The best defense is a good offense. When it comes to preparing for RAC audits, a proactive approach will pay off in the long run. The worst time to respond to a records request from a Recovery Audit Contractor is after the request is received. By planning ahead and utilizing in-depth and regularly scheduled internal audits by coding and billing professionals, a medical practice can respond to a RAC request, comfortable that the outcome will be in the practice’s favor.
By using the reports available in state-of-the-art Practice Management software, a medical practice can identify billing patterns of specific CPT, HCPCS, and ICD-9-CM codes. The RAC contractors regularly publish what issues they plan on monitoring. Identifying these and investigating a practice’s utilization of these code sets is the first step in setting pre-audit parameters. If a practice provides and bills for the services targeted by their region’s RAC, the practice should review its records for appropriate supporting documentation.
Certified and credentialed professional medical billers and coders are involved in the business of compliance with Medicare regulations and coverage determinations, both National Coverage Determinations (NCDs), and Local Coverage Determinations (LCDs). Based on their professional understanding of the documentation requirements dictated to justify billing for medical services, coders and billers review available documentation to assess how the record compares to the bills, and to the standards CMS has published for accurate reimbursement.
A physician can look at a patient’s record and say, “Of course this helped the patient.” While no one is arguing with a physician’s determination, RAC auditors are required to measure the data in the medical record against the guidelines that CMS and its intermediaries have determined as medically necessary. In a RAC audit, which is performed by professional medical auditors who are also credentialed and qualified coders, the documentation must meet established criteria. As every physician knows, if something is not documented, it did not happen.
By performing regularly scheduled pre-RAC audits, a medical practice can be comfortable that it is assigning codes appropriately and billing for provided services in a way that complies to CMS reporting standards.
If a practice bills for services identified by a RAC as being of interest, the first step a practice must take is to audit its charts associated with claims already billed to Medicare. These post-payment (but pre-RAC) internal audits establish a baseline of documentation practices currently in place in the practice. By comparing the contents of individual medical records to the guidance provided in NCDs and LCDs, a practice can then make changes in current documentation standards to guarantee that medical bills are justified in the eyes of CMS.
Sound internal compliance protocols are not brain surgery, but they do require patience and attention to detail. Read with an auditor’s perspective, rather than a provider’s perspective, gaps in documentation are often revealed in the medical record. Ideally, each entry in a patient’s chart should stand alone to justify provided services. This eliminates the need for costly and time-consuming appeals when a finding is against the provider’s interest. Appeals require gathering and submitting supplementary documentation outside the original request to substantiate an individual date of service.
Findings revealed in pre-RAC audits can increase future compliance as documentation standards are tightened and providers document the necessary information at the time of service. They reduce the need for addenda, and for combing through past or concurrent record entries to find relevant evidence that a procedure or service was medically necessary.
EHR and PM software provide valuable tools for practice managers looking to respond to a RAC audit without worries of whether their coding and billing practices are compliant with industry standards. Auditing past documentation with the goal of improving future documentation is the best practice when dealing with the increasingly complex regulatory environment in which healthcare providers are reimbursed for their services.