Looking Over Your Shoulder in Healthcare: Chart Audits

Part 2

Carolyn Buppert, NP, JD


December 08, 2011

In This Article

Audit Focus of Various Payers

Recently, Blue Cross has focused on clinicians who bill the higher-level CPT codes.[2] Highmark Medicare Services recently announced it will be concentrating hospital audits on admissions for chest pain. The organization will evaluate whether the severity of signs and symptoms warranted admission, whether "the medical predictability of something adverse happening to the patient was or was not supported by the documentation," and whether diagnostic studies could have been provided in an outpatient setting.[3]

Incident-to billing. A Medicare Administrative Contractor may conduct an audit with incident-to billing in mind. Under the Medicare concept of incident-to billing, a physician may bill, under his or her own name, the services of another provider, such as an NP or PA. The advantage of billing incident-to is that the practice receives 100% of the Physician Fee Schedule rate, rather than the 85% it would receive when services are billed under an NP's or PA's name.

In an audit, the investigator looks for evidence that the rules on incident-to billing were followed. First, an auditor will examine bills for new patient visits and the accompanying documentation, to determine whether any visits conducted by an NP or PA were billed under a physician's provider number. If so, the auditor will ascertain whether the physician had an employment or contractual relationship with the NP or PA.

Second, the auditor will review documentation for established patient visits, to see whether a physician provided an initial service and whether a physician remained involved in the care of the patient.

Third, the auditor will peruse the appointment books to determine whether a physician was on-site at the medical practice on days and times when an NP's or PA's service was billed incident-to.

Fourth, the auditor will review the place of service codes. Incident-to billing is appropriate only in offices or clinics. (Billing of "shared visits," with somewhat different rules, is allowed in hospital inpatient units, hospital outpatient units, and emergency departments.)

Here are instructions from a Medicare contractor with respect to documentation to support incident-to billing:

"To ensure proper reimbursement according to the fee schedule, Medicare requires that documentation submitted to support billing 'incident-to' services must clearly link the services of the non-physician practitioner to the services of the supervising physician. For 'incident-to' services that are billed and undergoing medical review, documentation sent in response to the carrier's request should clearly show this link. Evidence of this link may include:[4]

  • Co-signature or legible identity and credentials (eg, MD, DO, NP, PA, etc.) of both the practitioner who provided the service and the supervising physician on documentation entries

  • Some indication of the supervising physician's involvement with the patient's care. This indication could be satisfied by:

    • Notation of supervising physician's involvement (the degree of which must be consistent with clinical circumstances of the care) within the text of the associated medical record entry

    • Documentation from dates of service (eg, initial visit) other than those requested, establishing the link between the 2 providers.

Failure to provide such information may result in denial of the claim for lack of documentation from the billing provider."

General requirements for documentation. Medicare's general principles of health record documentation of medical and surgical services are:[5]

  1. Medical records should be complete and legible.

  2. Documentation of each patient encounter should include:

    • Reason for encounter ("chief complaint") and history relevant to that complaint ("history of present illness")

    • Physical examination findings and prior diagnostic test results

    • Assessment, clinical impression, and diagnosis

    • Plan for care

    • Date and legible identity of observer

  3. Rationale for ordering diagnostic tests or ancillary services. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.

  4. Past and present diagnoses should be accessible for the treating and/or consulting physician.

  5. Appropriate health risk factors should be identified.

  6. Patient's progress, response to changes in treatment, and revision of diagnosis should be documented.

  7. The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

Some hospitals and practices employ certified professional coders to review encounter forms and progress notes -- before claims are filed -- to determine whether the choice of code was appropriate. Others do not. Hospitals or practices who elect not to bring on professional coders can nevertheless apply some safeguards by instituting frequent self-audits and training clinicians about deficiencies found in these audits. (Part 3 of this series will describe an auditing and training program.)

Quality-improvement audits. Medicare has become increasingly interested in documenting quality of patient care, or lack thereof, and with linking payment to quality measures. Medicare now has a variety of programs aimed at improving quality of care. One such program is "Hospital Compare." The program publishes data on the number of times that hospital-acquired conditions -- such as falls -- occur at Medicare fee-for-service hospitals within a set time period. The program tracks other quality measures; a complete discussion of Medicare's quality measurements is beyond the scope of this article.

However, those interested in auditing should know that it is inevitable that internal or outside auditors working on quality-improvement programs will be reviewing clinician documentation. Information on the Hospital Compare program is available online.


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