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Build Revenue with Surgical Chart Auditing

By Charla Prillaman, CPC, CPMC, CPC-I, CCC, CEMC, CHCO

The number and scope of external auditing agencies pursuing improper payments are increasing significantly, making medical record auditing more important than ever. If you think your practice is exempt, consider this: The “Improper Medicare Fee-For-Service Payments Report: November 2009,” revealed that 7.8 percent of Medicare dollars paid did not comply with one or more Medicare coverage, coding, billing, or payment rules. That is approximately one out of every 12 dollars paid was in error.
To ensure accurate surgical coding—not to mention, peace of mind in the event an outside audit occurs—your practice’s quality protocol should include regularly scheduled proactive reviews of all code selections.
In a surgical practice, an essential part of your auditing efforts should include checking the accuracy of evaluation and management (E/M) levels and reviewing surgical services charts. These are critical steps to ensure CPT® codes submitted for adjudication accurately represent the services your physician provided. You also should be on the lookout for erroneously selected CPT® codes, missed charges, missing or inaccurate modifier selections, and/or inaccurate ICD-9-CM diagnosis code selections.

Catch Overlooked Surgery Details

Something else to look for during an internal audit is operative note headings that inadequately or incompletely describe rendered services. The heading might indicate, for example, “colonoscopy with polypectomy.” 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.
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.
When an audit reveals miscoding, formulate steps to improve coding and capture all appropriate revenue.

Uncover Internal Weaknesses

Routine auditing demonstrates how well you apply complex coding principles and payer policies to your specialty. You may find documentation weakness that (if uncorrected) could lead to allegations of wrongdoing or misunderstanding that is a source of lost revenue. An audit also can uncover billing area weaknesses that could result in claims denials.

Get Expertise From Surgical Auditors

Auditing in the surgical practice setting requires skills beyond the foundational ability to identify and assign correct CPT® and ICD-9 CM codes for the services provided. The surgical specialty auditor also must remain up-to-date in other areas, including:

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

When your audit is completed and you have analyzed the impact of any issues, you can strengthen any documentation weaknesses, mend any holes in the claims management process, and rest easy knowing your coding is accurate.
To assist you with surgical chart audits, AAPC will be offering an Advanced Surgical Chart Auditing workshop in March. For details, visit
Charla Prillaman, CPC, CPMC, CPC-I, CCC, CEMC, CHCO, has more than 25 years of health care experience, including seven years as a director for physician compliance for a health care system employing more than 1,500 providers. She also has worked as a consultant. She has been a CPC® since 1997. She was named AAPC Coder of the Year for 2000, and is one of the original members of the AAPCCA board of directors.

Evaluation and Management – CEMC

Medical coding books

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