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CMS Chart Audits: Proper Coding to Avoid Chargebacks
By Laurie Zabel

The Centers for Medicare & Medicaid Services (CMS) has for years been conducting documentation and coding audits in hopes of recouping monies paid out for claims. These audits have, over the years, proven to be effective—in many instances revealing that provider documentation does not support the level of codes—particularly the higher level codes—as billed. It is important to note that, in most cases, providers are administering the level of care necessary to justify the billed service; however, the provider may not be sufficiently documenting to properly capture all the elements of the services they have rendered.

It seems to me, after years of working in the medical field and conducting and reviewing audits, that CMS targets those areas where it determines it can readily recoup monies. For many years, CMS has been conducting documentation audits of evaluation and management coding—again, most often focused on the higher level codes billed by providers. Many chart audits of providers' office visit charges have been conducted; it was often determined that when handwritten notes were reviewed, the provider's documentation did not support the level of service billed. We, in our consulting practice, began the process of educating our providers on the required elements of documentation. Some of our providers understood and improved their documentation; others did not.

Along came EMRs and templates. The use of templates soon made it somewhat easier for our providers to be "reminded" of required documentation elements. This began to change what CMS personnel were uncovering in their office visit/outpatient chart audits; they began finding, in many instances, that the electronic documentation either met or exceeded the level of code billed by the providers. Subsequently, to recoup monies paid on claims, CMS has looked to long term care facilities, nursing homes, and assisted-living facilities. In some instances, these facilities are not utilizing EMRs, and providers coming in to render care to the patients in these facilities are completing handwritten chart notes.

Let's look at two of the high-level codes utilized for nursing facility charges: 99306 — Initial Nursing Facility Care and 99310 — Subsequent Nursing Facility Care. Each of these codes requires certain elements of the patient's history and examination be documented within the note and that the medical decision-making be of a particular complexity. The required elements of both 99306 and 99310 are comprehensive history, comprehensive exam, and high-level medical decision-making.

When CMS personnel conduct audits and find that the required documentation elements are not contained within the note, they are able to recoup monies that have been paid. The process CMS personnel utilize to conduct audits and recoup overpayments is typically to request approximately 30 visits per provider. Once they have conducted their audit, they will have made a determination as to how many, if any, of the services were incorrectly billed. They may audit 30 visits, and in nine instances the documentation will not support the level of service billed. So, in this instance, 30% of the visits audited did not have the required documentation to support the level of service billed. Through extrapolation, CMS will determine that 30% of all visits billed with that specific CPT code over the last two, three, four, or five years were overbilled and that overpayments have been made on those claims.

These overpayments can quickly add up when extrapolation is used. If, for example, CMS conducts an audit of 30 visits where the CPT code 99306 was billed and in their audit it determines that 30% or nine of those visits were overcoded by one level, they can extrapolate and determine that 30% of all 99306s that were billed to them over the last three years were overcoded by one level, and that an overpayment was made to the provider. CMS will then request a refund of the overpayments for all of these claims submitted during this period.

If this has been going on for years, why have providers not ensured that their documentation contains the required elements or bill a lower-level code? I believe the main reason is lack of education and understanding by providers. Providers spend many years in medical school and residency programs learning how to appropriately diagnose and treat their patients. They learn how to document a note but not how to translate that documentation into a CPT code. There is no reminder on their paper note stating, "If you feel your treatment and care plan supports a 99306, then please remember that you must have documented four or more elements of history of present illness, 10 reviews of systems, and all elements of past, family, and social history." In some instances, providers need to know how to appropriately document that they received the medical history from someone other than the patient to receive the additional "points" needed in determining the overall level of medical decision-making.

How can a practice's administration staff assist their providers in ensuring that their documentation supports the level of CPT code billed? Start with an internally generated audit. If you do not have a qualified certified professional coder on staff, consulting companies can conduct the audit. Once the internal audit is complete, ensure that your providers have had the time to review their results and offer them any necessary education. Target the personnel who were lacking in documentation and help them set up templates or coding cheat sheets that will serve as reminders. In many instances, providers are fulfilling all of the necessary elements to bill at a given level of service, but they are not sufficiently documenting it in their notes.

As we have all heard, "If it is not documented, it did not happen." Let's ensure that providers are receiving the appropriate reimbursements for the services they deliver.

— Laurie Zabel is director of coding and compliance at MedSafe.