Why Chart Audits?

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Why Chart Audits?
Presented by Pam Leal
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Chart Audit Strategy

• Initiatives
• Finding Conditions Documented in the Chart but
  not coded
• Identify documentation errors preventing
  appropriate coding
• Identify chronic recurrent conditions not being
  coded in subsequent periods (Old MI,
  Quadriplegia)
• Outcomes
• Revenue Recovery
• Provider Feedback
• Reminders to assess and document chronic
  conditions

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Chart Audit Approach

• Use of Vendors
• experts (certified coders, nurses, physicians)
• flexible resources - can tackle the masses
• Date Range to Audit
• keep CMS sweeps in mind currently 2004 2005
• Pilot - Nevada
• IPA setting, capitated for professional, and
  delegated for claims payment
• PCP Audit yielded 8 times the investment
• Specialist Audit yielded 2.6 times the investment
  

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Chart Audit Approach

• 100 of Charts vs. Targeted
• Targeted based on enhanced data mining strategy
  (Prevalence Reports) most likely to find HCC
• Using targeted data results in auditing about 25
  of all charts
• What to Audit
• Once chart is pulled, report ALL existing
  conditions, not just the one that identified the
  chart as a suspect
• PCPs vs. Specialists
• ROI on Specialist records is about 2 times the
  investment
• PCPs evaluate a broader spectrum of codes (
  HCCs) than Specialists how many HCCs will an
  endocrinologist really see in the chart compared
  to a PCP?

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Chart Audit ROI

• ROI using Data Mining to Target Suspect Charts
• California Range from 15 times to 37 times the
  investment
• California Average 25 times the investment
• Example one IPA conducted audits looking only
  for the diagnosis codes targeted by reporting -
  Vendor audited the targeted charts, noting all of
  the diagnosis codes documented, and the NEW ROI
  was still 33 times the cost of the audit.
• ROI when Auditing 100 of Charts
• California Range from 8 times to 18.6 times the
  investment
• California Average 10.5 times the investment

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Chart Audit Metrics

• 10 of charts reviewed have unreported HCCs
• Average RAF increase per chart with at least one
  finding .374

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What is the Potential?

• Colorado chart audits revealed findings in 12 of
  charts reviewed and provided a 9 to 1 return on
  chart audit expense.

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Post Chart Audit Activity

• Feedback Reports by Physician
• Feedback Reports by Patient
• Problem List for Patient Charts
• Physician Education
• Follow-up with Monitoring

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Feedback Report Phys Summary
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Feedback Report Member Level
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Problem List
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Education Follow-up

• Post Chart Audit Education Follow Through
• for Physicians - review physician summaries and
  identify potential causes / issues
• for Office Staff
• Problem List Report, by member, includes ALL
  codes
• Review Existing Superbill for Potential Causes
• consider changing superbill to provide a more
  defined set of codes
• consider other support tools / job aids to assist
  in the selection of the proper code in difficult
  or common situations

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Monitoring

• Define Issues
• Design a Monitoring Process
• Incorporate into regular activities not just a
  one-time chart audit and one time follow up
• Identify continued compliance with Best Practices
• Track progress with identified measures
• i.e. Signing ALL Progress notes?, using multiple
  diagnosis codes per claim, using the CORRECT
  diagnosis code at the highest level of
  specificity, evaluating all chronic conditions at
  least annually.