audit Program
Upon notification of an appeal by a provider, the Recovery Auditor is required to stop the discussion period; providers don't receive confirmation that their discussion request has been received; Recovery Auditors are paid their contingency fee after recoupment of improper payments, even if the provider chooses to appeal; Additional Documentation Request (ADR) limits are based on the entire facility, without regard to the differences in department within the facility; and ADR limits are the same for all providers of similar size and are not adjusted based on a provider's compliance with Medicare rules
Focused audit
Looks at one item, one type of service, or one provider
Global surgery status indicator: 090
Major procedures with one day preoperative period and 90-day postoperative period are considered to be a component of global package of the major procedure. E/M services on the day prior to the procedure, the day of the procedure, and during the 90-day postoperative period are not reimbursable.
Auditing psychiatric diagnostic evaluations
Make sure the documentation includes history, mental status, and recommendations; the service may require a discussion with the patient's family or caregiver
Global surgery status indicator: MMM
Maternity codes; the usual global period concept does not apply
Peer review audit
May be performed if the clinical decision-making is questioned, based on the documented exam and treatment plan; some practices use a peer review audit on a quarterly basis to provide feedback among the providers; a provider performing a peer review audit may take into account the coding accuracy as well as clinical information
Why is a full signature generally the best practice?
Medical records can, and often do, become legal documents
Nancy prepares to begin a focused audit for Dr. Jacobsen, a general surgeon.The resources that she will gather in addition to the CPT®, HCPCS Level II and ICD-9-CM codebooks, that will be needed to accurately complete the audit will be:
Medical terminology book, surgical package definition, global days, surgery audit tool, insurance carrier rules and NCCI edits.
Common reasons Medicare may deny a procedure or service include:
Medicare does not pay for the procedure/service for the patient's condition; Medicare does not pay for the procedure/service as frequently as proposed; and Medicare does not pay for experimental procedures/services
Global surgery status indicator: 010
Minor procedures with preoperative relative values on the day of the procedure and postoperative relative values during a 10-day postoperative period are reimbursable services. E/M services on the day of the procedure and during the 10-day postoperative period are not reimbursable.
Errors identified in outpatient therapy services by Medicare's Comprehensive Error Rate Testing (CERT)
Missing the plan of care, missing signatures and dates, missing certification and recertification, and missing the total time for procedures and modalities
CMS Examples of Abuse
Misusing codes on a claim, charging excessively for services or supplies, billing for services that were not medically necessary, failure to maintain adequate medical or financial records, improper billing practices, billing Medicare patients a higher fee schedule than non-Medicare patients
Common modifiers for pathology include:
Modifier 90, modifier 91, modifier 92, and modifier QW
When a resident is involved with care, what modifier should the teaching physician append to the procedure codes?
Modifier GC
What modifier is appended to the code to indicate the service was provided without the presence of the teaching physician?
Modifier GE
If sampled claims were not reported appropriately, the ___ ________ (or _______) must be identified.
Net overpayment; underpayment
Are insurance contracts always available to the auditor?
No
As an auditor, should you expect to see operative notes from the surgical assistant?
No
Can physicians seek payment from beneficiaries when Medicare denies screening and stabilizing care as medically unnecessary?
No
Do all payers require physical status modifiers?
No
Does CMS allow rubber stamps for signatures?
No
If the dollar value of an overpayment can be identified through simple data analysis, is an audit required?
No
Is contrast always considered an integral part of the study?
No
Is routine blood work to monitor side effects of medication be considered an additional workup?
No
Is the patient's signature required for assigned claims (that is, claims submitted by and paid to a physician on behalf of the beneficiary)?
No
Are compliance plans mandatory?
No, they are currently voluntary. The Affordable Care Act makes compliance programs mandatory for providers and other healthcare providers but there is not yet an implementation date
For Medicare, if the provider was out of the office, can the service be billed?
No, this is based on the incident-to guidelines
Do all payers require the modifier to identify the anesthesia provider?
No; Medicare does
Purpose of a Discovery Sample
Used to determine the net financial error rate; if the error rate exceeds 5%, a Full Sample must be reviewed, along with a Systems Review
How is the intensity of an E/M service measured?
Using graduated levels. Within each E/M level, CPT lists specific components to measure service intensity.
Compliance audit
Usually involves an analysis of claims data on behalf of the provider or entity providing the services; may be commissioned by, or is performed on behalf of, an external entity
As an auditor, you identify that Dr. Jones consistently codes 99212 more than the other providers in his group practice. This was determined by reviewing Dr. Jones':
Utilization pattern
The most important step in any compliance audit is:
Validation of the rules particular to the services being audited and the payer that the services are being billed to
In what cases can a provider select the E/M code based on time?
When counseling or coordinating care take up the majority of the visit with the patient
When is hydration not reported separately?
When fluid is used to administer the drug
According to the Privacy Rule, when must a covered entity disclose PHI to an individual or HHS?
When he or she requests his or her own information or when HHS is investigating for compliance, review, or enforcement action
How does appending modifier 78 to a claim for a service provided to a Medicare beneficiary affect the payment and global period?
When modifier 78 is appended, only the intraoperative percentage is paid and no new global period begins
When can psychotherapy be performed as a stand-alone service or as an add-on code?
When performed in addition to an E/M service; when reporting the add-on psychotherapy codes, the time spent performing the E/M service is not included in the time reported with the psychotherapy code; the documentation for each service must stand alone
When are outpatient therapy services covered?
When services were required because the individual needed therapy services; and a plan of care has been established and is periodically reviewed; and services were furnished while under the care of a physician; and the physician or nonphysician practitioner certifies the plan of care
When does anesthesia time start?
When the anesthesia provider prepares the patient for anesthesia care
When should +99100 not be reported for the qualifying circumstance?
When the extreme age of the patient is included in the description of the anesthesia CPT code
When is constant attendance (direct one-on-one) required for the application of a modality?
When the provider must be present to manually apply the therapy or the safety of the patient requires it
When do state laws regarding medical records retention pre-empt the federal regulations?
When the state laws require longer record retention
When does Medicare relieve beneficiaries from financial liability?
When they did not know and did not have reason to know a service would not be covered
When should you not report 2 or more panel codes?
When they include the same tests. Separately report tests not included in the panel.
Reverse false claims provision
A provider who knowingly retains money belonging to the government is liable for FCA damages and penalties
When might the government impose a Corporate Integrity Agreement (CIA)?
As part of a settlement agreement (usually) involving repayment of money to the government
The explanation of why Medicare may deny the service or procedure should be:
As specific as possible
Add-on code icon
+
How many systems are recognized for purposes of ROS?
14
What is one unit of time equal to according to recommendations from the AMA and ASA?
15 minutes of anesthesia time
What are the elements of HPI that can be included in the documentation?
Location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms
Where errors result in mere overpayments for which there was no evidence of fraudulent conduct, an entity must:
"Voluntarily" identify, disclose, and refund overpayments so as to avoid False Claims Act (FCA) liability under the "reverse false claims provision" of the FCA
Steps for radiology auditing
1. Determine the scope of an audit. 2. For diagnostic radiology services, make sure there is an order that includes the test to be performed (including views when appropriate) and the diagnosis for ordering the test. 3. Verify that there is an interpretation and report and retention of a permanent image, when required, for the radiology service. Without an interpretation and report, the service cannot be reported. 4. Verify if the diagnosis meets medical necessity. 5. Verify the accuracy of the coding with the detail in the written radiology report. 6. Many surgical procedures include imaging guidance. The instructions for reporting imaging guidance separately are found in the coding guidelines or parenthetical note(s)
Steps for surgical auditing
1. Determine the scope of the audit. 2. Make sure the documentation is complete. 3. Review the entire operative note. 4. Verify the procedures have not been unbundled when more than 1 procedure code is reported. 5. Review MUEs for the codes to prevent reporting excessive units. 6. When sequencing multiple codes, make sure it is done in RVU order, from highest to lowest. 7. Verify medical necessity. 8. When coding for an assistant surgeon, make sure an assistant surgeon is approved for the surgery. 9. Verify modifier use. 10. Make sure all charges are captured.
Steps for auditing chemotherapy and therapeutic drug administration
1. Determine the scope of the audit. 2. Verify the order for the service. 3. Determine the primary service. 4. Use caution when hydration is reported in addition to chemotherapy or therapeutic drug administration. 5. Administration codes are time based. The IV flow sheet must indicate the site of the infusion, medication and dose, and start and stop times. 6. Drugs that are mixed together are usually documented as "piggy back". A separate administration code is not reported. A code with the appropriate units is reported for each drug. 7. Verify the correct units are reported with the HCPCS Level II code for the supply of the medication. 8. Follow Medicare's guidance for drug wastage. You can only report drug wastage for single dose vials. 9. Follow NCD/LCD and private payer policies for the chemotherapy medication. Because of the expense of chemotherapy drugs, many of the drugs have payer policies for payment determinations.
Steps for pathology and laboratory auditing
1. Determine the scope of the audit. 2. Verify the orders for the lab/path services performed. The provider must indicate the reason for ordering the test. 3. Verify medical necessity has been met. 4. Review the analyte tested, and method for performing the test. 5. Check the accuracy of the coding for panels. 6. Verify the accuracy of modifier use.
Steps in the audit process
1. Determine the scope, or what services will be a part of the audit. 2. Determine the sample that will be used for the final selection. 3. Consider what tools or resources will be needed to conduct the audit prior to beginning (create/obtain audit tool) 4. Gather the documentation and perform the audit 5. When the audit has been completed, it is time to consider how the results will be reported
Steps for anesthesia auditing
1. Determine the type of anesthesia. 2. Determine the appropriate anesthesia code for the surgical procedure(s) performed. 3. Verify the correct modifiers to identify the anesthesia provider reported. 4. Verify the physical status modifier is documented and the diagnosis supports it. 5. Verify the accuracy of any qualifying circumstances codes reported. 6. Review the documentation for additional procedures performed by the anesthesia provider. When documented, report the services in addition to the anesthesia code. 7. Determine anesthesia time to report total minutes on the claim form. 8. In a post payment audit, use the calculation to determine the expected reimbursement to make sure the claims paid correctly.
When auditing physical therapy services, the documentation must include:
1. Plan of care, including diagnoses, long-term treatment goals, type of rehab services (include the intervention and modality), amount (number of treatment sessions per day), duration (number of weeks or treatment sessions), and frequency (number of sessions in a week) 2. Initial certification-the physician or other qualified healthcare professional approve, by signature and date, the care plan w/in 30 days of the initial therapy treatment 3. Recertification-Not required if the duration of the certified care plan is more than the duration of the entire episode of treatment; used to document the need for continued/modified therapy and should be done at least every 90 days after the initiation of the care plan. 4. When modalities are performed, report the specific modality and the time.
Steps to follow when billing time-based codes
1. Review each time based code to see if it is performed for at least 8 minutes, to be billable. 2. Look at total time. If we have 2 codes, both performed for 8 minutes, each is billable. But, for the total time, we only have 16 units. Only one unit can be billed, based on the total time. Because both services are performed for the same amount of time, report the code with the highest RVUs.
What are the recommended number of charts to audit per provider and the minimum frequency of the audit?
10 records per provider each year
For how long must providers who accept the Medicare Managed Care program maintain medical records?
10 years
What is a good selection size for an audit?
10-15 charts per provider
What should the baseline audit consist of?
10-15 records, per practitioner, and include a random sampling of E/M service levels, office, and surgical procedures
What percent of precision and confidence are required to estimate the overpayment?
90% confidence and 25% precision level
What codes are reported when psychotherapy is provided for a patient in crisis?
90839 and 90940, based on time
Coding for Swan-Ganz catheters
93503 is the CPT code and the catheter must be placed by the anesthesia provider. It is important to determine how many lines the anesthesia provider has inserted, as the provider may place multiple lines. If the Swan-Ganz catheter is threaded through a central venous line, you do not report the insertion of the central venous line. Only report the Swan-Ganz catheter because the same line is used. If 2 separate lines are inserted and 2 different vessels are used, report the insertion of the line and the insertion of the Swan-Ganz catheter and append modifier 59 to the central line.
What E/M code is commonly reported in error for a nurse visit?
99211
What components are commonly found in all medical records?
A personal identification number specific to every individual patient; a patient's medical history; often a medical directive
What is an example of an exception under the Privacy Rule that requires a written agreement to disclose protected health information?
A physician sending patient's treatment plan to a marketing pharmaceutical company
What do the most commonly performed pathology and laboratory services require?
A physician to collect a specimen for testing and send it to an outside lab (can be a hospital outpatient lab or an independent lab), which conducts the ordered test and sends a report back to the physician
AD modifier
A physician who is medically supervising more than 4 concurrent procedures
Who must also sign the certification for outpatient therapy services if a physical therapist or speech-language pathologist establishes the plan of care?
A physician, NPP, clinical nurse specialist, or physician assistant
A chief complaint is required for every encounter except for what kind of service?
A preventive service
Definition of workup
Anything that the physician plans to make or confirm a diagnosis such as a diagnostic test
Nerve blocks performed for pain management and not for anesthesia may be reported separately by:
Appending modifier 59
Audit concerns with modifier 25 include:
Appending the modifier on the minor procedure, instead of the E/M code; documentation does not support a separate E/M; and various interpretations/guidance from payers regarding proper use. Review the payer policies for the services you are auditing
Multiple surgical procedure reduction
Applied when multiple procedures are performed during the same operative session; the highest valued code is paid at 100%, the second highest valued code is paid at 50%, and each additional procedure is paid at 25%; if a claim exceeds 5 line items, payers may evaluate for special pricing; the fee schedule for add-on codes already accounts for the reduction and the payment is made at 100%
If the auditee cannot make sense of the report or understand the basis for the allegations of error, what cannot occur?
Appropriate corrective action
The accuracy of an audit must be validated through:
Appropriate risk analysis
A random audit will often identify:
Areas for potential education and future focused audits to determine the effectiveness of the education
The compliance program guidance (CPG) document identifies four risk areas most likely to affect a physician's practice. The risk areas include:
Coding and billing, reasonable and necessary services, documentation, improper inducements.
An audit of 20 family practice charts for code 20552-20553 reveals that the provider used fluoroscopic guidance when performing trigger point injections. In reviewing claims data for these charts, it is found that 76942 was reported with 20552-20553. What should be stated on the audit findings report?
Coding is incorrect, code 77002 should be reported for these cases.
Who may conduct periodic, internal audits?
Coding staff trained in auditing medical records or by a practitioner trained to audit for coding and compliance
For E/M services, when the physician has met the teaching physician requirements:
Combine the resident's note and the teaching physician's note to select the E/M code. For procedures, the physician must be physically present to supervise the procedure performed by the resident.
Potential risk areas for individual and small group practices indicated by the OIG in the CPG
Coding and billing, reasonable and necessary services, documentation, and improper inducements, kickbacks, and self-referrals
Medical record
Chronological documentation of a patient's medical history and care
What do most payers use to review claims?
Claim edits or automatic denial/review commands within their computer software
Services provided by Business Associates
Claims processing or administration, data analysis, utilization review, billing, benefit management, and re-pricing; for a covered entity, services are limited to legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, or financial services
Examples of what might be included in a surgical procedure:
Cleansing, shaving, and prepping of skin; insertion of intravenous access for medication (IV); local infiltration of medication-topical, or regional anesthetic administered by the physician performing the procedure; surgical approach, including identification of landmarks, incision, and evaluation of the surgical field; exploration of operative area; insertion and removal of drains, suction devices, dressings, pumps into same site; surgical closure; application and removal of postoperative dressings, including analgesic devices; surgical supplies
Because a coding audit is unlikely to identify Stark or Anti-kickback Statute violations, the disclosures associated with these particular violations usually do not involve the services of a:
Code auditor. Where such violations exist, all claims that were the product of an improper referral in violation of the AKS or Stark laws must be identified and refunded; usually simple data analysis only is required to identify the improper claims and the overpayment amount
If no definitive diagnosis is yet determined:
Code symptoms and/or signs instead of using rule-out statements
Left posterior oblique (LPO)
Left rear angled view
In the case of audits associated with voluntary repayments or disclosures under the SDP for potentially fraudulent conduct, it usually falls to the entity's _____ ______ to make corrective action recommendations or to develop a corrective action plan.
Legal counsel
What is the highest E/M level that can be billed for the primary care exception?
Level III
Effective oral communication of the audit results
Listen to the concerns or questions of the auditee and address those questions and concerns objectively
G8 modifier
Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure
G9 modifier
Monitored anesthesia care for patient who has history of severe cardio-pulmonary condition
Standing order policy
Must be written and adhere to state law requirements, must indicate the clinical condition, and must be reviewed for validity
A provider receives denials from a private payer for E/M services performed on the same date as a minor procedure. You review documentation for 25 records and the payer contract which states the provider must follow CMS coding guidelines. You determine that 20 of the records have appropriate documentation to support both E/M and the procedure and were coded correctly when the claim was originally submitted. You submit an appeal for the 20 dates of service that are supported by documentation. To support you findings, you will include in the appeal a letter reporting your findings, claim forms, copies of documentation, EOB copies and:
NCCI policy manual for modifier 25.
What is included in the body of the notes?
Specific details of the surgery
The SDRP is appropriate for detected violations under the:
Stark self-referral law
It is usually best to retain a ______ to design the sample and to perform the error rate projection.
Statistician
Civil Monetary Penalties Law
The Social Security Act authorizes the HHS to seek civil monetary penalties and exclusion for certain behaviors. These penalties are enforced by the OIG through the Civil Monetary Penalties (CMP) Law. The severity of penalties and monetary amounts charged depend on the type of conduct engaged in by the physician. A physician can incur a CMP in the following ways: Presenting or causing claims to be presented to a federal healthcare program that the person knows or should know is for an item or service that was not provided as claimed or is false or fraudulent.Violating the Anti-Kickback Statute by knowingly and willfully (1) offering or paying remuneration to induce the referral of federal healthcare program business, or (2) soliciting or receiving remuneration in return for the referral of federal healthcare program business. Knowingly presenting or causing claims to be presented for a service for which payment may not be made under the Stark law
Coding for insertion of arterial lines
The anesthesia provider must perform the insertion. Do not report line placement if the surgeon placed the line, or if the line was already in place and it is not clear who placed it. If more than one line is inserted into different vessels, report all the line insertions and append modifier 59 to the additional codes for the arterial catheter placement.
Coding for insertion of central venous lines
The anesthesia provider must perform the insertion. If the surgeon placed the line or if the line was already in place and it is not clear who placed it, the line placement should not be reported. If more than one line is inserted into different vessels, report all of the insertions and append modifier 59 to the additional codes for the central venous catheter placement.
Physical status modifiers are determined and documented by:
The anesthesia provider. This is not a requirement for all payers.
What must be reported on the claim when reporting anesthesia services?
The anesthesia time in minutes along with modifiers to identify the anesthesia provider
What code should you report when the epidural is the method for anesthesia?
The appropriate anesthesia code
What code should you report when a nerve block is performed for regional anesthesia?
The appropriate anesthesia code instead of the code for the nerve block
What is the primary method of communicating the audit results?
The audit report
What audit tool should the auditor use?
The audit tool used by the MAC for the provider(s) audited, unless one is not available; the E/M tools for the MAC should be reviewed to seek clarification and availability of audit tools
Who selects the IRO?
The auditee's legal counsel
Independent Review Organization (IRO)
The auditor who performs the audit associated with a CIA; a neutral auditor with sufficient expertise in the subject matter to perform an annual audit of the entity's level of compliance; works on behalf of the OIG
An IRO may explain:
The basis for the audit result and the perceived cause of any declared error, and may explain how the auditee applied the relevant binding standards in formulating the audit conclusions
Who must receive a copy of the completed, signed ABN?
The beneficiary or representative and the provider must retain the original notice on file
Medicare allows that an estimate that substantially exceeds the actual costs would generally still be acceptable because:
The beneficiary would not be harmed if the actual costs were less than predicted
The auditor must review the contract to determine:
The rules the provider is bound to follow. Specifically: 1. Is the provider obligated to conform to the insurance company's published medical policies? If so, does non-conformance entitle the carrier to recoup the money, or is the only sanction potential termination of the provider's network status? In such a case, is the provider offered a chance at implementing corrective action? How these questions are answered will significantly affect the audit result, in terms of whether an auditor can declare error or can simply declare potential risk. 2. Where the provider is not contracted with a particular payer, consider the provider has no legal duty to conform his/her reporting or documentation to the mandates of the carrier's medical policies. Although this might prevent an auditor from declaring an error, it does not prevent an auditor from identifying potential risk and suggesting change that would assist the provider in avoiding an issue with that carrier.
A sample is statistically valid if:
The sample was collected using scientific sampling methods
Random audit
The selection will be random and each service is as likely to be chosen for audit as any other service
For all payers, even if a service is reasonable and necessary, coverage may be limited if:
The service is provided more frequently than allowed under an NCD, LCD, or a clinically accepted standard of practice
The documentation for services provided by teaching physicians with resident services must include:
The services provided by the resident, as well as the services provided by the teaching physician. If it is not clear that the physician performed a face-to-face encounter with the patient, the service cannot be billed.
When an audit reveals an error or non-conformance, what must be identified?
The specific reason for the non-conformance, with citations to the applicable policy provisions or binding rule
Definition from the 1997 guidelines regarding general multi-system examination
To qualify for a given level of general multi-system examination, the following content and documentation requirements should be met: Problem Focused Examination-should include performance and documentation of one to five elements identified by a bullet in one or more organ system(s) or body area(s); Expanded Problem Focused Examination-should include performance and documentation of at least 6 elements identified by a bullet in one or more organ system(s) or body area(s); Detailed Examination-should include at least 6 organ systems or body areas. For each system/area selected, performance and documentation of at least 2 elements identified by a bullet is expected. A detailed examination may include performance and documentation of at least 12 elements identified by a bullet in 2 or more organ systems or body areas; Comprehensive Examination-should include at least 9 organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least 2 elements identified by a bullet is expected
In what situations can a covered entity use and disclose certain information without an individual's authorization?
To the individual who is the subject of the information; PHI may be used by a covered entity for treatment, payment, or healthcare operation activities; the individual may grant informal permission by being asked outright, giving them the opportunity to agree or object in circumstances where the individual is not capable of providing his or her signature; incidental use and disclosure is permitted as long as the covered entity has reasonable safeguards in place to ensure that the information being shared is limited to the "minimum necessary"
What should happen if there are elements missing in an operative note?
Training should be provided to remind physicians that the note is the only way to represent what was actually done in the operating room, and that everything must be clearly spelled out through documentation