Physician Compliance Auditing

By: Suzan Berman, MPM, CPC, CEMC, CEDC

When you were asked as a young child what you wanted to be when you grew up, you talked about being a teacher, a baseball coach, a performer, or a doctor. I'm fairly certain I, for one, never said I wanted to audit physician documentation when I grow up. However, this is my chosen career path and for so many reasons I wouldn't want it any other way! The role of a physician auditor is multi-faceted and ever changing and challenging. I am a teacher, a coach, a performer, and sometimes I even pretend I'm a clinician (call it an armchair doctor)!

As a teacher I am tasked with meeting with a physician to discuss documentation guidelines and audit results. These physicians can be part of the routine rotation of audits and education, a new provider, a mid-level provider (PA/CRNP, etc.), an outlier to the specialty bell curves, or someone wanting additional training in documentation. Knowing about the guidelines and the intricacies of the billing requirements is imperative to a successful practicealthough a very daunting and complicated task. That's when I wear my teacher hat. There are two sets of documentation guidelines and either is acceptable for an encounter. However, does the provider really need to know that they are known as the 1995 and the 1997 guidelines and you should use the most advantageous to you when seeing patients and you don't have to stick with one over the otherbut you can switch for each encounter and there are bullets and points and systems and areas, etc. etc. etc.? What the provider needs to know is how to appropriately document, to not only provide high quality care to his/her patients but to also be able to substantiate the appropriate level of service. That's what the providers want to know. They want to be able to incorporate the guidelines into a daily routine.

Encouraging the providers to bill at the appropriate levels of service requires the coaching hat to come on. They know they'll be audited and that their charges are being submitted for payment. They are sometimes afraid to bill high levels of service because they don't want to "raise red flags." They may want to keep their charges at low levels to avoid un-due scrutiny. They should bill for what they've done and the care they've provided their patients.

The coach's job is to encourage them to document appropriately and bill for the services they actually provide. This takes patience, time, hand-holding, guidance, and all those other characteristics of a coach. The reward for the coach is the end product of a great note, appropriately billed service levels, and a happier physician knowing he/she's done the right thing all around.

To understand the audience and to be able to deliver the information in a way that will not only keep them engaged, but also take something away from the time they spend with you is all in your delivery. You have to "act." You have to put yourself in their shoes and be able to train them at the level they are comfortable. Sometimes, just as an actor prepares for a role, I do the same thing. I encourage every auditor and coder to shadow the physicians. Shadow them in their clinics, on their hospital rounds, and even in the operating room if you have that luxury. You get to walk in their shoes and better understand their workflow. You get to see how they interact with their patients and the information they are writing down. You will also see how they document and be able to help them along. Once you've prepared for your role, you'll have a better sense of how to deliver! It's hard material; there are a lot of particulars and also many exceptions. But your message is important and one they know they need. Pretending to be a clinician gives me lots of room to stretch my acting skills. With appropriate anatomy, terminology, physiology, and coding knowledge, I am able to relate to the physicians. I am able to create examples that they can relate to. By starting the conversation using examples, they often provide more and that's where the discussions and training really take off. I learn more about their day-to-day world and I expose them to the requirements and how they can benefit from adopting them.

I also write my own scripts. I determine the best approach whether it is a PowerPoint presentation, an outline, a discussion, or a handout or pamphlet. Just as a director determines if the movie should be made for TV, on the big screen, or go straight to DVD, I'm assessing my audience, the material, and my message to determine how to convey the information.

But with all of this, my favorite role is truly being there for them when they need me. I make myself available through email, phone, and face-to-face. I've walked through the halls of the hospitals and clinics where I've worked. By making myself available and approachable, it shows them that I just don't care about the bottom line, but that I care about them. They can ask any question and they know I'll either give them the answer or do the necessary research to get the answer. I then use their questions when creating new educational material. I stay current with my knowledge by attending seminars, reading magazines, and participating in list serves. This way they can feel confident in the answers and solutions I provide.

So you may be asking, when I was asked as a child what I wanted to be when I grew up, what did I say? I said I wanted to be a teacher!

Suzan Berman (Hauptman), MPM, CPC, CEMC is currently the manager of Physician Compliance Auditing for Allegheny Health Network (West Penn Allegheny Health Systems). Before that she was the Senior Director of Physician Services at Health Revenue Assurance Associates and prior to that, the Senior Manager of Coding Education and Documentation Compliance at UPMC. She is active with the AAPC having sat on their Board of Directors for local chapters as well as the National Advisory Board. She is a current member of the Optum Coding and Referential Advisory Board as well as the Coding Institute Editorial Board.