medical record auditing for medical necessity

Posted and filed under Medical Record Auditing.

A little background, one of areas where Advize provides consulting services is in the medical record review space.  We have been providing this service to clients for over 20 years, both proactively, and reactively. Our CEO, Jeanmarie Loria, was actually a part of the development of the medical record review platform used by the Medicare contractors for these reviews, and I, the Director of Litigation, FWA, Eric Rubenstein, was part of the process improvement team for that same system (Unified Case Management, or UCM). 

From a proactive perspective, it is important to consider the OIG’s Model Compliance Guidance, which includes self-audits. Naturally we take that guidance very seriously, as being a retired HHS-OIG Special Agent, I understand that from an FWA and compliance perspective, proactive analysis can pinpoint coding and documentation issues and weaknesses and afford a provider the opportunity to make corrections quickly.

By doing the proactive self-audits on a regular cadence, issues can be addressed early and quickly, and result in the provider remaining in the “driver seat,” so to speak.  I can tell you first hand that if providers had taken on this approach, some of the waste and abuse related cases I oversaw while I was with the OIG may have never even come to fruition. 

Reactively, we work to facilitate an understanding of UPIC and commercial audits that are being conducted. Whether it be a “second set of eyes” to make an independent assessment of the records under review, seeking to facilitate appeals for a provider, or other requests that a provider is seeking to gain a better understanding of, tackling these reviews is an important step in compliance.

As part of any quality documentation audit, it is a combination of reviewing the documentation to the codes submitted for payment, as well as the medical necessity for that service, as it relates to the documentation. Often, we find ourselves counseling providers that the documentation has to meet the requirements of the code. In discussions with providers, we are also often told that the provider is documenting to the treatment, but that can still lead to a failure to code to the documentation. It is a “360 degree” view; document to the treatment, and code to the documentation.  Failure in one area, will likely lead to an audit issue.

We have had many conversations with individuals with respect to medical necessity, and how medical necessity is strictly a “clinical determination”. In these discussions, people have argued that only a clinician should be making that assessment, and that it is outside of an auditor’s responsibility or capability to opine on such areas. 

We have always taken the stance that medical necessity is a salient part of the audit. Medical necessity is not always about the service itself, but the documentation that justified the service. 

My two favorite examples are the patient who goes to the provider for a sore throat, and receives an EKG, and the patient who goes in for that same sore throat and a high level office visit (E/M 99214 or 99215, for example) are billed.  In the first example, the sore throat documentation would clearly show that the medical necessity for the EKG was absent (even if the EKG itself was well documented), thus making it part of the documentation audit.  An auditor need not be a healthcare provider to be able to make that assessment.  In the other instance, it may not be that the office visit was not medically necessary, but that the level of service billed was not medically necessary. 

The Center for Medicare and Medicaid Services (CMS) has provided some clear guidance on the topic, and has been echoed by the Healthcare Compliance Association (HCCA).

According to the CMS Claims Processing Manual, medical necessity is “the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported.

It is not that the provider rendered a service that was not necessary for the evaluation and management of the patient, but that the documentation failed to demonstrate the medical necessity for the level of service that was billed. While we agree that there may be clinical considerations as part of the type of treatment of service provided, it is also standard practice as part of a quality audit to review the entirety of the document in front of an auditor. 

At Advize we often prefer to use the term “auditor” opposed to “coder,” as an auditor is truly looking at that 360 degree view of the record, and not just a snippet. We can confirm, when a UPIC or a payor is conducting an audit, that audit will be for every word on every page provided, and not necessarily with a myopic view. 

In any FWA matter, investigators will always seek to gain an understanding of everything that is available to understand the potential overpayment, loss amount or scheme being investigated. 

By: Eric Rubenstein