By Charla Prillaman, CPCO, CPC, CPC-I, CCC, CEMC, CPMA, CHCO

With ever increasing regulatory and payer audit activity seeking to identify improper payments, the pro-active physician practice will implement processes to ensure compliance.  The Office of Inspector General (OIG) Compliance Program for Individual and Small Group Physician Practices, first published in the Federal Register in 2000, identifies monitoring and auditing as one of the seven components that provide a solid basis for an effective compliance plan. Many practices have programs in place to conduct medical record audits.  Auditing programs come in many shapes and sizes; some utilize internal staff and others contract with an outside independent company.   Some even combine internal and external reviews to provide a more robust program.
There are many ways to present audit findings.  All include a "score" or a measurement of accuracy but the effective compliance plan does not stop at assigning a score. Analyze the details that support the findings to ensure that potential vulnerabilities are addressed and gaps closed.  The goal is more accuracy.   

Most commonly, practices begin auditing activities using Evaluation and Management (E/M) codes as the sample selection criteria.  Scoring usually reflects the accuracy using both the E/M category and level as criteria.  In general, documentation gaps and coding mis-steps are addressed in face-to-face meetings with the providers where the coding experts describe how an auditor reads the medical record to determine the supported level.   All too often,  auditors  lapse into "code-speak" using auditing terminology and acronyms with alacrity commensurate with their passion to help leaving the physician in the dark about what steps he/she should take to ensure coding that accurately reflects the services provided. 

Since the desired effect of a coding audit is increased accuracy, keeping the provider attuned to the steps he/she should implement is critical in reaching the goal.   What are some steps the auditor/educator can use to avoid the potential "disconnect"?

Check your attitude and approach  
Genuine interest in their successful coding is the foundation for a successful meeting.  A hurried or pre-occupied communicator will not generate confidence.  Never approach a provider whose attention you want in an accusatory manner.  
Schedule adequate time

E/M coding principles and guidelines are complex and do not always translate easily into the provider's clinical perspective.  Make sure that you have adequate time to share your information and to hear their questions.   You may be the first person in their life sharing a less than A+ score; it could take a few minutes for that to process.

Prepare
The auditor must know the criteria for accurate selection of the sampled codes.  Additionally, the auditor should be intimately familiar with the specific documentation responsible for any identified coding variance.  Knowledge about physician's specialty is helpful.   Take the time to refresh your understanding of any abbreviations or acronyms in the audit sample.   Nothing will lose respect more quickly than using an illustration that is not relevant to the provider (i.e., do not use cardiology examples when talking coding to an orthopedic surgeon).

Be pro-active
Offer solutions, not accusations. Your focus should be on how to capture the cognitive work the providers do in the medical record documentation so that it can support the appropriate code selection.

 Consider the difference in impact between the following sentences and decide what you want to accomplish.  A fight? Or modified coding?  
You failed to document a family history! 

The medical record did not include information about the patient's family history.

Any sentence that begins with "you failed to" or "you didn't" has the potential to shut down all communication.  Train yourself to speak respectfully with careful attention to your word choices.

Never accuse
Assume that the provider's interest is in doing the right thing and describe documentation gaps without using character-judging language.  Saying that the documentation of the examination supports a detailed level instead of exclaiming, "Your examination isn't comprehensive" delivers the same message without the emotion raised by accusatory word choices.   It is unlikely that you will be providing audit services for a person intent on conflicting with the regulatory expectations.

Listen
Develop listening skills.   Remember that most of your physicians are introduced to coding well after the fact of learning medicine.  The complexity of assigning codes can be frustrating to providers who have not yet become comfortable with the guidelines, structure, and nuances involved in coding.   They may need to vent that frustration-do not take that frustration personally.   An empathetic ear will lay the groundwork for sharing helpful tips.   Active listening includes paying attention, staying engaged, and resisting the temptation to interrupt (even to defend yourself if it feels like he/she is disagreeing with a specific audit decision).   If you can wait until he/she is finished, the provider will feel like they made their point and will be in a frame of mind to "hear" the coding instruction you bring.

Summarize
End your meeting by summarizing the audit findings with specific clear action points the provider can implement to improve accuracy.   If possible, keep the instruction to two or three main points.  Address compliance risk areas first and refine coding "perfection" later.  Too much information at once can be confusing and will certainly cause resistance. 

You might summarize like this, "Doctor, today we talked about two issues that caused the codes to be unsupported.  To close these gaps:
When you review the patient history form, refer to the form in your dictation.  That will allow a reader to capture that information.
Remember that Medicare no longer uses consultation codes; report from the New Patient category. The Key element requirements are the same between the two categories.  Level 3 consult has the same documentation requirement as a Level 3 new patient service."

Support
As you prepare to leave your coding meeting with the provider, thank them for their time and attention.   As appropriate, pledge your continued support and assistance in helping them to document successfully the work that they do and select codes that correctly represent the work.

Auditing medical records for coding compliance is foundational to an effective compliance plan yet without an effective way of communicating results and appropriate changes, auditing could become an exercise in futility.   Increase the effectiveness of your communication to improve your coding compliance!

Charla Prillaman, CPCO, CPC, CPC-I, CCC, CEMC, CPMA is the AAPC Physician Services Regional Director, Southeast. Charla has more than 25 years experience providing coding, compliance, and billing services to physician practices. She has worked in a number of capacities including coding and compliance for billing companies, a physician practice consultant for both mid-size and Big 4 consulting firms, and 7+ years as a director of physician compliance for a major health care system employing approximately 2,000 physicians. She is a frequently sought speaker and educator and continues to be active in her local AAPC chapter, serving on both the AAPC's National Advisory Board and AAPC Chapter Association's Board of Directors.