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Establish an audit team at your physician practice to address common compliance problems

By Sharon Bolarakis, CPC, CPC-I

In a July JustCoding article, I discussed five evaluation and management (E/M) documentation challenges that I encountered during recent audits. Building on that information, I would like to highlight additional factors the audit team should consider when reviewing medical records and E/M notes or when conducting other focused reviews.

Incorrect links between diagnosis and procedure codes

I often find that staff members who post charges (e.g., office charge entry/posters) who have not received adequate coding training inappropriately link one diagnosis code to several CPT codes when physicians perform more than one service or procedure. In some cases, the diagnosis may be inappropriate for the procedure.

For example, consider a patient in the post-operative period for a total knee arthroplasty. The patient presents to the physician’s office for a follow-up visit. On the morning of the follow-up visit, she slips while stepping out of the shower. While slipping, she twists her ankle, which is now painful and swollen.

A physician performs a follow-up exam of her knee, and a coder reports CPT code 99024 (Postoperative follow-up visit, normally included in the surgical package) to indicate that an E/M service was performed during a postoperative period for a reason(s) related to the original procedure. The coder also reports diagnosis codes V54.81 (Aftercare following joint replacement) and code V43.65 (Organ or tissue replacement by other means, knee). The physician then proceeds with an E/M of the ankle pain, and a coder reports E/M code 99213 with diagnosis code 845.03 (Sprains and strains of ankle and foot; tibiofibular [ligament] distal).

In this case, the coder correctly linked E/M code 99213 with the diagnosis code for the sprain. If the coder had linked code V54.81 to E/M code 99213, this would have been incorrect.

Missing or incorrect modifiers

For this same total knee arthroplasty example above, payers will deny the claim when coders don’t append a modifier to E/M code 99213. Coders should report modifier -24 in this case to denote that the E/M service is unrelated to the total knee surgery for which the patient is still within the global surgery period.

Let’s take this ankle pain a step further. Instead of a sprain, consider a scenario in which the patient fractures an ankle instead. For the ankle fracture, report ICD-9 code 824.2 (Lateral malleolus, closed fracture), which requires fracture care with manipulation.

Coders should append modifier -24 to E/M code 99213 as well as one of the following modifiers, depending on the specific payer’s policies:

• Modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service)
• Modifier -57 (Decision for surgery)

These modifiers denote that the E/M service is unrelated to the knee surgery. They also indicate that a procedure will follow this E/M service. Report CPT code 27788 (Closed treatment of distal fibular fracture; with manipulation) for the procedure.

Coders should also append modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) to CPT code 27788 to indicate that this procedure is not related to the total knee arthroplasty.

Inappropriate diagnosis code assignment

I find that diagnosis codes often misrepresent the true picture of the encounter. This is particularly true for fractures.

There are diagnosis codes that distinguish between pathologic versus traumatic fractures. The ICD-9 Manual describes a pathologic fracture as one that is due to weakened bone structure because of a pathological process (e.g. osteoporosis, neoplasms, and osteomalacia). These codes are located in the 700 series.

A traumatic fracture is due to an injury. Trauma fracture diagnosis codes are located in the 800 series of the ICD-9 Manual. Physician documentation should indicate which series to choose.

More confusion arises with aftercare and follow-up diagnosis codes. The ICD-9-CM Official Guidelines for Coding and Reporting are located in the front of the professional edition of the ICD-9 Manual. See Section I, 18.d.7 titled Aftercare. It states to use aftercare visit codes once the provider has performed the initial treatment, and the patient requires continued care during the healing or recovery phase. These codes should also be used for long-term consequences of the disease. When a patient returns for a follow-up visit after the initial treatment for the fracture, coders sometimes incorrectly report a diagnosis code for the fracture. Instead, they should report an aftercare code because the fracture is actually healing.

Section I, 18.d.8 titled Follow-up states that these codes are used to explain continuing surveillance following completed treatment of a disease, condition, or injury. ‘Follow-up’ implies that the physician has completed treatment for the condition, and the condition no longer exists.

Illegible or inappropriate physician signature

Signatures for authorization on documentation should be legible. If physicians at your practice still prefer to provide traditional, handwritten signatures, have a list of each provider’s name typed alongside the physician’s signature and initials. When practices receive a denial due to illegibility of the physician’s signature, submit this list to the carrier with the claim to help it recognize the signature. Rubber stamps are no longer an acceptable form of signature for Medicare. Check with other carriers regarding their signature policies.

For example, Medicare Administrative Contractor (MAC) Palmetto GBA has issued guidelines that identify the following methods as acceptable:

• Handwritten signatures or initials
• Electronic signatures
• Chart ‘accepted by’ with provider’s name
• ‘Electronically signed by’ with provider’s name
• ‘Verified by’ with provider’s name
• ‘Reviewed by’ with provider’s name
• ‘Released by’ with provider’s name
• ‘Signed by’ with provider’s name
• ‘Signed before import by’ with provider’s name
• ‘Signed: John Smith, MD’ with providers name
• Digitalized signature: Handwritten and scanned into the computer
• ‘This is an electronically verified report by John Smith, MD’
• ‘Authenticated by John Smith, MD’
• ‘Authorized by: John Smith, MD’
• ‘Digital signature: John Smith, MD’
• ‘Confirmed by’ with provider’s name
• ‘Closed by’ with provider’s name
• ‘Finalized by’ with provider’s name
• ‘Electronically approved by’ with provider’s name

When the physician signature on the documentation does not meet these guidelines, the MAC may deny payment.

Over-documentation for services which are not medically necessary

Providers are aware of the burdensome documentation requirements needed to report the different levels of E/M services. Although some providers rely on electronic medical records (EMR) to help ease these burdens, the use of EMRs could lead physicians to document more than what is necessary for a patient visit. An audit team should monitor this potential tendency to over-document and ultimately report a high-level E/M service for which medical necessity requirements are not met.

Let’s consider another patient who has a sprained ankle. Suppose the encounter is a new patient visit. The physician office asks the patient to complete a medical history form. It may be easy for the physician to provide the necessary documentation to report code 99204 after he or she has reviewed the completed patient history form.

The physician performs an exam for the sprained ankle and decides to perform closed manipulation fracture care on the day of this first encounter. It is most likely not medically necessary to examine all organ systems for this ankle sprain. The physician should use his or her clinical judgment to determine which systems to examine. The physician should thoroughly document his or her entire thought process to support medical necessity to the insurance carrier.

Create an audit team to tackle these compliance problems

It’s not always practical to employ an auditor in the physician practice setting due to staffing constraints. However, it’s also unwise for a physician practice to cut corners when it comes to compliance. Most physician practices have an effective plan in place through their compliance programs. But it might be time to reassess those programs to ensure that important details haven’t slipped through the cracks due to the hectic pace of every-day activities.

An audit team can help ensure the success of a compliance program and help maintain conformity with the many guidelines that apply to physician practices. Members of the audit team, including coders and other staff members, should share responsibilities associated with the audit process while also performing their other daily responsibilities.

A seasoned coder should lead the audit team. Front-office personnel who can help monitor HIPAA and other compliance concerns should also serve on the team. Depending on the practice’s size, a minimum of two or more employees could form the audit team.

This team could be a part of or report to the compliance committee or compliance officer. The purpose of the audit team is to train staff members on a number of areas including coding, compliance, billing, reimbursement, and HIPAA regulations. The team could also provide coding and compliance education to new physicians.

Insurance carrier policies of E/M guidelines and other coding and reimbursement rules may vary. The audit team should stay up-to-date on these differences.

The audit team should address compliance findings with appropriate staff members and educate those responsible for the errors to prevent future inaccuracies.

Due to the number of activities that take place in a busy physician practice and the many rules to which it must adhere, it is easy to see the value of a strong audit team.

It is wise to use a team approach to share ideas and keep watchful eyes out for the many guidelines and regulations that CMS and other coding authorities constantly update. For example, there is a new red flag identity theft prevention policy that will take effect November 1. Physician practices should establish a policy to monitor and prevent identity theft. Likewise, physician practices and other providers will face more stringent enforcement of HIPAA in the near future. Is your audit team ready?

Editor's note: Sharon Bolarakis, CPC, CPC-I, is a coding and compliance consultant for Ethos Partners Healthcare Management Group where she performs audits and offers physician education and answers to reimbursement questions. She also answers coding questions for Ethos clients. E-mail her at sbolarakis@ethospartnershc.com.