Piedmont Access to Health Services, Inc s8

PIEDMONT ACCESS TO HEALTH SERVICES, INC.

Policy Number: 01-03-011

SUBJECT: Medical Patient Billing and Coding Chart Audits

EFFECTIVE DATE: 09/15/2013

REVIEWED/REVISED: 09/11/2013, 09/02/2014

POLICY: PATHS will maintain a high quality and attention to detail in activities related to documentation in patient records. This applies to all portions of the patient chart, but specifically issues related to coding and billing. PATHS will have established protocols to ensure the adequate training and supervision of all providers so as to ensure adequate and responsible coding and billing.

PROCEDURE:

1.  PATHS’ Billing Coordinator, or designee, will complete two chart audits per medical provider, per month, using the form attached to this policy. The charts audited will be chosen at random from visits billed two or more months prior to the date of being marked as complete by the provider.

2.  The findings of each audit will be scanned and stored in private, confidential files on PATHS’ network, and the original audit forms will be forwarded to PATHS’ Medical Director.

3.  PATHS’ Medical Director will review the audit findings with each provider. Together, they will come up with an action plan to address any deficiencies.

SIGNATURES:

______/ ___ /______

Chief Executive Officer Date

______/ ___ /______

Medical Director Date

______/ ___ /______

Chief Operating Officer Date

______/ ___ /______

Billing Coordinator Date

01-03-011 Billing and Chart Audits

Page 1 of 1

Medical Coding Audit Worksheet

Provider: ______Audit Date: ___ / ___ / _____

Patient Name: ______Date of Birth: ___ / ___ / _____

Date of Services: ___ / ___ / _____ Insurance: ______

CPT Code(s) Selected: ______

Documented Diagnosis(es): ______

Visit Type:  New Patient  Chronic Disease Follow-up  Physical

 Acute Office Visit  Hospital Follow-up

History of Present Illness (HPI) Elements / Review of Systems (ROS) Elements / History Elements
 Location
 Quality
 Severity
 Duration
 Timing
 Context
 Modifying Factors
 Associated Signs and Symptoms
 Status of 3 or more chronic conditions /  Constitutional
 Eyes
 ENT/Mouth
 CV
 Respiratory
 GI
 GU
 Musculoskeletal
 Integ/Skin/Breast
 Neurological
 Psych
 Endo
 Hem/Lymph
 Allerg/Immuno /  Past Medical History
 Family History
 Social History
Problem Focused (Min-1)
Expanded Problem Focused (Min-1) Detailed
AT LEAST 4 or at least 3 Chronic DX Comprehensive
AT LEAST 4 or at least 3 Chronic DX / Problem Focused (N/A)
Expanded Problem Focused (2-9 systems)
Detailed (2-9 systems)
Comprehensive (min-10 required) / Expanded Problem Focused (N/A)
Detailed 1
Comprehensive
2-Established 3-New

History:  Problem Focused  Expanded Problem Focused  Detailed  Comprehensive

General Multisystem Examination

Exam / At least 1 element identified from a bullet from any system / 6 items identified by a bullet from any system / 2 items identified by a bullet from a minimum of 6 systems (12) / 2 items identified by a bullet from a minimum of 9 systems (18)
Constitutional /  Any One of the Three Vitals  General Appearance of Patient
Eyes /  Conjunctiva and Lids  Pupils and Irises  Optic Discs
Neck /  Neck  Thyroid
Respiratory /  Respiratory Effort  Percussion  Palpation  Auscultation
Cardiovascular /  Palpation of Heart  Auscultation  Carotids  Abdominal Aorta
 Femoral  Pedal Pulses  Extremities and Varicosities
Chest /  Inspection of Breasts  Palpation of Breast and Axillae
GI (Abdomen) /  Masses/Tenderness  Liver and Spleen  Hernia
 Anus, Perineum, & Rectum  Occult Test
Lymph /  Lymph Nodes in 2 or More Areas  Neck  Axillae  Groin  Other
Musculoskeletal /  Gait & Station  Digits & Nails
 Muscles of at Least One Area with Exam including:  Inspection/Palpation  ROM
 Stability  Strength & Tone
Skin /  Inspection of Skin and Subcutaneous Tissues
 Palpation of Skin and Subcutaneous Tissues
Neuro /  Cranial Nerves  Reflexes  Sensation  Judgment & Insight
 Orientation to Time and Place/Person
Psychiatric /  Memory  Mood  Mental Status Exam Complete  Recent/Remote Memory
 Orientation to Time/Place/Person  Attention Span and Concentration
 Language (naming objects, repeating phrases, etc.)  Judgment and Insight

 Problem Focused  Expanded Problem Focused  Detailed  Comprehensive

Medical Decision Making / Audit of Evaluation and Management Service
Number of Diagnosises and Management Options / Points Assigned / Points per Category / Amount and Complexity of Data / Points Assigned / Points per Category
Self-limiting or Minor Problems (Stable, improved or worsening). Maximum of 2 points can be given. / 1 / Ordered and/or reviewed clinical lab. / 1
Established Problem – Stable or Improved / 1 / Ordered and/or reviewed radiology / 1
Established Problem – Worsening / 2 / Discussed tests with performing or interpreting physician. / 1
New Problem – No additional workup planned. Maximum of 1 problem gives credit. / 3 / Ordered and/or reviewed test in the CPT Medicine section / 1
New Problem – Additional workup planned / 4 / Independent visualization and direct view of image, tracing, specimen.
Total Points: / Decision to obtain old records or additional history from someone other than patient, e.g., family, caretaker, previous physician. / 1
Reviewed and summarized old records and/or obtained history from someone other than the patient. / 2
Total Points:

Table of Risk: The Highest Level in ONE Area Determines the Overall Risk

Level of Risk / Presenting Problem(s), or / Diagnostic Procedure, or / Management Options
Minimal /  One self-limited or minor problem, i.e., cold, insect bite, tine-corporis /  Laboratory test requiring venipuncture
 Chest x-ray
 EKG
 Urinalysis
 Ultrasound
 KOH prep /  Rest
 Gargles
 Elastic Bandages
 Superficial dressing
Low /  Two or more self-limited or minor problems.
 One stable chronic illness, e.g., well-controlled hypertension, non-insulin dependent diabetes.
 Acute uncomplicated illness or injury, e.g., cystitis, allergic rhinitis /  Physiological tests not under stress, e.g., pulmonary function test.
 Non-cardiovascular imaging studies with contrast, e.g., barium enema
 Superficial needle biopsies
 Clinical laboratory test requiring arterial puncture
 Skin biopsies /  Over-the-counter drugs
 Minor surgery with no identified risk factors
 Physical therapy
 Occupational therapy
 IV Fluids without additives
Moderate /  One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment.
 Two or more stable chronic illnesses
 Undiagnosed new problem with certain prognosis (e.g. lump in breast)
 Acute illness with systemic symptoms, e.g., pyelonephritis, pneumonitis, colitis. /  Physiological tests under stress (e.g., cardiac stress test, fetal contraction stress test)
 Diagnostic endoscopies with no identified risk factors
 Deep needle or incisional biopsy
 Cardiovascular imaging studies with contrast and no identified risk factors, e.g., arteriogram, cardiac catheterization
 Obtain fluid from body cavity, e.g., lumbar puncture, thoracentesis. /  Minor surgery with identified risk factors
 Elective major surgery (open, percutaneous, or endoscopic) with no identified risk factors.
 Prescription drug management
 Therapeutic nuclear medicine
 IV fluids with additives
 Closed treatment of fracture or dislocation without manipulation.
High /  Once or more chronic illness with sever exacerbation.
 Acute or chronic illness or injuries that pose a threat to life or bodily functioning
 An abrupt change in neurologic status (i.e., seizure, TIA, weakness, or sensory loss) /  Cardiovascular imaging studies with contrast with identified risk factors.
 Cardiac electrophysiological tests.
 Diagnostic endoscopies with identified risk factors
 Discography /  Elective major surgery
 Emergency major surgery
 Parenatal control substances
 Drug therapy requiring intensive monitoring for activity
 Decision not be resuscitated or to deesculate care because of poor prognosis.

Decision Making Total: 2 of 3 Must Meet

Points Assigned / 1 / 2 / 3 / 4
Number of Diagnoses /  Minimal /  Limited /  Multiple /  Extensive
Amount of Data /  Minimal /  Limited /  Moderate /  Extensive
Risk of Complications /  Minimal /  Low /  Moderate /  High
Levels /  Straightforward /  Low Complexity /  Moderate Complexity /  High Complexity

Level of Service: History: ______Exam: ______

Medical Decision Making Chart note:

 Signed  Signature missing  Diagnosis Code(s) supported

Diagnosis Code(s) Billed: ______

Other services billed: ______

Comment(s): ______

______

______

______

______

______

______

______

______

______

Auditor’s Signature: ______Date: ___ / ___ / _____

01-03-011 Billing and Chart Audits

Page 1 of 1