Self-Audits Are Worth the Effort
by Peggy Stilley, CPC, CPC-I, COBGC
Conducting a baseline audit of your practice—and taking proactive action to correct and prevent coding, billing, and other compliance shortfalls—does require a considerable effort. But however painful that process may be, it almost certainly will be less stressful and costly than finding yourself under the microscope of a payer audit, unprepared and unsure of what the audit may turn up.
Peace of mind has tremendous value. Audits verify that the provider’s documentation meets applicable guidelines, and that he or she is reporting the appropriate level of service for services provided. When a provider understands E/M documentation guidelines and practices compliant documentation there will be less risk for error and concern.
Audits look for a medical record to be complete and compliant for patient care. If the standards of care are not documented, it could leave the practice vulnerable. To ensure the records are complete and compliant, determine:
- Did the patient sign all the necessary forms and consents?
- Did the physician document risks and benefits of recommended treatments?
- Did the service need an order?
- Is the procedure note adequately documented?
- Did the physician sign the record?
- Did the patient sign an ABN (advanced beneficiary notice)?
Auditing may uncover services billed but not documented in the patient record. Documentation that lacks pertinent information and is inadequate for services billed is indefensible. On the positive side, comparing documentation in the medical record to the billing ticket could identify services performed that weren’t charged; avoiding lost revenue.
Whatever issues are identified, you’ll want to educate providers and staff, and to develop protocols to prevent future errors. This is far more productive than sitting back, waiting for a payer audit to result in mandatory action.