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Course Overview

Many physician practices, including independent practices, physician practice groups, and freestanding clinics owned by facilities, lack a medical documentation expert who is able to review and audit claims to ensure accuracy and compliance. This course will take participants through the entire audit process, from learning about what coding and billing elements are reported through how to interpret and respond to audits.

By learning about the latest regulations and coverage guidance, physician offices will reduce vulnerability to Medicare contractor audits (e.g., UPIC, SMRC, RAC/RA). Over the course of three-and-a-half days, this boot camp will delve into coding and other documentation issues unique to professional services – including appropriate application of modifiers, accurate E/M reporting, and the impact of value-based payment programs.

You will leave this program knowing how to:

Identify the coding systems and source authorities used for reporting and guidance in professional services

Explain the role of federal auditing bodies, regulations, and penalties associated with fraud

Accurately assign evaluation and management (E/M) codes, including modifiers

Perform successful professional services audits

Identify how to implement a corrective action plan

Who should attend?

• Physician practice billers and auditors
• Payer staff
• Consultants
• Physician practice managers and administrators
• Physician practice office or billing managers
• Physician practice revenue integrity professionals

See the HCPro difference for yourself!

Focus on the rules: Learn how to find and apply Medicare rules and guidelines that apply to professional services to help ensure accurate and appropriate billing.

Tools and skills to navigate Medicare rules: Our instructors provide valuable tools and resources that will help you prioritize and research questions long after the Boot Camp ends.

Hands-on learning: Attendees work a set of exercises/case studies after each module to ensure they understand the concepts and know how to apply them to real-world situations.

Small class size: A low participant-to-teacher ratio is guaranteed.

Highly rated, well-established program: Participants consistently give HCPro Boot Camps an overall rating of 4.75 or higher (on a 5.0 scale).

Learning Objectives

At the conclusion of this educational activity, participants will be able to:

Demonstrate an understanding of professional service auditing, its purpose and types of audits performed.

Locate and utilize source authorities required for professional medical record auditing.

Demonstrate an understanding of available medical record audit certifications available.

Articulate the role of the auditor.

Outline/Agenda

Module 1 – Overview of Professional Services Auditing and ICD-10-CM, CPT, and HCPCS Coding Concepts

Demonstrate an understanding of professional service auditing, its purpose and types of audits performed

Be able to identify the coding systems applicable to professional medical record audits

Be able to locate and utilize source authorities required for professional medical record auditing

Demonstrate an understanding of available medical record audit certifications available

Be able to articulate the role of the auditor

Module 2 – Documentation Guidelines and Medical Records

Demonstrate an understanding of HIPAA Overview and Privacy Rule

Be able to understand the medical record as a legal documentation

Be able to identify the necessary components of medical record documentation

Be able to identify documents and forms of the medical record: Registration, Benefit Assignment, Privacy Notice Receipt, Release of Information, Advanced Beneficiary Notices, Notice of Non-coverage, and Consent

Be able to demonstrate an understanding of the documentation requirements of operative reports, diagnostic testing and laboratory reports

Be able to abstract, audit, and verify the medical record based on type of service

Be able to correctly interpret teaching physician guidelines and demonstrate an understanding of documentation requirements

Module 3 – Evaluation and Management Categories

Be able to identify the categories of E/M codes

Be able to apply the CPT E/M category guidelines

Be able to define the common symbols and terms used in the CPT book

Be able to accurately assign Evaluation and Management codes by category

Be able to accurately assign appropriate E/M modifiers

Module 4 – Evaluation and Management Level Assignment

Be able to identify history of present illness (HPI) terms and definitions

Be able to identify terms in documentation and assign them to the HPI

Be able to understand and apply the HPI documentation guidelines

Be able to identify the review of systems (ROS)

Be able to understand and apply the review of system documentation guidelines

Be able to identify past personal, family, social, history (PFSH)

Be able to identify terms in the documentation and assign them to the PFSH

Be able to assign the overall history using the history elements

Be able to identify organ system and body areas of the examination

Be able to understand and apply the examination guidelines appropriately

Be able to understand and apply the medical decision making elements

Be able to assign Evaluation and Management codes by level

Be able to apply E/M knowledge and effectively utilize E/M tools

Module 5 – Elements of Surgical and Other Professional Services

Be able to apply correct coding for surgical, radiology, pathology, and medicine services

Be able to correctly append surgical service modifiers

Be able to correctly assign CPT and HCPCS Level II modifiers

Be able to identify a “Separate Procedure” and when they are reported

Understand the auditor’s role in determining medical necessity

Identify National and Local Coverage Determinations

Module 6 – National Correct Coding Edit Initiative (NCCI)

Be able to present an understanding of NCCI and MUE edits

Be able to access NCCI files and NCCI policy manual

Demonstrate an understanding of PTP, MUE and Add-on Code Edits files

Identify NCCI associated modifiers

Be able to apply NCCI edits accurately to ensure correct coding

Module 7 – The Audit Process

Be able to demonstrate an understanding of types of audits

Be able to identity audit process and associated steps

Demonstrate an understanding of audit sampling: random, focused, and statistically valid

Be able to identify audit type based on audit focus

Be able to demonstrate an understanding of coding vs. payer guidance

Be able to understand the importance of E/M bell curve profiling and how to use the information as a guide for audit and compliance

Be able to demonstrate and understanding of implementation of audit findings

Be able to identify components of a corrective action plans

Be able to identify self-disclose audits and demonstrate and understanding

Demonstrate and understanding of Corporate Integrity Agreements and the role of Independent Review Organizations

Module 8 – Regulations, Statutes, and Compliance

Demonstrate an understanding of the following Federal regulations: False Claims Act (FCA), Anti-Kickback Statute (AKS), Physician Self-Referral Law (Stark Law), Civil Monetary Penalties Law, Exclusion Statute

Be able to identify the Civil Monetary Penalties associated with specific violations and entities

Be able to understand the role and function of the Office of the Inspector General

Demonstrate and understanding of the Office of Inspector General’s Compliance Plans

Demonstrate an understanding of the Centers for Medicare and Medicaid Services program oversight

Be able to understand the role and function of the CMS Recovery Audit Program

Course outline/Agenda subject to change.

Speaker

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