With the rising yearly expenditure for the federal Medicare program, the OIG is diligently targeting physicians that are using improper coding techniques or are not following through with their compliance plans.  Conducting routine coding and chart documentation reviews will help keep your practice out of trouble with the federal government upon audit.  Internal monitoring and auditing of your medical records is recommended by the OIG as part of an acceptable compliance plan.  Is your practice conducting regular internal and external medical record reviews?  Snyder, Cohn can help!

The following are some "Red Flags" for both Medicare as well as most managed care carriers when they are conducting an audit.

• llegible documentation - If your practice were to be audited by Medicare or any other carrier, it is a general rule that if a note or any part of the documentation is illegible, then it is treated as if it is not present on the chart at all.
• Undercoding - Some physicians try to "play it safe" and undercode their services to stay off the OIG's radar screen.  This method is not only non-compliant, but it also causes the practice to lose potential revenue, and in most cases will not help your practice avoid audit scrutiny or penalties.
• Consultation Visits - All of the required elements of a consult must be clearly reflected in the medical record.  This has been a hot topic for the OIG over the past few years and appears again on the “hit” list for 2007. 
• Templates for Documentation - EMR systems make documentation easier, but it is important to ensure that your documentation is not "overly templated".  This method can lead to contradictions in notes, and/or long, detailed documentation of a patient's stable condition, which would not help to substantiate medical necessity.
• Physician billing for the same codes over and over again - This will get the attention of the carrier very quickly with their new tracking software edits.  Remember documentation must match the services billed and always has to justify the medical necessity of the service rendered and billed for.
• Time-based coding - In order to code according to time, the physician or non-physician provider must spend more than 50% of the visit time engaged in face-to-face counseling with the patient.  When using this method of coding, time must be documented clearly on the medical record.
• Hospital admissions - Adequate documentation must be provided in the patients medical record to justify a hospital admission

We recommend that a practice conduct internal chart reviews every three to six months, more for providers where a problem is identified.  This would include the review of five to ten random visits per provider.  In order to conduct an internal review, you must have a staff member who is competent enough in coding to be able to verify that the provider is using proper coding techniques, that documentation is complete and legible, services billed match the medical record for that visit, and that the documentation in the chart meets the standard of medical necessity.  An experienced certified coder is strongly advised to complete this type of review.  If you do not have a certified coder on staff, you may need to hire an outside consultant to conduct the first few medical chart reviews, as well as the external reviews after that.

External reviews need to be conducted every year, but no less than every two years, in our opinion.  The timing of your chart audits will vary according to your patient population by payor, types of services rendered, the level of coding education and expertise of the providers and staff in your practice, as well as past-identified problems. 

An external review should consist of the analysis of coding and documentation, observation and education regarding the coding techniques of staff and physicians, analysis of code frequency including comparison to national averages for the same specialty, and identification and assistance with resolving overpayments uncovered during the review. 

The key to making a medical record review successful is to identify problems or issues and learn from them.  Follow through and training is very important.  Remember that the OIG expects you to disclose any errors you uncover, correct them, and repay any over billed amounts that your practice may have collected in error. 

Margolis & Company has the experience and expertise to assist your practice with implementing a complaint medical records review process. Please do not wait until Medicare or another carrier audits you to put these safeguards in place. If you are interested in an external chart audit or would like us to assist you in setting up your initial internal audit, please give us a call at (610) 667-6250 and ask to speak to one of our healthcare specialists.

Robert J. Salvitti, CPA is a member of the Healthcare Services Group at Margolis & Company. If you would like to learn more about the topic or related topics Bob can be reached at bsalvitti@marg.com.