Dennis P.H. Mihale, MD, MBA, CEO

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Dennis P.H. Mihale, MD, MBA, CEO CMO, PARSES,
Inc.Stephanie L. Jones, NRCMA, NRCAHA, EMS, CPC
VP Ops and CAO, PARSES, Inc

• Data Capture from the Actual Medical Record to
  Validate Accuracy in Reporting

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HIPAA Standardized Reporting

• A triumph for the EDI system
• Efficiency and speed of reporting
• No separate reporting protocols
• Standardized data for studying claim patterns
  accuracy
• Or does it?

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Standardbut correct?
Office visits - new 92.60
Consultations 84.50
Office visits - established 76.00
Emergency room visit 72.10
Hospital visit - initial 58.00
Nursing home visit 50.00
Hospital visit - subsequent 36.40
Advanced imaging - MRI 25.90
Hospital visit - critical care 21.20
All Types of Services 40.10
May 2006 CMS CERT report of Payment Errors
Caused by Incorrect Coding
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Introduction

• Close Enough physician coding hurts practices,
  payers, patients, employers.  
• Reasons to ensure accuracy in coding
• Payment Accuracy
• P4P
• HSAs and Employer driven plans
• DATA STUDIES
• Regional Cost Differentials
• Rate Setting
• Utilization
• Quality Measurement

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PARSES Coding Data
Has Analyzed, Audited and Validated
(Statistically) coding from the actual medical
record since 1999 Data Mined gt 10 Million
physician claims data Conducted gt 500,000
comparative MR reviews Key Executives 200
years of experience Auditors MD, LPN/RN,
Certified Professional Coder
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The Advantage of Standard Code Sets

• Valuable data for analysis
• Uniform capture of Diagnoses, Procedures, and
  Utilization

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Hidden within the Standardized Code Sets Data

• Overpayments
• E/M Coding Mistakes Cost gt22B
• The appearance of ? Access to Care
• Incomplete P4P data
• Inaccurate Data

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Why do Providers Miscode?

• Under Documentation
• Innocent mistakes
• No correctness incentive
• Audit avoidance
• Ignorance
• Easier to not report it
• Fraud and Abuse

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Common CPT-4 E/M Errors

• ? coding Level 5 pt visits
• ? coding New Patient visits as Consults
• ? coding Level 3 visits to Level 4
• template abuse pt severity low
• ? coding Level 4 visits to Level 3
• audit avoidance pt severity moderate to high

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Common ICD-9 Errors

• Loss of persistency
• Incorrect diagnoses coding
• Improper sequencing
• Missing the Highest Level of specificity

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Other Common Findings

• Unreported services
• Under-documentation
• Unbundling
• Abuse
• Fraud

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Data from the Medical Record

• Code correctly
• Under-code
• Over-code
• Leave off a code
• Bill the wrong code entirely

Did the provider.?
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Auditing New Trend-able Data

• Adds data for validation and expanded analysis
• Clinical
• Actual history of illness reason for visit (CC)
• Documentation of physical exam
• Assessment and related problems
• Plan of treatment
• Key labs and tests
• Specialty issues
• individual patient needs
• Trending exceptions and alerts

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The Actual Medical Record

• Point of Service Clinical Documentation
• Paper Records
• EHRs

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The EHR
Blue Cross and Blue Shield Association fourth
annual Medical CostReference Guide Facts and
Trends to Support Knowledge-Driven Solutions

• Implemented an EHR
• 12 smaller groups
• 19 larger groups
• Intend to implement an EHR within 2 years
• 42 smaller groups
• 68 larger groups

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Methods Capture Data from the Actual Record

• EHRs
• Run EHR/Billing analytics - assess code
  compliance
• Audit record
• un-documented services
• Medical Necessity and E/M leveling
• Paper Records
• Run Billing analytics - assess code compliance
• Audit record
• Abstract the medical data / over under coding
  and mistakes
• un-documented services
• Medical Necessity and E/M leveling

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Acting on Errors.

• Determine the need for statistical validation for
  reporting
• Determine the need for further action with
  billing providers

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Methods to Improve Accuracy

• Education
• Make it available and easy
• On-line Video Series
• Website References
• Provide specific audit feedback
• Monitor/Re-audit activities
• Incentive Based Compliance

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Auditing Operational Considerations

• Neutral Organization
• Trusted Organization
• Preserve Oversight and Accountability
• Appropriate Control and Security of Data

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Resources/References

• CERT REPORTS
• https//www4.cms.hhs.gov/apps/er_report/index.asp
• BCBSA Medical Cost Reference Guide
• http//www.bcbs.com/mcrg/index.html
• http//www.codexact.com
• http//www.ama-assn.org
• http//www.cms.hhs.gov/

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Summary

• Validating Data by Medical Record audit ensures
  best outcomes
• Additional data can only be obtained by an actual
  medical record audit
• Leverage Vendors as outsource partners

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• Dennis P.H. Mihale, MD, MBA
• CEO CMO, Parses, Inc.
• dmihale_at_parses.com
• Stephanie L. Jones,
• NRCMA, NRCAHA, EMS, CPC
• Vice President of Operations and Chief Auditing
  Officer
• sjones_at_parses.com