A United Approach

by  NAMAS
Jun 14th, 2019

A United Approach

As auditors, we all have a different perspective when evaluating documentation. It would be unreasonable to think that we all view things the same way. In my opinion, differing perspectives are what makes a great team because you can coalesce on a particular chart, work it through and decide on different approaches to help educate providers. Our shared ultimate goal is always to provide the best education to providers on documentation and compliance guidelines.
This being said, I feel it is important that the methodology and the message conveyed be consistent across the board. Let me share with you a situation I encountered over the last month to provide some background on my thought process.

A very good friend of mine, whose practice I have worked with for 8 years, was recently notified by their MAC that they were to have a TPE (Targeted Probe and Educate) audit of their level 4 established patient visits. TPEs are pre-payment audits that CMS started and per the CMS website "the program is designed to help providers and suppliers reduce claim denials and appeals through one-on-one help."

OK, lower those skeptical brows, there's more. On their website, CMS also states that "Providers whose claims are compliant with Medicare policy won't be chosen for TPE." Great news! (Eyebrows back down folks.) They were given a list of 40 charts to pull documentation for, and being me, I went in to review those charts before they were submitted and audited them myself.
This way the practice would have an idea of what they may be looking at from the MAC's perspective. Out of those 40 charts I reviewed, at least half did not support a level 4 established patient visit. The only reason they did not was because the picture painted of the visit did not support the medical necessity of a level 4 visit. If you have ever heard my colleague Shannon DeConda, president and founder of NAMAS, talk about E&M auditing, you can probably hear her voice in your head saying "Guys, CMS states that medical necessity is the overarching criterion for payment in addition to the documentation requirements of a CPT code."

At NAMAS and DoctorsManagement, this is a topic we constantly educate our clients on. These charts had wonderfully lengthy documentation thanks to our EHR vendor; however, when it came down to the assessment and plan along with the HPI, the purpose of the visit wasn't clear. Honestly, it looked like a painting by Monet: great from a distance, but the closer you looked at it, the uglier it got.
Fast forward to a week after submission, and the results came back. The MAC agreed with 36 of the 40 charts, and the 4 they disagreed with, they UPCODED to a level 5. Now I suspect that not only are eyebrows up in your hairline but your jaw also has hit the floor. I thought to myself, wow, that is a vastly different perspective of the paintings I looked at. Then I thought about it, and thought about it some more. Remembering that I had been doing other E&M research that week I recalled seeing a bunch of old PowerPoint presentations on the web and was shocked at how many of them said that Medical Decision Making was what determined your level of service, and none of them mentioned medical necessity at all. The light bulb went off: I don't think it was a different perspective, but a different methodology. The auditor could not have factored in medical necessity when reviewing those charts.

Now you see the reason I chose to write about this. If we as auditors are not auditing and educating using the same methodology, how can we be a benefit to our providers and clients? At NAMAS we are provider advocates; we work hard to help providers understand the documentation that needs to be in their encounters to support the medical necessity of the visit. If we are successful in our teaching, the providers can have meaningful visits with their patients without having a computer in their face, complete the visit, sit down and document based on the level of medical necessity, saving valuable time, and the result are notes with clearly documented assessments and plans that paint a clear picture of why patients were seen and what was done in response.
When auditors are not on the same page, we send conflicting messages to our providers which is a disservice. And if an auditor is not evaluating medical necessity and helping to educate providers about it, come 2021 they may not be very successful in their careers. The medical necessity and the value of care provided to the patient are the most important parts of documentation, and not all the EHR templates that create lots of noise and yield 18-page notes. That's just my perspective.