Taking Advantage of the Radiology Audit

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A radiology provider should look at an audit as a strategic opportunity, not a punishment, Claudia A. Murray, RCC, told her audience at the RBMA 2009 Radiology Summit in Orlando, Florida, on June 8. Murray, who presented “Internal Compliance Auditing: How to Implement an Effective (and Doable) Audit Plan,” is a principal at CMC Consulting, LLC (Fallston, Maryland), a company specializing in regulatory compliance, Medicare billing rules, operations assessments, and coding audits. Murray says that an internal audit cycle can help a facility or practice correct flaws that reduce revenues and impede both work flow and patient care, whether those problems originate with referring physicians, information systems, technologists, radiologists, or support staff. In addition, the self-auditing process helps the provider stay prepared for the escalating levels of external scrutiny imposed by regulators and payors. Radiology Audit Protocols The radiology audit, Murray explains, should begin at the end: The audit protocol cannot be designed until the imaging provider decides what use will be made of the results. The audit’s findings could be used to pursue reimbursement refunds or appeals, to train clinical and billing staff, to take corrective action when flawed processes are found, to establish a baseline for future audits, or to serve all of these purposes. Murray describes the audit as the only way to stay on top of operations, and suggests choosing an auditor who has experience in claims processing (as well as auditing) and who understands applicable regulations and statutes at the state and federal levels. When the auditor and the audit’s purpose have been determined, the next steps are to define the size and complexity of the practice and to select the sample of records to be evaluated. These records are then retrieved and reviewed, after which the auditor prepares a report. Later, the practice schedules a follow-up audit that will cover the same ground to see whether any changes that it undertook have been helpful. In defining the practice, Murray says, the auditor considers its number and type of sites, number of physician FTEs, services offered, and procedural volumes. Because a statistically significant review of records would be prohibitive for all but the smallest practices, Murray recommends choosing a manageable number of records (for example, 200) and determining whether to focus primarily on sites of service, physicians, or coders. Records are then selected for review randomly in 60% of cases and manually in the remaining 40%. The random selections ensure that the review is unbiased, but the manual selections make it possible to guarantee inclusion of all service sites, physicians, coders, and procedure types. If solely records selected at random were reviewed, Murray says, many practices might end up with detailed audits of chest radiography and mammography, but no audit of procedures that are rarely performed, leading to incomplete conclusions. Records retrieved should include all of the referring physician’s orders, source documents, and instructions; all staff notes documenting instructions from the physician’s office; all intake data (including medical history and allergic reactions); claim forms; radiology reports; other medical records; and all pertinent comments and account/payment information (by line item). The auditor follows the entire imaging process, from referral to claim resolution, while noting any denied claims or procedural errors. The volume of denials is then determined, and corrective action is recommended wherever a pattern of difficulties emerges. Records are reviewed singly, but problems are grouped by type and by cause. The auditor’s final report should describe all of the steps taken during the audit itself, should indicate the errors discovered, and should suggest methods of correction for each problem found. Common Problems Murray points out that the problems found through auditing typically fall into three categories: missing documentation, poor individual training or habits, and coding errors. Among the common types of missing-documentation problems in Murray’s case studies were records generated by physicians in training at teaching institutions; these might be countersigned by an attending physician, but lack documentation of the appropriate attestation. In similar cases, where imaging has been used to guide a procedure, the radiology report might fail to document the ultrasound exam used for guidance. Order documentation is another problem. For example, when an abdominal CT exam is ordered, CT of the abdomen and pelvis might be routinely performed, or when pelvic ultrasound is ordered, a pelvic and transvaginal ultrasound study might be done. Documentation of diagnosis-code sources is often troublesome, since the suspected or confirmed diagnosis that prompts an imaging study might be taken from a source other than the physician’s imaging order (such as a hospital record) without being documented in the imaging report. Murray refers to the individuals who cause errors found through auditing as renegades, noting that they may need more training due to misinformation, may be operating using outdated methods, or may be unwilling to conform with protocols to the degree required by payors and information systems. These renegades, she says, might invent patient histories or chief complaints—while ignoring the preoperative orders in the RIS—in order to perform chest radiography for every patient before surgery. Another type of renegade is the physician’s assistant who bills payors, under the physician’s name, for services described as incident to the physician. A renegade might insist on using new codes to bill for 3D reconstruction when only 2D work was performed, or might bill for an investigational procedure or the use of equipment that does not have FDA approval. Coding problems found often in Murray’s audit experience can involve both downcoding and upcoding. Particularly when coding is outsourced, she notes, a percutaneous or needle biopsy might be upcoded as a vacuum-assisted breast biopsy. Services that were not performed could nonetheless be billed, as when mammography and breast biopsy are routinely coded together without documentation that both were performed. Downcoding is among the audit-discovered errors most directly detrimental to the provider, since revenue is lost simply through failure to bill correctly for the work that has already been performed. Codes for interventional radiology are especially subject to downcoding mistakes, Murray says, giving coding for incorrect angiography access sites, orders, and vascular families as examples. In freestanding imaging centers, contrast media may be billed at an incorrect dosage or not coded at all. Audit Results The point of the radiology audit is to review the entire imaging process, from referral to final payment, to ensure that there are no weak links present that could reduce revenues or increase exposure to fraud/abuse risks. An audit should not be a one-time exercise, since part of its value comes with repetition to assess whether changes have been made (and are valuable). Murray recommends setting up a permanent audit schedule as the best way of gaining the full benefit of the review process. Kris Kyes is technical editor of ImagingBiz.com.