Presented byLynn Graham, CPC

Revenue Cycle Manager

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What does OIG stand for?

Who do they do Audits for?

What is a Work plan?

What is a Whistleblower?

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What does CIA stand for?

What is the purpose of the CIA?

Does OIG endorse or assist a provider in choosing an independent Review Organization?

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Where do you begin?

Can you ask for assistance?

How do I know if I am correct?

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An auditor must look beyond the point system and look at the medical necessity for the patient encounter from the presenting problem to the data documented in the history, the exam performed, and all elements of the patient assessment along with the plan of care.

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Place-of-service misrepresentations Monitor your denials Do not look only at documentation when

submitting claims Modifier usage Time based

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What do you have to work with?◦ Encounter Forms◦ Progress Notes◦ Lab Studies, X-rays

Down in the list Medication List

I assume I know what the doctor means◦ If it is not written, it does not exist

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Was the patient in the office on the date of service?

Does the physician charge too many of any one particular code, while not charging any of a very common code for the specialty?

Was the amount charged for the office visit and procedure(s) reasonable for the services rendered?

Can every chart stand up to an audit?

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Total Duration Critical Care Codes

Less than 30 minutes N/A, Use appropriate E/M codes

30-74 minutes 99291 x 1

75-104 minutes 99291 x 1 and 99292 x 1

105-134 minutes 99291 x 1 and 99292 x 2

135-164 minutes 99291 x 1 and 99292 x 2

165-194 minutes 99291 x 1 and 99292 x 4

194 minutes or longer 99291 and 99292 as appropriate

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General Charting Protocols◦ Is there evidence the patient demographic form has

been updated?◦ Are there “scratch” over on the patient demographic

form?◦ Is a patient found in the software system?◦ Is a copy of the current insurance card in the system?◦ Is the patient’s ID (full name) on every page?◦ Is each encounter dated?◦ Does the date in the medical record correspond with

the date on the encounter form?◦ Is the medication / problem list current?

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Sets a national standard for accessing and handling medical information

National standards include the right of the patient to – See, copy, and request to amend their own medical records

Health care providers, health plans, and other health care services have to abide by the minimum standards set by HIPAA

Provider can charge for copies of records – HIPAA sets limits on the fees

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Consent must state that the individual has the right to request restrictions on the use and disclosure of his or her personal medical information, but it must also state that the covered entity may refuse the request.

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An Audit is not an accusation Auditor’s role Advocate to the coder and provider Educator Trainer Attitude Communication among various

departments Written communication Do not overwhelm for the provider

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Publicly available on the HHS OIG website:

http://oig.hhs.gov/reports-and-publications/archives/workplan/2014/work-plan-2014.pdf

Provider Compliance Traininghttp://oig.hha.gove/compliance/provider

compliance-training/index.asp

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