How robust audits reduce clinical risks associated with behavioral health 

The clinical risks healthcare provider organizations face grow in number and complexity each year. As organizations work to minimize those risks to patients, robust clinical audits are becoming an essential tool. 

In its most recent annual Top Risks report, Kodiak identified clinical risks as one of the top four risk domains confronting providers. Among the target areas of audits to consider to mitigate risk is behavioral health.  


As noted in our previous article, behavioral health presents a unique set of challenges and risks for providers As mental health diagnoses among patient populations increase, awareness of this clinical risk area has become crucial. Through robust audits, internal auditors can help provider organizations identify deficiencies in key behavioral health risk areas and counter those deficiencies with recommended remedies, preventing any harm to patients. 

 

Covering behavioral health risk areas 

Behavioral health patients are not seen and treated solely in areas specializing in such care, like inpatient psychiatric units, designated receiving facilities, or outpatient therapy offices. Behavioral health patients today can be found across the continuum of care, including in emergency departments and other inpatient units like intensive care and medical-surgical floors. 

Because behavioral health isn’t the focus of care in these departments and staff often lack experience and training in treating these patients, an organization’s risk for poor outcomes and inadequate patient care becomes substantially elevated. 

Some areas for internal auditors to consider conducting behavioral health audits in include:  

• Suicide risk screening 
• Restraint and seclusion use 
• Level of care documentation 
• Coding and billing 

Combining technology and clinical and auditing expertise, and by using full datasets versus small samples, internal auditors can test across entire patient populations. The insights gleaned can provide deeper, more meaningful insights that enhance an organization’s patient safety efforts.  

 

The following case study highlights how an audit on an organization’s behavioral health coding and clinical documentation processes revealed several risk areas and led to key changes that reduced risk of patient harm and helped minimize loss of reimbursement. 

Case study: Spotlight on behavioral health coding audits 

To improve and address gaps in its behavioral health coding and clinical documentation processes, Kodiak worked with a large health system to conduct an audit. Using data analytics and full datasets, the team reviewed 7,000 annual claims among 20 individual providers. 

 

Findings: 

The internal audit team and Kodiak uncovered several root causes of gaps in behavioral health coding and clinical documentation at the health system, including: 

• Inadequate staff and provider training on coding guidelines. 
• Lack of a process for monitoring and validating provider/staff documentation that supported the services that were coded and billed. 
• No policies or procedures for staff and providers to create and follow standardized documentation practices or to outline required documentation. 
• Lack of a formal process for auditing patient charts to validate documentation aligned with Centers for Medicare & Medicaid Services regulatory requirements. 

 

The audit team identified several risk areas resulting from the above process gaps, including: 

• Documentation was missing critical, CMS-required components, such as: 
• Session duration 
• Suicide risk screening 
• Mental status examination 
• Patient symptoms 
• Objective findings 
• There were no standardized documentation practices being used among providers. 
• Inaccurate charge capture of services rendered based on providers’ documentation was occurring, including over-coding (over-billing), under-coding (under-billing), and incorrect CPT code billing. 
• In some cases, the lack of providers’ supporting documentation rendered the code non-billable. 
  
  

Recommended remedies: 

After reviewing the findings, the team outlined several recommended actions to fix issues going forward and close behavioral health risk gaps. The recommended actions included: 

• Submitting corrected claims for the identified variances. 
• Developing policies and standard work documents to outline behavioral health documentation requirements. 
• Developing the standard work for a formal monitoring process to validate documentation quality and make sure there is supporting evidence of the services coded. 
• Educating providers on the new policies and standard work for documentation requirements, including elements that must be included in psychiatric evaluations and progress notes and coding requirements. 
• Performing monthly chart audits for three months for a stratified provider-representative sample of behavioral health patients to monitor and verify that the required elements are documented and validate accurate charge capture and coding. 
• Providing live feedback to staff where documentation is deficient. 
  
  

Results: 

Poor documentation practices can have wide-reaching negative impacts, including poor clinical outcomes and financial loss. After implementing these actions, the health system now has processes in place to avoid improper reimbursement: overbilling, which can lead to audits or fines; and underbilling, which can adversely affect net patient revenues. It also has insights into its risk baselines associated with billing and coding, which the organization can now monitor on an ongoing basis. 

Need help auditing your clinical risks? 

Especially in emerging clinical risk areas like behavioral health, robust audits can help your team stay ahead of risks and minimize their impact. Contact Kodiak’s clinical audit experts today to discuss how we can help you enhance your clinical audits, meet your patient safety goals, and reduce your overall risk.