June 27, 2012
4 min read

Medicare audits may motivate doctors to revisit patient record protocols

Take action now to be sure your records are compliant with national rules.

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Medicare audits are increasing in frequency, volume and impact. Within the past month, I have heard of doctors who are being told to repay hundreds of thousands of dollars in Medicare payments following audits of their claims and medical records.

The audits usually begin with a request from the contractor to review the medical records for 10 to 20 randomly selected Medicare claims. If the auditors find anything “of interest” in those first records, the audit expands to 100 claims and then, based on the potential dollars involved, the extrapolation begins. We have seen audits stretch out to more than 4 years of Medicare payments, and rumor has it that auditors may soon be authorized to go back a full 10 years.

Here is a hypothetical example of extrapolation: An auditor reviews 10 charts (total claims paid were $2,165) and determines that, in the auditor’s opinion, the doctor over billed by a total of $421 (19.4%). Medicare data shows that the doctor received Medicare payments of $13,260 during the previous 12 months. The Medicare carrier informs the doctor of required repayment of $2,572.

Audits: a threat or not a threat?

It is hoped that audits are not a threat to doctors who have paid attention and have established solid internal protocols for providing care to their patients, are familiar with the definitions of procedures in Current Procedural Terminology (CPT) and choose all diagnosis codes and procedure codes based on accepted national rules. Sure, it will still cause concern when the letter arrives announcing the audit. It might even require a spirited defense of one’s protocols for billing, but such offices will be fairly confident that all will be well.

Charles B. Brownlow, OD, FAAO

Charles B. Brownlow

On the other hand, it is probably safe to say that there will be more than a little concern when an audit letter is sent to doctors who have provided care without paying much attention to national rules and standards for medical records and are not so clear on CPT definitions.

Which group are you in? The time to fix the shortcomings in your protocols and record keeping is now, before the letter arrives. If you are not confident that your records, protocols and coding will stand up to audit, will you do something about it now? If not now, when? It will not do you much good to make your corrections after you have an audit.  

More bad news: Because the audits are performed by independent contractors whose payment is a percentage of the doctors’ repayment, you can expect the audits to be more frequent and uglier in the near future. If you have been complacent about medical records compliance, this uptick in audits may be the motivation you need to commit to better medical record keeping and more accurate coding in your practice. The sooner you become confident in your medical record keeping and the sooner you master proper CPT and ICD-9 coding, the sooner you can return to concentrating on good patient care.

Audits and EMR

The U.S. government contracts with Central Government Services (CGS)  for administrative and provider audit services for Medicare programs covering durable goods in Medicare’s region C, as well as Ohio and Kentucky Medicare Part B. CGS has become quite active in audits of Medicare providers, including physicians, and their policies may “spill over” into other Part B and durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) physicians and suppliers. Their influence makes it critical for us to pay attention to their opinions regarding physicians’ billing practices and the issues they focus on during audits.

A few months ago, I read in a CGS publication that they do not accept documentation for the elements of case history unless the record shows that the physician, rather than staff, has completed and reviewed the content. If it is not clear in the record that the physician reviewed the information, the elements will not count in the assessment of those sections of the medical record, and the resulting office visit code will be lower.

The CGS interpretation of this rule is disturbing, as it seems to represent a narrow reading of the Documentation Guidelines for the Evaluation and Management Services—1997. To comply with the CGS requirement, each record should have a place where the doctor can indicate that the doctor has personally reviewed all elements of the case history. The note would be accompanied by the doctor’s signature and the date the information was reviewed by the doctor.

The CGS opinion apparently stems from the documentation guideline in the case history section of 1997 Documentation Guidelines for the Evaluation and Management Services, 1997, (99000 series office visit codes), which states: “The ROS [review of systems] and/or PFSH [past/family/social history] may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.”

CGS has extended this requirement to the entire case history.

Reassess your paper, electronic records

Most doctors would argue that their signature at the end of the chart has traditionally been sufficient to make it clear that they accept responsibility for all that is recorded in the chart, including the notes made by ancillary staff in the case history and elsewhere. To be on the safe side, though, until this disagreement is settled, it will be important for all doctors to be sure that their paper or electronic records have a place for the doctor to indicate the obvious: that the doctor has reviewed all components of the case history and that the doctor accepts responsibility for it.

PMI created a medical record form 13 years ago that includes the following statements, dated, initialed or signed by the doctor: “Primary ROS [review of systems] taken today” and “Reviewed ROS and PFSH from __/__/__, no changes except as noted.” Doctors may, given the current situation, consider rewording that statement slightly to meet these CGS rules, such as “Reviewed all elements of case history as recorded on __/__/__ , no changes except as noted” (signed and dated when reviewed). For more details about the sample medical record form refer to: http://pmi-eyes.com/purchase.php#Records.

With audits clearly on the upswing, this would be an excellent time for every physician to review internal protocols for medical record keeping and coding and to consider changes or adjustments in those protocols to be sure the office complies with current rules. There is nothing you can do to avoid audits by the payers with which you are contracted, but you can take action to lessen the likelihood of big paybacks to the insurers.

Most importantly, taking action now will permit you to worry less about the imminence of audits and to realize the side benefits of better medical records: better patient care, better internal communication and possibly even increased income.

For more information:
  • Charles B. Brownlow, OD, FAAO, is a member of the Primary Care Optometry News Editorial Board and a health care consultant. He can be reached at PMI, LLC, 321 W. Fulton St., P.O. Box 608, Waupaca, WI 54981; Brownlowod@aol.com.