EDITOR’S NOTE: Here is the second installment by the author. Part I appeared in the Nov. 17, 2016 edition of the RACmonitor eNews.

Earlier we discussed the approach and reasoning for audits, and how that should drive the findings to separate “this will do” from “this is compliant documentation.” It’s hard to know if a third-party auditing firm is going to provide this type of review for you. I was working with an auditor in a training course the other day who had some redacted encounters she recently audited, and she asked me to review them. The cases involved the use of the -25 modifier, and while the auditor had allowed all 12 encounters utilizing the modifier, I only allowed one. It was a dermatology review, and the HPI only addressed the reason for which the procedure was performed.  The exam listed a simple statement of dry skin patch, noting where, and a templated plan of care for the dry skin for which the provider left blanks. The plan of care was essentially what one would find if Googling “dry skin.” 

The dermatologist created such documentation on 11 out of the 12 encounters we reviewed. The question becomes, is the -25 modifier supported? I answer that by saying, if I needed to defend it, yes. But the real issue is that this is not the purpose of performing an internal audit. The purpose is to identify areas of poor compliance and thereby identify how to improve. If you asked me if they would have survived a carrier audit process, my answer is “absolutely not.” The provider failed to truly demonstrate the significant and separately identifiable issue of the patient and ended up creating a trend within her documentation of an “oh, by the way,” in what appears to be an effort to ensure that the -25 modifier is always supported.

I asked the auditor if she noticed this, and she said, “well yes, but it is really a different problem than the procedure, and when I talk to the provider she is going to say to me- ‘OK, then what should I say?’” She then asked me for my opinion on how to respond.   

My explanation is simple: if you cannot tell the provider how to modify their documentation in this instance to make it more supportive of the -25 modifier, then that tells me you feel unable to come under fire for your audit findings, and therefore, that may skew findings by allowing questionable content to pass an audit. I would think that is NOT the expectation that your organization has for the audit for which you are paying.

How do you know if your audits are being reviewed under the pretense of true corporate compliance, or that with which we can get away? The only way you will know for sure is to ensure in the statement of work with the auditing firm that you specifically implement this requirement for your project. While it should be assumed that an auditor would automatically proceed in this manner, the reality is that providers do not always value the audit process as a learning exercise in compliance, but rather see it as a judgment of their patient care or their work. Therefore, auditors try everything they can to make what is documented “just work.” Carriers will not make things just work, so ensure that your audits are truly representative of your actual compliance.

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