Internal audits: A winning strategy for navigating E/M obstacles

Navigating E/M documentation and coding compliance is like making your way through an obstacle course. The current 1995 or 1997 guidelines are woefully outdated and out of step with current medical practice, adding an extra layer of confusion to an already complex process. Obstacles such as poorly designed EHR templates can further obfuscate documentation and make optimal E/M documentation seem out of reach. As physician practices join multispecialty groups or health systems, workflow and process variances only add to the confusion. And as both government and commercial payers steer patients to primary care and outpatient services, it’s inevitable that payers will use tools such as Targeted Probe and Educate audits to scrutinize physician practice claims.

But improving E/M documentation and physician practice workflows doesn’t have to be an unreachable goal. Evangelical Community Hospital in Lewisburg, Pennsylvania, has acquired approximately 30 practice locations over the past several years. Each practice came with its own unique processes and workflows. To address these variances, the practices brought operations directors on board as part of their compliance work plan committee, says Carol Waughen, director of compliance at Evangelical.

“By working with the coding and billing manager, the operations directors, and the entire revenue cycle team and reviewing audit findings, this has allowed us to identify inconsistent workflows and processes across these locations,” Waughen says. “Where before a workflow or process may have been changed, through this committee and working together we identify the root causes of any identified audit issues and then develop action plans to implement changes and follow up with auditing and monitoring the new workflows.”

The objective is to minimize variation in workflow processes by:

• Implementing operational standards
• Ensuring that documentation is complete and accurate according to CMS’ definition of medical necessity
• Integrating best practices into all the locations that will yield high patient satisfaction and safety, quality standards, and profitability

One area Waughen and the committee have focused on is E/M documentation compliance. Documentation and coding processes can vary greatly among physician practices, particularly when it comes to E/M services, and these facilities might not have the same internal monitoring and auditing processes as hospitals. The compliance work plan committee has worked to bring the newly acquired practices on board and conducted internal audits and reviews to ensure that compliance goals are met and risks to revenue are mitigated.

Auditing E/M documentation and coding can be challenging, Waughen says. At some practices, physicians handle their own E/M coding. Although this can save on work in some respects, internal auditors should keep an eye out for gaps in documentation. The physician may be charging the correct E/M codes based on the services that were actually provided; however, the documentation might not fully support the assigned codes.

EHR templates can help physicians create consistently structured documentation but templates shouldn’t be used as documentation crutches, Waughen warns. A physician who relies too heavily on templates could include irrelevant information or even the wrong information—everything but the information that truly needs to be recorded for the encounter.

E/M documentation guidelines are another major paint point for internal audits, Waughen says. Although the 2019 Medicare Physician Fee Schedule (MPFS) final rule removed some E/M documentation hurdles, physicians are still required to use the 1995 or 1997 E/M documentation guidelines until at least 2021.

Compliant E/M coding is inherently more complex than procedure coding, according to Waughen. For procedure coding, the question ultimately comes down to whether the procedure was performed. But even complete E/M documentation requires a certain degree of interpretation to code correctly.

Revenue integrity and compliance can work together and use data from the organization and payers to highlight E/M pain points. Then, compliance can focus internal audits on those areas and share the results with revenue integrity. Finally, compliance and revenue integrity staff can develop recommendations including education and process improvements. Some staff might push back against change, Waughen notes, but it’s important to persevere.

“Just because you’ve always done it that way and haven’t been audited doesn’t mean that’s correct,” she says. “So, let us help you. How can we make you be more efficient and document better while ensuring patient safety and maybe even increase income?”