Medicare Compliance & Reimbursement

Make sure you’re comparing apples to apples when calculating accuracy.

Communicating the findings of an audit to providers can feel overwhelming, but couching the good, bad, and ugly in terms of opportunities rather than mistakes can help everyone work together to make corrections. Grounding your findings in outside references, like relevant regulations and calculated accuracy percentages, strengthens credibility.

Pam Warren, MHA, COC, CPC, shared her best tips for organizing and delivering audit results during her 2025 HEALTHCON presentation “Delivering Audit Results: How to Say What Needs to be Said.”

Ground Your Findings With References

“When I do convey my findings, I name the issue. I provide the regulatory reference. I illustrate and qualify and quantify the finding,” she said. This can be done via citing the findings and providing an accuracy percentage for each element audited.

Warren recalled an audit where her team looked at informed consent being documented in the patient chart. “We provided cataract surgery to a patient or a number of patients, and we didn’t get consent to do that, or, if we did, it never made it into the chart. So, somebody screwed up somewhere, and I’m not going to say it that way, but that’s essentially what happened.”

This kind of situation is an opportunity to tie your finding to a reference, like the code of federal regulations for meeting Medicare requirements or the conditions of participation.

“It says you must have a properly executed informed consent form for the operation in the patient chart before you roll the wheels into the OR [operating room] unless there’s an emergency,” she said.

When she looked at the charts for this situation, she realized that 24 out of 50 accounts reviewed were missing or involved invalid informed consent, which is a 52 percent accuracy rate.

Calculate Accuracy for Maximum Impact

When you’re calculating the accuracy rate for your finding, it’s crucial to compare apples to apples, Warren said. “In your finding, make sure that you’re looking at one particular mistake or one particular issue, and only count the mistakes for that particular issue.” With the informed consent situation, it’s easy to review a chart for that one variable, but looking at accuracy of code selections can be a lot more complicated.

With CPT^® codes, for example, you’ll have to calculate how many correct codes could possibly be reported and how many were incorrect. The same goes for diagnosis codes, especially in the professional fee and facility spheres, where multiple diagnosis codes are usually at play.

Finally, for local coverage determinations (LCDs) or national coverage determinations (NCDs), which usually want to see conservative care offered before bigger, more expensive care, you can organize the variables by categories like conservative care, lab values, and medication, Warren suggested. Your team can then audit for each of the elements and determine whether the service was provided, and then calculate the accuracy across each element.

Don’t forget the nitty-gritty details in your own “documentation.” “Sometimes, when we report findings in an executive summary, we use words and language that are considered intellectual property, so make sure that you cite appropriately or use the correct symbol, either copyrighted or trademarked, or registered trademark, so your document is appropriate,” Warren warned.

Make Recommendations, Request Proof of Resolutions

If you’re finding issues with coding, then the problem may be as simple as a coder making mistakes, which a coding manager can address once presented with the findings.

However, the cause of an issue may be less obvious, and that’s when a root cause analysis may be appropriate, Warren said. “That way you can address your finding and your recommendation to the right person,” she said.

When making audit recommendations, it’s helpful to convey the standard expected, and then identify the person who can impact the change, Warren said. For example, a billing manager probably won’t be very helpful in resolving a coding issue.

You can decide whether you want your recommendations to be acknowledged in any kind of formal way, which can be determined on a case-by-case basis and change depending on the organization’s policies for escalating issues up the chain of command. Having your recommendations acknowledged can help make sure that issues are addressed, protecting the organization should another entity pursue an audit. You can also request acknowledgement of resolution for additional accountability.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC