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Auditing

AI Auditing: Walking Backward Toward Home

Way back in 1976, as an elementary school kid in the suburbs of Philadelphia, I came across a book in the library called 2010: Living in the Future. In my then-current world of AMC Pacers and seersucker suits, the book promised great things. Apparently, when I turned 44, the skies would be filled with flying cars, and teachers would look at a wall of televisions containing the faces of their students, among other aspirational goals of the imagination.

In the end, I turned 44, and the only thing the book got right was the ability to have food delivered to my house via computer. I'm not zipping through the skies in my new Nissan Jetson, but I am overweight, thanks to DoorDash (baby steps…).

Which brings me to 2023, the year of Chat GPT and the 50/50 balance of promise and threat that is artificial intelligence (AI). There isn't a single industry that doesn't have the topic of AI front and center of their planning process right now, and medical auditing is no exception. It has led to a burst of Sturm und Drang in our industry, racing between existential dread and thoughts of innovation.

For this week's auditing tip, I'd like to try to calm those in the former camp who see AI as a threat.

Since the dawn of computing, all output from information systems has stemmed from programming on the front end. As programming languages evolved, binary code to basic to C++, they became more complex, but, at the same time, faster and more efficient. With each technological innovation tied to computing, such as graphics, communication, and the internet, this pattern repeated itself.

Now we find ourselves in the nascent world of artificial intelligence, with innovations in the space expanding so rapidly that it was recently being reported that Chat GPT now has the ability to speak, listen, and process images.

Based on this rapid rate of change, as it applies to medical auditing, auditors and CDI specialists need to get involved with AI now, rather than later.

For a corollary, think for a moment about electronic medical record systems and templates. As auditors, we all quickly learned and regurgitated the term "garbage in, garbage out" to describe templated documentation, specifically as it applied to the now (thankfully) retired 1995 and 1997 E/M guidelines. In other words, the output of any computer program or application is only as good as the information that is being fed into it.

Problems with early experiments in creating AI documentation of an encounter are already apparent. In short, the "smart phrase," or "phrase that pays" phenomenon of EMR templates tied to E/M guidelines is showing no signs of slowing down in the world of AI. To recap, there is no "phrase that pays," and every visit is not a level 4 or 5 encounter. The better approach, as has always been the case, is to link level of service to severity and intensity on an individualized basis.

AI can be of assistance in this area, but only if the AI being utilized to create documentation is also programmed to provide clinical decision support. Only physicians can create that, and it must be built as a separate piece of the puzzle prior to integrating it with decisions regarding levels of service. Thus far, early documentation examples indicate that the creation of AI documentation is putting the cart before the horse, generating verbose level 4 encounters that have only a passing reference to the specific severity and intensity of the patient.

As 2023 draws to a close, flying cars and effective remote schooling still find themselves in their infancy, but Moore's Law is rapidly bringing them closer to reality after years of testing. It is understandable to look upon AI as a possible savior to medical documentation, but it will take a few more years of work to refine AI applications to create clinically relevant documentation of a patient encounter.

Your next steps:

Expand your compliance knowledge! Check out the agenda for the 15th Annual NAMAS Auditing and Compliance Conference and register to attend!
Read more blog posts to stay updated on the 2023 Revisions to the 2021 E/M Guidelines.
Subscribe to the NAMAS YouTube channel for more auditing and compliance tips!

By J. Paul Spencer, CPC, COC

NAMAS is a division of DoctorsManagement, LLC, a premier full-service medical consulting firm since 1956. With a team of experienced auditors and educators boasting a minimum of a CPC and CPMA certification and 10+ years of auditing-specific experience, NAMAS offers a vast range of auditing education, resources, training, and services. As the original creator of the now AAPC-affiliated CPMA credential, NAMAS instructors continue to be the go-to authorities in auditing. From DOJ and RAC auditors to CMS and Medicare Advantage Auditors to physician and hospital-based auditing professionals, our team has educated them all. We are proud to have helped so many grow and excel in the auditing and compliance field.

https://namas.co/

Looking to start up a medical practice or grow your existing practice? Contact our parent company, DoctorsManagement.

Auditing

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Auditing

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Auditing

Monthly Spotlight on Fraud, Waste, and Abuse

Auditing

Monthly Spotlight on Fraud, Waste, and Abuse - August 2023:The following cases highlight fraud, waste, and abuse (FWA) and serve as a reminder to uphold high ethical standards when providing patient care and services.

Auditing

If Conduct Appears to Buck the Legal Norm, Chances Are That It Does:It's akin to wearing Doc Martens to a professional cocktail party reception or Uggs to court. In other words, the wardrobe choice jumps out as not being appropriate for the situation. Likewise, certain conduct that violates the Anti-Kickback Statute (AKS) and the False Claims Act (FCA) unequivocally jumps out as being unlawful under the facts and circumstances, yet persons engage in the inappropriate behavior.

Auditing

As CMS Focuses on Quality, There Are Monumental Changes to Reimbursement for Quality on the Horizon!:The Centers for Medicare and Medicaid Services (CMS) utilizes risk adjustment factors to estimate the cost of Medicare Advantage (MA) beneficiaries and those associated costs of providing care. Risk adjustment factor scores govern the amount paid by the health plan during the year for the beneficiary's care.

Auditing

Choosing the Right Tool: Targeted vs. Random E/M Audits:The realm of E/M (evaluation and management) auditing is vast, and 2023 will bring more work here than before thanks to CPT's extensive revisions to its E/M guidelines for inpatient, facility, and home visit services - now in effect. Both compliance professionals and providers must always keep in mind that E/M services (which account for a third of annual Medicare Part spending) will go from being a perennial easy target to an urgent area of attention in 2023.

Auditing

Who Can It Be Knocking at Your Door? Are You Prepared? :The truth is, you can never be fully prepared when a Special Investigative Unit (SIU) from Medicare or Medicaid shows up unannounced.

Auditing

Self-Audits:Self-audits are critical. They demonstrate compliance, or at least a "good-faith effort" to be compliant; they minimize refunds of overpayments to "actuals" and also mitigate the potential for a multiple being added.

Auditing

Provider Education: The Most Important Step of the Audit Process:You've taken the time to complete a painstaking audit of a provider, combing through their documentation on an EHR or maybe even navigating through a handful of handwritten notes.

Auditing

Modifier 25 Pre-Bill Review: Were You Ready?:After all the hype surrounding the upcoming Cigna policy regarding modifier 25 and pre-bill reviews, it seems as if Cigna is not planning on implementing the policy as planned on August 14, 2022.

Auditing

Navigating the UPIC Investigation from a Compliance Consultant's Perspective:Over the past year and a half, I have seen a significant increase in the volume of Unified Program Integrity Contractor (UPIC) investigations taking place in private physician practices.

Auditing

Culture in Compliance:For years, we have talked about the culture in healthcare, especially for compliance purposes, but for many practices, that culture takes a backseat despite continued guidance.

Auditing

2022 Annual Audit Elements: What Should Be Reviewed:Four months into 2022 and the question is: How far along is your audit of high, medium, and low-risk services? If you are like most practices or health systems, something always gets in the way and causes audits to take a back seat.

Auditing

Should Your 2022 Audit Plan Include Paid Claims?:In 2022, when we sit down to configure an audit plan, we often consider whether we will perform an audit retrospectively or prospectively, and whether the sample will include evaluation and management (E&M) services, procedures, or some combination of them both.

Auditing

Don't Sleep On Small Claims Denials:Are you ever tempted to just sweep those small claims denials under the rug? Do you sometimes wonder if it is worth the time and effort to figure out why a code, which will end up yielding $30, is being denied? Does it feel like it takes years to understand a denial and find a solution - leaving you to question if you really know what you are doing? I've had many of those moments.

Auditing

Auditing Infusions, Hydrations, and Injections:If your facility and/or practice is providing infusion, hydration, and injection services, they should be included in your annual compliance auditing plans to ensure proper coding guidelines are being followed and documentation education is not necessary to assist with any loss of revenue gaps.

Auditing

Ciox: Not a Bleach, But Not to Be Ignored:In my role as a compliance consultant specializing in carrier audit response, a lot of items are brought to my attention on a daily basis, with the bearer of said items asking questions

Auditing

Acute Uncomplicated vs Complicated Illness or Injury:When selecting Number and Complexity of Problems Addressed, the complication of treatment required should not be considered. The Risk of Complications of Patient Management is where the treatment options are considered in code selection.

Auditing

Getting Serious About Compliance:By now, most health systems, practices, and providers should know that the Office of Inspector General (OIG) has been stressing the importance of creating and abiding by a compliance plan since the passage of the patient Protection and Affordable Care Act in 2010.

Auditing

As Pandemic Eases, OIG Ramps Up Audits:With Americans having widespread access to effective vaccines, the COVID-19 pandemic is finally fading into the background for most practices, but the issue of compliance is once again rearing its multi-faceted head.

Auditing

HHS/OIG Exclusion List Violations:An important subject that should not be far from your mind is the OIG exclusions list. The HHS/OIG is not backing down on Employment of Excluded Individuals.

Auditing

OIG Plans for Onslaught of Risk Adjustment Audits Claiming 9.5% Error Rate in Code Assignment:According to an Office of The Inspector General Report, the Centers for Medicare & Medicaid Services (CMS) estimate that 9.5% of all payments to Medicare Advantage organizations are improper due to unsupported diagnoses submitted by the organizations themselves.

Auditing

Auditing for Success: Part V of the Back to Basics Series:If the words "medical record audit" conjure up images of high anxiety and pounding headaches, this Back to Basics article is especially for you. For some managers, having their medical records audited is a high stress event.

Auditing

TPE Audit Program Resumption:On Thursday August 12, CMS put providers on notice that the TPE audit program was kicking off again after more than a year hiatus due to the public health emergency (PHE)! As you can imagine, there is some chatter about when and what to expect once the letters start going out.

Auditing

The Year of the Audit: Stand Your Ground with Payers:Over the years I have worked with so many wonderful and talented auditors and professionals at Blue Cross Blue Shield payers, UHC, Aetna, CIGNA, Humana, Medicare carriers, etc.

Auditing

2021 E and M Changes - Diagnoses in the MDM :

The year 2021 will bring significant changes to how we determine the level of evaluation and management services in the outpatient setting.

Auditing

It is My Organization: I Can Do What I Want:The age-old question of Can we offer cash-pay discounts, professional courtesy and/or the waiver of co-payments or deductibles continues to be as relevant today as it was 2-decades ago.

Auditing

Avoiding a Compliance Nightmare in 2020:I've never been a huge fan of horror films and not because of the blood and guts but simply because of the bad choices the victims always seem to make;

Auditing

OIG Compliance 101 - Ensuring the Next Generation is Prepared:

Each day our industry gains new members who are eager to learn and make a difference in the organizations in which they work.

Auditing

EM Changes for 2021 Help is Out There:the hardest part of our job going forward will be in shaping documentation of assessments

Auditing

Why is HIPAA So Important:Some may think that what they do to protect patient information may be a bit extreme.

Auditing

Medical Necessity and The False Claims Act:With so many things to consider regarding why compliance needs to be established

Auditing

Auditing for Reimbursement:

One may believe that audits are performed primarily for compliance, but there is more that can be gleaned from an audit.

Auditing

Joint Commission and the Value of Accreditation:Around the world accreditation is used to assure a high baseline level of healthcare quality. In the United States, accreditation is a multi-million-dollar industry without any sign of slowing down because it's compulsory for federal payments and a marketing necessity in an increasingly competitive landscape.

Auditing

New DOJ Guidance on Evaluating Corporate Compliance Programs:The DOJ's guidance document sets forth topics and questions to address three fundamental questions that prosecutors ask when evaluating compliance programs to guide its investigation:

Auditing

You CAN Charge Medicare More Than You Charge Some Patients:there is no governmental requirement that a clinic have a uniform charge for all payers

Auditing

But All My Friends are Doing it:Just because friends or colleagues are doing something doesn't mean it's the right

Auditing

Lost in a Pile of Numbers Are Your Doctors Who They Say They Are:one of my primary projects is predicting the likelihood that a particular provider may be audited

Auditing

OIG Compliance 101 - Ensuring the Next Generation is Prepared:Each day our industry gains new members who are eager to learn and make a difference in the organizations in which they work.

Auditing

Anthem is Changing their Timely Filing Requirements for All Plans Including Medicare Advantage:Anthem has been very busy sending out notices

Auditing

What about Midnight Billing for Time Across Calendar Days:the calendar day is defined as lasting from midnight to midnight

Auditing

Extrapolation Policies Apply to RADV Audits:Risk Adjustment is a program that was implemented to identify and support Medicare

Auditing

What to Look for When Auditing Smoking Cessation Services:These services are unlikely to create a financial windfall

Auditing

Small Breaches Can Be Subject to Large Penalties :We may have heard about the large fines issued by the Office for Civil Rights

Auditing

HIPAA Changed Again Are You Compliant:The most common violations that providers encounter will occur under Tier One or Tier Two.

Auditing

Conducting a Fraud Investigation Part 1 Taking a Common Sense Approach:I thought I would create a post that would really ensure understanding

Auditing

Auditing Hospitalist Services:The inpatient side of coding and auditing can be enormously complex

Auditing

I Know What We’re Doing is Wrong I Need My Paycheck:Knowingly submitting false statements or making misrepresentations of fact to obtain a federal health care payment

Auditing

An Update on the DHS OIG's Effort to Combat Fraud & Abuse:The fall edition of the Semiannual Report to Congress covers OIG activities

Auditing

Understanding Prepayment Audit Reviews:Being placed on prepayment audit review is extremely frustrating for a physician

Auditing

What Do You Need to Know About Contact from a Federal Agent:Here are some basic principles everyone should know

Auditing

The Myth about Pass Fail Rates for Providers:leadership wants a general idea of what their compliance risk looks like

Auditing

The Importance of Being Earnest Why HIPAA and HITECH Compliance Matters:What's significant is the underlying violations of the Security Rule

Auditing

Auditing Ophthalmology and Optometry Exams:Having this knowledge in your pocket allows you to have a great opening discussion

Auditing

Auditing Chiropractic Services:Chiropractic is unique among healthcare specialties

Auditing

Overview of AMAs E&M Revisions for 2021:The AMA is allowing comments for reconsideration until midnight Central Standard Time on Monday

Auditing

Prolonged Services :I find in my own audit reviews that the prolonged service code set is often mistreated

Auditing

Voluntary Repayments:cShould you volunteer to repay money from Medicare or other federal healthcare programs

Auditing

How to Correctly Unbundle NCCI Code Pair Edits:An NCCI code pair consists of two codes representing procedures

Auditing

How to be an Effective Compliance Officer:Being a Compliance Officer can often feel like a thankless job

Auditing

Revenue Cycle Management Considerations for Auditors:By analyzing key elements and reviewing applicable guidelines

Auditing

Attestations Teaching Physicians vs Split Shared Visits:The only difficulty will be trying to find out if your commercial payers decide to follow CMS

Auditing

Medical Necessity vs Documentation for Inpatient Services :Many of the notes we are provided for review include so much information

Auditing

Medical Student Documentation CMS Relaxing of the Rules:Medicare Claims Processing Manual to allow the teaching physician

Auditing

What is Virtual Communication G0071:This visit descriptor is Virtual Communication and is not indicated as a telehealth service

Auditing

Auditing looking between the lines:When given the task of auditing a group of charts

Auditing

Billing 99211 Its not a freebie:It seems like a simple code to bill

Auditing

Using a Billing Company versus Hiring a Biller When Starting a Medical Practice:The option I do not recommend is the option that requires hiring a biller.

Auditing

We've Always Done It This Way and Other Challenges in Education:This is one sentiment that we all have had at one time

Auditing

Prolonged Services Its Not Just About Time:One way of looking at this is to take note of the threshold times

Auditing

When to Use Modifier 25 and Modifier 57 on Physician Claims:it is important to know the distinctions between these two modifiers.

Auditing

The Potential Impacts of a Flat Rate EM Reimbursement on our Industry:Proposed Reimbursement Model Change

Auditing

Getting the Right Eligibility Information for Payment Your Rights and Health Plans Requirement:We need timely and accurate patient information to bill health plans and receive appropriate payment.

Auditing

When Medical Necessity and Medical Decision Making Don't Match:Determining Medical Necessity

Auditing

Ensure Personal Quality An Auditor's Approach to Research:We often associate research with a large amount of time

Auditing

The Importance of Policies:With a growing awareness of just how many organizations do not have published policies

Auditing

Auditing Incident to Services:Incident to billing offers two key benefits

Auditing

Provider-Based Facilities and Split Billing Is Your Facility Being Reimbursed for All Work Performed?:Are you stumped by billing guidelines for provider based facilities

Auditing

Auditing Therapy Evaluation Codes Not So Quick:New evaluation codes for physical therapy

Auditing

TKAs to Outpatient What We Have Learned with Q1:The release of the 2018 Final Rule for the Outpatient Prospective Payment System

Auditing

The Devil is in the Data Details:As an auditor who has reviewed thousands and thousands of encounter documents for level of service

Auditing

Critical Care Documentation:Critical care documentation should showcritical need for the patient AND immediate action by the provider.

Auditing

The Comprehensive Error Rate Testing Program:With nearly a million physicians in this country, how do auditing organizations determine whom to audit

Auditing

Is Your Practice in Need of a Wellness Visit?:Is your practice busier than ever

Auditing

Chiropractic Audits by Medicare Are Increasing:Despite the fact that only three treatment services are covered by Medicare

Auditing

PFSH Documentation: Q and A:Included with a NAMAS membership is the ability for members to submit their auditing questions to our auditing team for input.

Auditing

Coding and Auditing: Acronyms and Abbreviations - When they fall into the grey:When the record could mean too many things

Auditing

Responding to The Letter:It is frustrating enough to receive a letter demanding medical records from your group.

Auditing

When the Auditor Comes Knocking, Will You Be Ready?:There are many types of audits.

Auditing

Global Surgical Package: When to Bill and When Not to Bill, That is the Question:The global period is defined by the number of global days assigned to a CPT code.

Auditing

The Incredible Disappearing Consultation:In January of 2010, CMS ceased payment of CPT codes for consultations (99241 through 99245 for outpatient, and 99251 through 99255

Auditing

Case Law Update: Just Because HIPAA Does Not Provide a Private Right of Action, Doesn't Mean that Other Avenues Exist:Simply stated, the Health Information Portability and Accountability Act

Auditing

Auditing Vaccines:Auditing vaccines can be difficult

Auditing

DOJs Newest Evaluation Criteria for Investigating Compliance Programs:Here is a summary of the topics and questions that the DOJ finds relevant

Auditing

DOJ's Newest Evaluation Criteria for Investigating Compliance Programs:The Department of Justice (DOJ) recently published a guidance document titled

Auditing

The Big Myth If it isn't written, It wasn't done:This tip may contradict everything you've heard before.

Auditing

Diagnosing, Documenting & Coding for Radiculopathy:Radiculopathy can be an unpleasant condition, but diagnosing, documenting and coding for it does not have to be.