AE July/August 2018 Vol 27 No 4 - 23

* selecting the first patient of the
morning and afternoon for a
defined period of time;
* where paper charts are used, simply pulling charts "blindly from
the shelf "; or
* selecting a day of the week and
including patients in selected
appointment slots. (Caution:
This can skew your sample to all
"new patients" or all "established
patients" depending on the appointment slots selected.)
Consider basing your selection
on service utilization, focusing on
services you provide frequently.
Ideally the sample should represent
an array of services including new
and established patient exams,
diagnostic tests, and minor and
major surgeries. Consultations and
co-managed care should be represented, if performed.
GATHERING RESOURCES
To assess claims accuracy and
adherence to billing rules, reviewers
should have current versions of
CPT, ICD-10, and HCPCS books
and the National Correct Coding
Initiative (NCCI) edits. Payers' fee
schedules, policies, bulletins, and
notices are also essential.
DOCUMENTING OBSERVATIONS
AND RESULTS
Auditors should focus their
attention on behavior that either
puts the practice at risk, resulting
in overpayments, or that costs
the practice money, resulting in
underpayments. These are objective
findings. You can compare the claim
with a specific policy or instruction
for accuracy.
Overpayments result from coding
and modifier errors, under-documentation, performing payer-identified "medically unnecessary"

services, unbundling payer edits,
exceeding expected frequency
of services, or misrepresenting
non-covered services as covered
services to obtain payment.
Underpayments can result from
coding errors (selecting a level of
service lower than the documentation supports) or neglecting to bill
for a service.
As you proceed with your review,
keep detailed notes. Organize and
quantify the observations. This
becomes the basis of your report
and the starting point for corrective
action. Using a spreadsheet allows
you to look at any subset of the
data (e.g., by provider, by payer,
by location). It also allows comparison of results from one review
to the next to track improvement.
(Remember the expectation of
improvement in the TPE program
discussed above?)
Note any subjective findings such
as legibility, organization, understanding and proper use of EMR,
and adherence to internal policies.
These notes will be useful in future
training and if it becomes necessary to modify an internal policy
or process.
REPORTING AND ADDRESSING
FINDINGS
Subjective findings can be summarized in a table, often with the
most egregious issues first. Objective findings can be organized
two ways: frequency and financial
impact. For example, in a sample of
100 records, 35 errors were noted
(frequency) which changed the
reimbursement in the sample by
4% (financial impact).
Address identified problems. This
may include resubmitting claims,
making refunds, and changing
internal policies and training.

Your organized notes will guide
these efforts
Staff training should follow.
To keep from repeating the same
errors, meet with staff members
involved in documenting, coding,
and billing: providers, technicians,
scribes, coders, and billers. Share
your findings, get their input, and
train the appropriate people.
Then, repeat these reviews,
focusing on problems identified in
the prior review and searching for
new issues. Remember: The goal is
improvement over time. AE
NOTES
CMS Targeted Probe Educate (TPE). (2018,
Jan. 18). Retrieved from https://www.cms.
gov/Research-Statistics-Data-and-Systems/
Monitoring-Programs/Medicare-FFSCompliance-Programs/Medical-Review/
Targeted-Probe-and-EducateTPE.html
2
Office of Inspector General (OIG), HHS.
(2000, Oct. 5). OIG compliance program
for individual and small group physician
practices. Department of Health and
Human Services. The Federal Register
65(194): 59434-52. Retrieved from https://
oig.hhs.gov/authorities/docs/physician.pdf
1

"

Payer scrutiny
of provider
claims for
reimbursement
is a growing
concern for
physician
practices.
Investigations
for inaccurate
and
inappropriate
claim
filing have
increased.

Mary Pat Johnson,
COMT, CPC, COE,
CPMA (800-399-6565
x 209; mpjohnson@
corcoranccg.com), is a
senior consultant, Corcoran
Consulting Group.

www.asoa.org // AE

23


https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html https://oig.hhs.gov/authorities/docs/physician.pdf https://oig.hhs.gov/authorities/docs/physician.pdf http://www.asoa.org

Table of Contents for the Digital Edition of AE July/August 2018 Vol 27 No 4

AE July/August 2018 Vol 27 No 4 - Cover1
AE July/August 2018 Vol 27 No 4 - Cover2
AE July/August 2018 Vol 27 No 4 - 1
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AE July/August 2018 Vol 27 No 4 - Cover3
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