Capture Revenue and Stay Safe with Surgical Chart Audits

To help ensure accurate surgical coding and provide peace of mind if an outside audit occurs, you should regularly perform internal reviews of surgical code selection. The goal of an internal audit is to strengthen documentation weaknesses and mend holes in claims management to help you capture all revenue.

Know What to Look For

Evaluation and Management – CEMC

According to Charla Prillaman, CPC, CPMC, CPC-I, CCC, CEMC, CPCO, an essential part of audit efforts in a surgical practice should include:

  • Checking the accuracy of evaluation and management (E/M) levels and reviewing surgical services charts.
  • Looking for erroneously selected CPT® codes, missing charges, missing or inaccurate modifier selections.
  • Reviewing inaccurate ICD-9-CM diagnosis code selections.

Apply Complex Coding Principles and Payer Policies

Surgical services auditing has unique coding guidelines and rules to follow. When auditing, Prillaman says to pay close attention to:

  • Surgical global package concept
  • Correct modifier application
  • Payer policy
  • Screening vs. diagnostic vs. therapeutic procedures
  • Place of service (POS) reporting
  • National Correct Coding Initiative (NCCI) edits
  • E/M services provided during the global period
  • Complex rules surrounding services furnished by mid-level providers

Dissect the Op Report

When reviewing op reports, be sure to catch overlooked surgery details such as headings that inadequately or incompletely describe rendered services. An example of an incomplete heading, according to Prillaman, is “colonoscopy with polypectomy.” She said, “Selecting a code from just the heading might lead to a claim submission of 45384 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery. The detailed description in the body of the operative report, however, may reveal the surgeon removed two polyps using hot biopsy forceps, and removal of a separate polyp by snare.”

Prillaman continued, “A qualified auditor will recognize that an additional procedure (45385 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique) should be reported, with modifier 59 Distinct procedural service appended because the National Correct Coding Initiative (NCCI) indicates this code pair usually is ‘mutually exclusive.’ As a result, reimbursement may increase nearly $500 per case where this type of error has occurred.”

Take Coding Issues Seriously

When an audit reveals miscoding, formulate steps to improve coding and weaknesses. Don’t be afraid to call in the expertise of a surgical specialty auditor to help you with the audits and come up with a plan of attack. Proper audits will reduce claim denials and lost revenue and boost your billing confidence and your practice’s bottom line.


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