Audit to Promote Compliant Profit

By Deborah Grider, CPC, CPC-I, CPC-H, CPC-P, CPMA, CEMC, COBGC, CPDC, CCS-P, Vice President of Strategic Development, AAPC

Correct coding is critical to getting paid for medical services and for avoiding external audits by Medicare and other payers. Because medical coding is the main source of physician office and facility income, poor documentation, undercoding, and coding mistakes can be dangerous financially and legally. Undercoding can lead to decreased revenue, and wrong code choices with poor audit trails increase your liability and signal red flags to payers that an investigational audit may be necessary.

To determine whether a code is being appropriately chosen, it needs to be compared against the clinical documentation recorded in the chart through audits.

You can help your practice by conducting internal audits. With self-auditing there are pitfalls you can dodge and ways you can realize maximum benefits. This list of “Dos and Don’ts” will help you conduct a successful self-audit in your medical organization:

Don’t Audit Your Own Charts

An unbiased view of the medical record is the best way to achieve effective auditing results. The physician whose ink is on the chart is not the person you want auditing the documentation. Choose someone who is unfamiliar with the physician’s handwriting and work practices, but is knowledgeable in medical terminology, coding rules, and who can fill out an audit worksheet.

Don’t Pull Random Charts

Pulling medical charts randomly from racks won’t help you observe trends in medical coding during a specific period of time. Instead, ask a staff member to make a list of patients during a week’s period. Set a number of charts to pull from that list. For example, pull every fourth chart until you’ve reached 10 charts.

Do Follow the Same Rules as Insurance Auditors

When conducting an audit, use the same rules as Medicare and private insurers would. For instance, when auditing evaluation and management (E/M) documentation, choose guidance from the 1995 Documentation Guidelines for Evaluation and Management Services or 1997 Documentation Guidelines for Evaluation and Management Services. Assemble reference materials such as current coding manuals, National Correct Coding Initiative (NCCI) edits, and the Center for Medicare & Medicaid Services (CMS) policies or commercial payer policies.

Do Make Audits Educational and Congenial

With compliance as the audit’s goal, teamwork is essential. When errors are discovered in documentation or coding, take it as an opportunity to encourage improvement, not to demand it. Creating a non-threatening forum for open discussion is the key to improving chart audit results. Trying to correct miscoding in a scolding manner leads to offensive and defensive behavior—which potentially are more harmful to a practice than coding errors.

Do Fix Errors Systematically

Once existing weakness are identified, establish a system that includes written reports or findings, summary reports, and audit spreadsheets. These can include analysis and trends of identified coding errors broken down by coder and provider. Having hard data to refer to can show you areas that have improved or that will need continual improvement. Keeping a systematic commitment to compliance will continually grow practice revenue.

To find out more about AAPC’s Audit Services Division, e-mail audits@aapc.com or visit http://www.aapc.com/medical-audit/.

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