Targeted probe and educate audits coming to a provider near you

“When Medicare claims are submitted correctly, everyone benefits.” That’s what CMS says verbatim on its website about the newly-launched targeted probe and educate audits that are designed to reduce denials and appeals through one-on-one education.

During an AAPC chapter meeting on February 13 in Providence, Rhode Island, Lori Langevin, education consultant at National Government Services (NGS), walked attendees through the process. NGS is the Medicare Administrative Contractor (MAC) for jurisdictions 6 and K.

“It’s all about lessening the burden on providers,” she said.

Here’s how it works: MACs use data analysis to identify providers/suppliers with high error rates or unusual billing practices. Common claim errors include an omitted physician signature, lack of medical necessity, or incomplete certification. The initial probe includes a review of 20-40 claims. Practices have 45 days to respond to the request for documentation, though Langevin says 30 days is best practice. A lack of response equates to an error, she added.

After the review, providers receive a letter detailing the results. They’ll also have an option to receive one-on-one education via teleconference or webinar. During these sessions, providers will have the opportunity to ask questions and learn about the specific CMS policies that apply to each claim.

Langevin was unable to provide a concrete definition of what constitutes a high error rate, though she did say that she anticipates E/M codes and prolonged services will be targeted due to the high error typically associated with these services. Other targets will likely include topics that have surfaced during CERT and RAC audits, she added.

The overarching goal of these audits is to reduce the administrative burden on providers and MACs, said Langevin. Not only is it costly for providers to appeal denials, but it’s also costly for MACs to review the appeals and potentially overturn the denials. The probe and educate audits will hopefully drive process improvement, she said.

To learn more about targeted probe and educate audits, view this FAQ.

 

 

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The *perks* of working from home

For many of us, the idea of working from home conjures up images of individuals hanging out in pajamas and slippers past noon, taking long breaks to watch game shows and soap operas — or perhaps not even ‘working’ at all. I’ve always found this to be an odd assumption considering I’ve worked far more diligently since establishing my home office than I ever did while working onsite. As a self-employed freelance writer, I put my nose to the grindstone daily, though I must admit I do it while wearing orthotic leopard-patterned slippers.

Can you blame me?

Still, working remotely wasn’t something offered to me at the onset of my writing career. I worked for several years in a cubicle —  constantly distracted by others’ conversations (and drama). When my previous employer eventually told me I would have my own private office, I had to pinch myself. Was it a dream or reality? Luckily, it was reality, and once settled in, I could shut the door, dim the lights, and get my work done in half the time it would have taken me to do so before. It wasn’t until nearly five years later (when I relocated to a different state) that this same employer offered me the option to work remotely from home. Of course, I said yes — and even turned down another job offer because of it.

Once I got a taste of working from home, I knew there would be no going back.

Why? First off, I’m happier. There’s more space, and it’s my space. Second, the quality of my writing improved because I was able to focus. Third, I could accomplish more work in an average 8-hour workday even despite the fact that it didn’t feel as though I was over-extending myself.

I’d like to think that the same holds true for medical coders who work from home. Medical coding is a profession that has increasingly embraced remote work arrangements in an age of electronic health records (EHR). Remote coders with whom I’ve spoken love working from home, and many view it as an ideal scenario.

Still, remote work isn’t for everyone. I’ve interviewed many coding managers and HIM directors who say it’s not even possible in some circumstances. Following are some questions to consider before allowing an employee to work from home:

  1. Does the employee have sufficient Internet access and speed to support remote access to the EHR?
  2. Does the employee have a quiet working environment and dedicated work/office space at home?
  3. Is the employee self-motivated? If so, how has he or she demonstrated this?
  4. Has the employee already met productivity and accuracy standards?
  5. Will working from home improve the employee’s job satisfaction?

While you ponder these questions, I’m going to go pour another cup of coffee and get started on my next article…all from the comfort of my home office with my only co-worker (my cat) by my side.

 

 

OCR audits, risk-adjustment coding discussed at RIHIMA

OCR audits, FY2017 coding updates, and risk-adjustment coding were among the many topics covered during the most recent RIHIMA meeting on October 7 in Warwick, RI. These meetings provide an affordable opportunity to stay abreast of industry changes and network with peers. Another perk: Free coffee and donuts. 🙂

HIPAA branding, OCR audits

Norma Chitvanni, RHIT, CHPS, privacy officer and director of privacy and confidentiality at Beth Israel Deaconess Medical Center, spoke about her efforts to lead an awareness campaign to help employees understand the importance of HIPAA. She reminded attendees that employees are an organization’s biggest vulnerability, and she urged others to consider creative ways to brand an internal privacy and security program.

For example, Chitvanni worked with the hospital’s communications department to create an educational video in which members of a patient/family advisory group spoke about the importance of keeping information private (KIP). She and her team also:

  • Created a padlock logo for the program
  • Identified internal KIP coaches to help educate staff
  • Put KIP labels on salad contains and food wrappers in the cafeteria
  • Created a staff portal with resources about how to secure laptops
  • Handed out promotional materials about KIP (e.g., pens, phone wipes)

Chitvanni also urged attendees to prepare for upcoming OCR audits. She provided these tips:

  • Provide HIPAA education to all staff. Ensure that you have some way to monitor and assess staff member’s understanding along the way (e.g., test-your-knowledge questions or a final exam).
  • Use the OCR audit tool as a foundation for compliance. Do your policies and educational materials support each of the 109 elements included in the tool?
  • Compile information for your business associates in advance. HHS provides a complete list of necessary information.
  • Use technology to monitor and mitigate risk. For example, some applications can identify and flag unencrypted emails that include medical record numbers, patient information, or medical codes.

FY 2017 coding updates

Mary Beth York, CCS, CCS-P, CIC, senior associate at Barry Libman Inc., provided a helpful overview of important coding changes that took effect October 1. She encouraged attendees to review the updated ICD-10-CM guidelines and also pointed out several surprises, including:

  • 1.A.19: The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists.  The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

“I think we have to see how this is going to play out,” she said, adding that it remains unclear as to how insurance companies and Recovery Auditors will handle this guideline when a condition doesn’t meet clinical criteria.

  • 1.C.12.a(6): If a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, two separate codes should be assigned: one code for the site and stage of the ulcer on admission and a second code for the same ulcer site and the highest stage reported during the stay.

She urged HIM professionals to work with members of the quality team to raise awareness of this new guideline.

Risk-adjustment coding

Gerry Petratos, MD, MS, CEO of Hiteks Solutions, Inc. said HCC coding is becoming the “gold standard” in healthcare because of its ability to capture clinical complexity and predict costs.

Many organizations are already using HCC modeling in the outpatient arena, necessitating the need for documentation improvement, he said. “Ambulatory CDI will be the biggest growth area in which there are the fewest people to do the work,” he added.

Accountable Care Organizations can also use HCC data to segment populations and target preventive care.