Internal Medicine Coding Alert

Published on Wed Dec 01, 1999 PDF

Question: What does special random audit
by Medicare mean? Is it a serious problem? Is it even
a problem?

Anonymous Texas Subscriber

Answer: Although that particular term is not familiar, it is probably no reason to panic, says Stephenson. There are a number of reasonsother than suspected fraud or abusethat a practice may be asked to submit records for review or be audited by Medicare.

What happens is certain codes are focused upon from
time to time and if your practice provides services with
the codes in question, it is possible that you may be asked
to submit medical records for review, he notes. These
are random in that it doesnt necessarily mean that just
because you provide the services youre going to get
audited. And it doesnt mean youve done anything
wrong if you are audited, he says. That is a huge
misconception about audits in general.

Sometimes, a beneficiary complaint may trigger
audits against another provider in your vicinity, and
you may be audited as a comparison to that provider,
he adds.

Other times, Medicare may notice certain trends in
your billing that dont fall within the regional average of
code usage. This may prompt a request for review, but
doesnt mean youre under the gun unless your billing
isnt justified in the records.

A Medicare audit is never a problem unless you
arent following the guidelines consistently, he
emphasizes. People assume that because Medicare
requests an audit that they are done for. But in reality,
the carriers have to make sure that practices are
being compliant.

These types of audits are usually simple and may
require only 10 to 12 records.

Ive never heard of an audit referred to the way the question phrases it, however, he notes. I would say not to worry unless, of course, there are billing practices being done outside the guidelines. If thats the case, then there will be a lot more involved than just a handful of records getting reviewed.

An in-office compliance plan can save many headaches because it provides an organized method to ensure that your coding and billing are monitored for correctness, and because it shows that you are making an effort to go by the book, Stephenson advises. This can open the door for leniency in case things dont go well in an audit. (See related article on physician compliance guide in enclosed insert.)