Are You Ready For An Audit?

By: Cheryl “Chae” Dimapasoc, PT, DPT;  OptimisPT Director of Implementation and Compliance

Audits are becoming more frequent within the rehab world.  I started to pay more attention as to what triggers an audit and how to protect myself against one after reading an article by an exceptional PT in the outpatient ortho world, Kevin Hulsey, in the June 2011 edition of Impact Magazine.  The title is “$829,916.00.”  This is the overpayment that Medicare initially required his practice to repay based on an audit.

There are many reasons a practice may be audited.  The majority of audits are triggered by the following circumstances:

  • Excessive (i.e., above the norm) use of the KX modifier, which signals an automatic exception to the therapy cap on the basis of medical necessity;
  • Multiple therapists billing under a single provider number rather than individual enrolled PTs billing separately;
  • Billing a significantly greater-than-average number of codes per date of service compared to the national average;
  • Missing certifications in a patient’s plan of care.
  • Failure to provide adequate PTA supervision;
  • Noncompliance with the 8-minute rule and/or CCI edits;
  • Missing physician signatures;
  • Failure to recertify the plan of care when appropriate;
  • Noncompliance with frequency/duration rules indicated within Local Coverage Determinations (LCD);
  • Insufficient documentation; and
  • Post-denial modification to documentation.

Even if your documentation is in tip-top shape, these billing no-nos could arouse Medicare’s suspicions:

  • Incorrectly billing for services provided by therapy techs or aides;
  • Billing for one-on-one time when, in reality, the patient was participating in group therapy;
  • Billing for co-treatment when co-treatment did not occur;
  • Knowingly submitting claims for services that are normally covered by Medicare when they are “reasonable and necessary” without proving medical necessity in your documentation;
  • Failure to supply records to Medicare when requested;
  • Unbundling (e.g., billing separately for hot packs and dressings) or upcoding (i.e., billing for a more expensive service than the one you actually provided);
  • Failing to execute an advanced beneficiary notice of noncoverage (ABN) before providing non-medically necessary services and instead billing Medicare under the false premise of medical necessity;
  • Billing for a duration or frequency that falls outside the norm for the service in question; and
  • Billing for services not furnished or services furnished by a student.

How should you handle an audit?

  • Take every inquiry you receive seriously.
  • Carefully review the notice you received.  How many charts are needed?  When is the due date?  What is the stated reason for the audit?
  • Immediately begin assembling all the information requested in the audit letter.
  • Never modify the medical records that have been requested in an audit.
  • Thoroughly correct the issues that were raised in the audit, either at the conclusion of the audit or sooner, including instituting any new policies or practices.

Practices should prevent investigations and minimize risk by regularly conducting internal audits and education.  This is the best way to prevent and successfully respond to audits.  We also suggest that companies maintain compliance programs to help mitigate negative audit findings.  In a 2011 issue of Impact Magazine, Laurie Kendall-Ellis, then Executive Director of APTA’s Private Practice Section (PPS) stated that such programs will help you avoid fraudulent activities and reduce your practice’s risk.  Policies are written to guide behavior and although they are powerful tools, policies are most effective when used in the right way and for the right reasons.  A well-defined compliance program could be your organization’s life raft in today’s health environment in the face of the Medicare Recovery Audit Contractors, Zone Program Integrity Contractors, and Medicaid Integrity Contractors audits that are currently in process.

Self-Audits should be performed on a quarterly basis. A self-audit is an examination performed both by and within a given health care practice which generally focuses on reviewing bills and medical records to assess, correct and maintain compliance with applicable coding, billing, and documentation requirements.  The Compliance program should have these self-audits documented in terms of date/time and who participated.  MRNs (Medical Record Numbers) can be used to reference the patient charts being audited.  Some documentation “Do’s and Don’t” you’ll want to review within the audit include:

  • DON’T use “tolerated tx well”, “patient states they are feeling better” or generic statement that tells nothing of how the treatment may be impacting the patient;
  • DO establish and document functional progress as often as possible;
  • DO use the patient’s subjective to drive their objective, to drive their goals, to drive their treatment; this helps ensure it’s patient centered and based on their functional limitations;
  • DON’T copy and paste the same statement from one visit to the next (plan for next visit, assessment, provider interactions); and
  • Do scrutinize your documentation with the same elements that an auditor would use.

If you are an OptimisPT subscriber, Optimis offers “Compliance and Efficiency Reviews” that can be purchased for one therapist or all therapists within your practice.  These reviews follow the format of an audit and help therapists ensure they are meeting compliance standards within their documentation workflows.  They also assist in identifying areas where therapists could be more efficient in their workflow based on the features that are built into OptimisPT, which help therapists create compliant documentation.

During audits of both OptimisPT subscribers and non-subscribers, here are some common items we have found that therapists miss when we review their documentation:

  • If you reference something has been scanned into the chart (e.g., medications, flowsheet, HEP if not using embedded exercises) ensure a process is in place so the item is scanned into the appropriate episode of care.  There should be a check and balance in the clinic.
  • If no PTA co-signature is required, a biweekly case conference should be noted/documented either in the patient’s chart or in clinic notes.
  • Medicare patients being double-booked, but incorrectly billing 60 minutes of direct contact time.
  • Parameters for exercises, modalities or techniques being performed, or specific actions need to be specified in order to justify time being billed and to see change over time as the patient demonstrates progress or lack-thereof.
  • POC (Plan of Care) certification document not being done timely nor tracked properly.
  • Specific elements missing from documentation, including but not limited to:
    • Demonstration of Medical necessity, especially with extended episodes of care
    • Prior level of function
    • Contraindications to treatment (or documentation of “no contraindications” if appropriate)
    • Comorbidities that impact frequency, duration or intensity of the POC 
    • Prognosis
    • Discharges not being completed

Audits can be scary, but they don’t have to be.  Make sure you are utilizing an EMR that has features to help you document toward medical necessity, compliance, and other issues that are heavily looked at during an audit and frequently trigger them in the first place.  OptimisPT does include these features.