Is Your Electronic Health Record Putting You at Risk for a Documentation Audit?

4. DO review your E/M code distribution. Generate a CPT frequency report for each physician and for the practice as a whole. Compare the data with state and national usage in orthopedics as a baseline. The American Academy of Orthopaedic Surgeon’s Code-X tool enables easy comparison of your practice’s E/M code usage with state and national data for orthopedics. Simply generate a CPT frequency report from your practice management system and enter the E/M data. Line graphs are automatically generated, making trends and patterns easy to see (Figure).

“Identify your outliers, pull charts randomly, and review the notes,” recommends LeGrand. “Make sure there is medical necessity for the level of code that’s been billed and that documentation supports it.”

You may be surprised to find you are an outlier on inpatient hospital codes, or your distribution of level-2 or -3 codes varies from your practice, state, or national data. Orthopedic surgeons don’t typically report high volumes of CPT codes 99204, 99205 or 99215, but if your practice does and you are an outlier, best to pay attention before someone else does.

 5. DO select auditors with the right skill sets. Evaluating medical necessity in the note requires a clinical background. “If internal documentation reviews are conducted by the billing team, that’s fine,” LeGrand advises. “Just add a physician assistant or nurse to your internal review team. They can provide clinical oversight and review the note when necessary for medical necessity.”

If you are contracting with external auditors or consultants, verify auditor credentials and skill sets to ensure they can abstract and incorporate medical necessity into the review. “Auditors must be able to do more than count elements,” LeGrand says. “They must have clinical knowledge, and expertise in orthopedics is critical. This knowledge should be used to verify that medical necessity is present in every note.” LeGrand is quick to point out that not every note will be at risk, based on the amount of work performed and documented and the level of service billed. “But medical necessity must always be present.”

The addition of nurses to the OIG’s audit team is a big change and will refine the auditing process by adding more clinical scrutiny. The EHR documentation features are intended to improve efficiency, but only a clinician can determine and document unique visit elements and medical necessity.

Address these intersections of risk by ensuring your documentation meets medical necessity as well as E/M documentation elements. Conduct internal audits bi-annually to verify that E/M usage patterns align with peers and physician documentation is appropriate. And be sure there is clinical expertise on your audit team, whether it is internal or external. CMS now has it, and your practice should too.  ◾