CPCs Branch Out into Medical Auditing

Coding crossroads to health care’s future leave auditors in high demand.

By Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, COBGC, CPCD, CCS-P

Well over 20 years ago documentation was generated by the provider only as an information source for patient care. The information was housed in the patient’s chart and kept in a file and only the physician and staff looked at the record. Now, with providers under heavy scrutiny by payers and government carriers, documentation has become important not only for medico-legal reasons but to support charges submitted for payment to the carrier. Medical malpractice claims have soared and the medical record serves as a legal document incorporating information about the patient’s condition, care, and other important data from a clinical perspective. For the payer, the medical record supports the services billed to them and is used to defend malpractice claims as well as defend insurance fraud and abuse.

Certified Professional Medical Auditor

The Coding Profession Evolves

From 2007 to 2008 there was an 18.7 percent increase in physician practices adopting an electronic medical record (EMR)/electronic health record (EHR) system. Now with the stimulus package, even more physicians are adopting the EHR (Blumenthal D., “Stimulating the Adoption of Health Information Technology,”). More money is being allocated by the federal government to fight health care fraud and abuse, as well. This means with the intensity of insurance carrier audits, and government programs like Recovery Audit Contractors (RACs), Medicaid Integrity Programs (MIPs), and Medicaid Integrity Contractors (MICs), etc., audit-ing has become an important piece of coding compliance. The new health care reform incorporates mandatory compliance, which also makes auditing even more important because coders, physicians, and other health care professionals must comply with government regulations.

Although balancing reimbursement challenges, productivity, and accuracy is difficult, coders must strive to maintain com-pliance as the government and all carriers are watching. The only way to determine whether coding is appropriate is to compare the clinical documentation in the chart to what was billed on the claim.

Auditing for the Electronic Age

In the next few years, the face of coding will change. With the increasing number of physicians moving to EHRs and with the current capabilities of computer assisted coding (CAC), the role of the coder might change to the role of an auditor, which includes reviewing documentation to ensure the computer selected the appropriate code. A computer cannot assess medical necessity nor can it understand medical policy. Coders will be needed to review the documentation to ensure coding com-pliance.

A medical coding audit can reveal whether a variation from the national average is due to inappropriate coding, insufficient documentation, or lost revenue. Coding audits can help identify problem areas that need correction before insurance or gov-ernment payers challenge inappropriate coding.

With the costs associated with medical care and insurance escalating at an alarming rate, each year, billions of dollars are paid unnecessarily. The challenge we have is to train coders to take the next step into medical auditing. There is a shortage of good coding auditors in the industry and as we move into the electronic age in health care the demand will reach a critical state. Now is the time to think about how you can move your career forward to the next level.

Crossover into Auditing

Have you been coding for years and feel you need a change or to stretch your wings and learn more?

Some say coding and auditing are the same. This isn’t true: Auditing is the process of analyzing the medical record with puzzle pieces you must put together. When auditing a medical record post-payment, you review the documentation and the services reported on the claim, what was reimbursed, and medical necessity. Good coders make good auditors. Medical coding auditors are like detectives, trying to find the missing link and researching to fill in pieces of the puzzle. If you enjoy investigative work, this career path is a great option for you.

Auditing Is More Than E/M

Most people think of evaluation and management (E/M) services when they think of auditing coding. A well-rounded medical auditor audits more than E/M services. It’s true, most providers will evaluate patients and provide E/M services; however, auditing is so much more. If you work in a surgeon’s practice or a physical therapy practice, or for an ambulance service or a radiologist, you will not report a significant amount of E/M services. For example, a radiologist focuses on interventional procedures and diagnostic tests.

If you want to move your career forward into medical auditing, make sure to learn about all aspects of auditing, which include:

  • E/M
  • Surgical procedures
  • Radiology services
  • Therapy services
  • Mental health services
  • Ancillary services
  • Accounts receivable

What Should a Medical Coding Auditor Know?

Simply, the medical coding auditor should understand fully:

  • The structure and documentation principles of the medical record
  • How to assess medical necessity
  • Medical coding rules and concepts
  • Compliance
  • What insurance carriers are looking for
  • How to investigate and research
  • Insurance and government carrier policies
  • Corporate integrity and requirements as an independent review organization (IRO)
  • Adherence to protected health information (PHI)
  • National Correct Coding Initiative (CCI) and bundled services
  • Comprehensive Error Rate Testing (CERT) Program, RACs, MICs, MIPs, etc.
  • Fraud and abuse, self disclosure, stark, Joint Commission on Accreditation of Healthcare Or-ganizations (JCAHO), and more

This is an abbreviated list showing that medical auditing is not just about reviewing medical records for appropriate coding and documentation—it’s about understanding all the regulations associated with coding and billing.

What Does an Auditor Do?

Medical coding auditors examine coding patterns to evaluate how health care providers use coding to bill insurance companies. A medical coding auditor makes sure their physicians, non-physician practitioners (NPPs), fellow coders, and other medical staff are using the appropriate coding to maintain compliance. They evaluate whether providers are complying with local, state, and federal regulations and adhering to internal coding standards so the health care provider is billing the correct amounts. Medical coding auditors may work closely with and prepare reports for health care providers or his or her management team to provide information to help set their compliance and financial goals.

A similar job is the coder/revenue analyst. Because it requires examining of accounts payable and receivable and a background in coding, it’s ideal for business minded individuals. The coder/revenue analyst examines coding data and identifies problem areas that could cause a loss of revenue for a health care provider. He or she helps develop solutions to stop revenue loss while a medical auditor or consultant is engaged reviewing the accounts payable and/or receivable to identify errors, lost revenue, and ensure compliance.

Where Do You Begin?

Coders who seek an auditing position should be experienced in medical coding and hold coding certification. If you are a certified coder with at least five years of coding “in the trenches” experience, consider auditing. Most auditing positions require five years of hands-on coding experience.

It’s helpful to attend seminars, workshops, conference, and even an auditing class. You cannot learn to audit in a couple of days; however, for the seasoned coder, a two- or three-day course might be a good start. It does take a few years to sharpen your skills and become a seasoned auditor. Taking a three- to six-month auditing course will help a well-vetted coder to the next level. Once you have taken a course and learned how to audit, you are ready become certified. AAPC offers the Certified Professional Medical Auditor coding credential (CPMA™), which will help you to a new position, or strengthen your day-to-day work at your current organization.

With motivation, leadership skills, and credentials, an experienced medical coder can move up to a medical coding auditor and bring in an excellent income. While employers sometimes look for candidates with a degree, many employers value equivalent experience in the field. If this career path is something you have considered, visit AAPC’s website at www.aapc.com and learn how you can prepare to become a medical coding auditor and earn your CPMA™. Good luck!

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