Top Audit Findings

Posted by: Sarah Cartwright


Catch Your Documentation Failures Before Payer Auditors Do

We all know that medical record documentation is important to support medical necessity for the patient visit as well as all diagnostics, procedures and treatments performed or administered. This statement is also familiar to us – “if it wasn’t documented, it wasn’t done”. Most external audits performed by Medicare, Medicaid and commercial payers downcode or deny payment based on lack of medical necessity.

With this said, it’s important to perform routine documentation and coding reviews to ensure all is compliant with CMS, national, state, AMA, CPT and specific payer guidelines. Here are some of the top audit findings Edelberg & Associates has come across in recent external audits.

Emergency Department – Downcodes for review of systems (ROS) tops the scale! Higher acuity visits are oftentimes downcoded to a lower E/M level due to deficient ROS. Medical Decision Making (MDM) supports the higher level of 99285; however, ROS is not complete to support the E/M level. A complete ROS requires listing out pertinent positives and negatives as related to the presenting problem plus an acceptable finishing statement OR commenting on at least 10 individual systems. Be careful with the finishing statement as well. It must indicate that “all other systems were reviewed and are negative”.

Hospital Medicine – Missing time spent on discharge of the patient and the appearance of cloning tops the list. Documenting the time spent on discharge services determines the appropriate discharge code. Code 99238 covers up to 30 minutes and code 99239 requires 31 minutes or more. Time spent includes final examination of the patient, discussion of hospital stay, instructions for continuing care to caregivers, preparation of discharge records, prescriptions, referral forms, etc. as appropriate for the patient. Documenting these items will in turn help justify the time documented by the provider for discharge services.

Avoid the appearance of cloned documentation. Each time the patient is seen, the documentation must reflect the patient’s condition and plan of care at that time. It is appropriate to document an interval history for subsequent visits after the documentation of the initial service. CMS documentation guidelines state that, “A ROS and/or PFSH obtained during an earlier encounter do not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information.” If nothing has changed in the PFSH or ROS, providers should document “no change in history from (Date)” or something similar. Specific comments related to PFSH or ROS changes that have occurred since the patient’s last visit should be documented as well as a current exam and updates for the patient’s plan of care including additional tests, procedures and treatments.

Office Visits – New 2021 E/M rules as of January 1, 2021 are based on time or MDM. Question is, when is it appropriate to base the E/M level of service on time or on MDM? Under the new rules, providers are no longer required to document a certain number of elements in the history and exam. Instead, a medically appropriate history and exam should be documented. Medically appropriate refers to the systems referenced in the chief complaint/HPI plus any other systems that may be compromised at the time of the visit. Time is total time spent (face-to-face and non-face-to-face) providing the patient’s care on the date the patient was seen by the provider. Time spent on separately billable services is to be excluded from the total time.

Keep in mind that time may not always provide the best representation of the encounter. MDM may outweigh the time factor as the best measure for determining the appropriate E/M level. Regardless of whether the E/M is based on time or MDM, appropriate documentation to support the encounter is necessary. Remember to document concerns that are ruled out or ruled in by tests and/or treatment results ordered and/or reviewed at the visit. Differential diagnoses are helpful if further study is indicated and performed.

For more discussion or information on these topics, please contact us.

Author: Cheri Klein, CPC, CPCO – Edelberg + Associates, VP of Compliance

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