ED Coding and Reimbursement Alert

Question: We’re interested in performing a self-audit of our critical care claims but we’ve never done this before. Can you tell us how to get started?

Codify Subscriber

Answer: Your first step is to collect a random sampling of critical care claims from your ED practitioners. You’ll review the chart documentation and determine which code you would report for the service, then check what the physician actually billed. Keep a tally of any discrepancies so you know what to discuss with the doctor later, when you can offer the ED physicians tips on how to select the right code.

Once you perform the self-audit, you may want to create a schedule of internal audits going forward, expanding that out to other codes beyond critical care. How frequently you perform internal audits will depend on the size and type of your ED practice. Consider the amount of resources you can devote to the audit while simultaneously conducting day-to-day business.

Pointer: Remember that the more often you can audit, the cleaner your claims will continue. At a minimum, you should conduct an internal audit at least twice a year, experts advise. After you’ve prepared your staff for the auditing process and determined when you’ll perform an audit, you’ll need to define the focus of the audit. Ask: “What do we want to accomplish?” Then focus on the following points:

Determine the audit’s scope. Which providers, services, date range, and payers will it address?

Determine how to select charts. Will you fix this process for each provider, or will you randomize the chart selection? Pull charts and organize supporting documentation, such as a printout of physician notes, account billing history, CMS forms, and remittance advice.

Final thought: Remember that an audit is much more than coding -- it involves documentation, coding, billing and data input, denials management, and office process following policies and procedures.