CHART AUDITS A to Z

The following article is taken from a presentation given at the Colorado Phlebology Conference in Telluride this past January. My apologies for the length.

 

Medicare along with Blues and other commercial plans are ever more vigilant in regards to fraud. Unfortunately, the word ‘fraud’ seems to encompass a very wide definition including simply bad or incomplete documentation. With the heightened scrutiny, it is becoming more of a ‘when’ your practice will be audited rather than an ‘if’. Below are some poor charting elements we have seen in conducting chart audits for practices throughout the country.

 

History and Physical:

Everything flows from the History and Physical. If the H&P is incomplete or missing elements, the procedures submitted subsequently can be denied. Beyond the audit risk, an incomplete H&P can cost you money. The H&P is used routinely to justify care for the pre-authorization and in appeals regarding Medical Necessity. It is essential that this key document meet or exceed standards.

 

Conservative Therapy – The most common concern we see is poor documentation of conservative therapy. You can no longer take the patient’s word that they have been wearing stockings. Stocking use, by itself, is not conservative therapy. Most conservative therapy measures include use of NSAIDs, leg elevation, exercise and weight loss. Unless these factors have likewise been ordered and followed by another physician, you need to order conservative therapy for all patients.

 

Conservative Therapy – Part II – The payers would like to see all the elements of conservative therapy being ordered. Noting that you have ‘ordered conservative therapy’ is insufficient. You need to spell out the particular details behind that conservative therapy order such as use of NSAIDs, leg elevation, and weight loss. Use your payer policy so your documentation matches the requirements. If the conservative therapy program is ninety days, we recommend bringing the patient in for a check or, at the very least, calling the patient and documenting how they are doing in conservative therapy. Ninety days is too long for the patient not to hear from you. Finally, we recommend an office visit reviewing how well conservative therapy did or did not resolve the patient’s symptoms at the end of the conservative therapy window.

 

Activities of Daily Living – All too often we see very generic language noting how the patient’s varicose vein disease impacts the patient’s life. Stating that the disease ‘impacts the patient’s ADL’s’ is insufficient. There should be a sentence or two from the patient noting how the disease interferes with their activities. We recommend having a large section on your intake form which is reviewed carefully and, if need be, the patient is prodded for completion by a team member.

 

Patient to H&P Mismatch – One error that is unfortunately rather routine is a mismatch between what the patient reports and what is noted in the chart. For example, if the patient states they have had problems with their legs for nine months but the chart states ‘for several years’, this can be a reason to fail the chart.

 

Orders and Plan – Another frequent problem is there is no order for the diagnostic ultrasound. All too often we see the patient has a diagnostic ultrasound performed up to a week before the H&P. Who ordered that US? The receptionist cannot order an US. You cannot have standing orders for an US either. The US is a diagnostic test that should be ordered after a review of the patient has been initiated or completed. A relatively new issue we have seen from a Medicare auditor is a listing of the treatment plan ‘once conservative therapy fails’. While I know of no patients whose disease has been treated by the use of conservative measures, it is prudent to list out the plan of care in the office visit performed at the end of the conservative therapy window rather than in the initial H&P.

 

Diagnostic Ultrasound:

The next document in the chart is typically the diagnostic ultrasound. A few of the documentation difficulties we have seen include the physician signing the RVT’s report instead of documenting a formal interpretation report, the deep system not being reviewed and an insufficient number of data points on the GSV, SSV or other veins being proposed for treatment.

 

Training – A relatively new but progressing issue in regards to reimbursement for the diagnostic ultrasound is the physician having no formal training for reading the US. If the physician is not a radiologist or does not have the RPVI or RPHS certificates, some payers are now starting to not pay those claims.

 

Laterality – Finally, you cannot perform a bilateral diagnostic ultrasound if the patient is asymptomatic in one leg. If the patient reports no symptoms in one leg, you have to perform a diagnostic ultrasound on the symptomatic leg only.

 

Ablation Report:

The ablation report’s overall set of concerns is primarily in regards to generic information. The lack of specificity within the report can cause a claim denial or a bad chart audit outcome. For example, we often times see language that the vein was accessed at the ‘best possible location’. Where is this best possible location? Specificity should be used in noting where the vein was accessed. There should also be language describing HOW the vein was accessed. Some other information that should be in the body of the report is which vein is being treated and the vein diameter. Additional data that should be contained in the note is the number of thermal units or, for some of the newer technologies, the amount of adhesive or foam used.

 

Other issues arise out of the use of electronic health records. Some auditors are failing charts because there is almost no variation in the treatment reports. Another reason to ensure the specificity above is included. There are sometimes errors in which the header of the report does not match what was treated. We sometimes see the header noting treatment of the RT GSV and the body of the report talks about the left leg. Finally, be sure to develop templates for the GSV, SSV and AASV/Other veins. Reading a report that is really for the GSV but tries to capture an SSV treatment is sometimes awkward at best.

 

Free Consults:

One of the mainstays in marketing phlebology services is the free consult. We strongly recommend that you perform an educational visit rather than a clinical visit if you are advertising a free consult. Your time and expertise has a value. Providing free care could be construed as an inducement by the government and inducements are illegal. As an aside, you cannot order a diagnostic US from seeing the patient during a free consult. To order any test, you have to formulate a medical opinion. If you are reviewing the patient’s condition to the extent you can formulate a medical opinion and order a test, you have effectively performed a (albeit very limited) new patient examination.

 

Sclerotherapy:

Very similar to the ablation reports, it is important to note the location of the veins being treated either in the body of the sclerotherapy report or on a leg map that is part of the report. Vein size is critical to help differentiate between medically necessary sclerotherapy versus cosmetic treatment. Be sure to note the type and strength of the sclerosant used.

 

Office Visits:

One of the more maddening system issues with an EHR is how they sometimes copy forward the examination and other elements of the H&P into each progress note. You should turn off this feature if at all possible. Having a couple pages of information that is not new information makes it extremely difficult to find the new information elements and plan. Most follow up visit notes should be brief and to the point. As such, they will rarely rise above a 99212. Office visits cannot be billed the same day as a procedure.

 

Phlebectomies:

Like the other operative reports, be sure to include which leg and the location of the treatment either in the body of the note or on a leg map. The number of stabs needs to match what was billed as well. We have seen a generic use of 37766 (20+ stabs) for all phlebectomies yet the report notes 17 stabs performed.

 

The above contains a lot of suggestions and food for thought. My recommendation is to take it one step, one bite at a time. I would start with the History and Physical as everything flows from that critical document. Should you have specific questions, do feel free to call me. My desk number is 719.955.9128 ext. 201.

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