Auditing facility services using a three-pronged approach

Auditing Facility Services: Changes to evaluation and management (E/M) services in 2021 and 2023 have excited and confused auditors. I am glad that the seemingly trivial criteria required for the level of service (history, testing) are an advantage to confusion when implementing new medical decisions (MDM)  in a balanced environment. In early 2021, AAPC Services first introduced three methods to help supervisors think less clinically about office visit services (see “Train Your Supervisors to Think Clinically,” May 2023,). Now that the E/M Services Reform Act of 2023 is in effect, we are revising our approach to focus on hospitals, skilled nursing facilities (SNFs), emergency departments (EDs), and the remaining E/M services.

Ensure comprehensive Auditing facility service with this improved three-step method:

  1. Understand the patient

Auditing Facility Services:  People do change. There is no ‘one size fits all’ when it comes to patient care. Therefore, it is important to note that an elderly patient with multiple urinary tract infection (UTI) symptoms is more severe than a healthy 25-year-old woman presenting with a urinary tract infection.

 When you recognize danger, consider the following:

  1. Age: Is the patient a baby, teenager, or adult? Age factors in MDM risk factors. For example, an adult with a fracture has a lower risk than a newborn baby with the same condition.
  2. Reason for visit: Call complaints only. The History of Modern Diseases (HPI) tells the full story. How long did the break last? Where is he? Some areas are more difficult to access than others or may interfere with treatment if there is nerve damage.
  3. History: Patient, family, and personal history (PFSH) also have a significant impact on MDM. Is the patient taking medications such as anticoagulants that may cause increased bleeding during fracture healing? Are there any diseases that fractures can cause? The risk of infection is higher if the patient has been vaccinated and is taking immunosuppressive medications. Although it is no longer considered a standard E/M office visit, you now understand why reviewing the history section is still important. Every patient is different, and knowing everything can help you determine the level of risk. Now let’s move on to the question.
  1. Understanding the problem

Auditing Facility Services: Just as no two patients are the same, so each patient’s problems change, develop, and manifest differently. If you are stuck in a confusing situation to determine the risk, use the following tactics:

  1. Problem Management: How serious is this problem? Severity is easier to assess in some cases than in others. For example, cancer patients are generally at higher risk than fracture patients. Other diseases are unknown or may be chronic, severe, or mild. If you don’t know much about the disease, use other trusted sources to get the information you need to understand your risk.
  2. Severity: We teach providers to describe in general terms how serious the patient’s problem is. Some auditors may not know that a patient with a blood pressure of 180/120 is in a hypertensive crisis. The word “problem” indicates high risk. However, without knowing this, the auditor may assume that it is a moderate risk. Look for clues in the document to show how serious the problem is.
  3. Chronic conditions and combinations: As mentioned earlier, some diseases may affect the current complaint, while others may not. It is important to know if the doctor is referring to the disease or related medications or if they indicate that the disease is under control. Caution is essential, as the mere mention of a problem does not necessarily mean that it directly affects the primary complaint. (Hint: See the CPT® definition of terms such as problem, resolved problem, and  chronic disease, etc.), however, these terms should be considered when determining risk.

A common example is the patient presenting to the emergency department with chest pain. The first concern is a heart attack (MI), which can be a serious, life-threatening illness. After several tests to rule out MI, the patient is diagnosed with gastroesophageal reflux disease (GERD), a chronic condition that can be mild or severe. This should not automatically be relegated to moderate risk based on a GERD diagnosis alone. However, the provider considered MI, so we must use this differential diagnosis to measure service.

3. Know the risks

Auditing Facility Services: Our last step is to know the risks of the disease itself. This is likely to require research by the auditor as they begin their clinical audit journey or as they begin auditing a new specialty. An auditor specializing in neonatal intensive care services knows, for example, the risks of premature babies.

  1. Risks: What are the risks of treating or not treating the patient? A patient presents to the emergency department with symptoms of stroke. The patient is examined, but no treatment is recommended due to the resuscitation order or other reasons. In this situation, the risk is greater than in an otherwise healthy patient suffering from a transient ischemic attack.
  2. Drugs that can be purchased from other chronic drugs: auditors cannot easily identify drugs that interact with others. Look for instructions in the provider’s documentation, such as: The patient is given [medication] once daily and instructed to take the insulin separately; or the patient was informed about the use of antibiotics in contraceptive pills.
  3. Risk of complications from other complications: Surgical procedures are common in hospital settings. What conditions does the patient have that make the surgery more risky than usual? Remember that these are external risks: Infection, nerve damage, and delayed healing are inherent risks in any surgical procedure and should not make the operation high risk. Look for signs that a specialist consultation is necessary before surgery. If a patient with chronic heart failure requires surgery and consults a cardiologist, the risk level is high rather than moderate.
  4. Social Conditions Affecting Risk: This requires us to review the patient’s social history and the provider’s assessment notes and plan. Is the patient experiencing homelessness? A homeless patient with any illness or injury may not seek care at all unless it is severe. They are unlikely to return to their following. In addition, a patient with a tobacco, alcohol, or drug problem will now be more dangerous than clean and sober. If they are unemployed, they may not be able to pay for their prescriptions.

A thorough understanding of patient concerns is critical to determining the appropriate level of service. It is essential to educate healthcare providers about the importance of clear documentation to ensure quality patient care and accurate reimbursement for services rendered. Additionally, keeping up with changes is our responsibility to adapt to the dynamic healthcare environment. In this ever-changing environment, awareness is the key to success, especially when new information presents new challenges. Implementing auditing facility services further enhances our ability to maintain quality standards and adapt to evolving requirements.

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