Outpatient Facility Coding Alert

Published on Wed Mar 20, 2013 PDF

Tip: Start searching your records now, not when you hear from OIG.

Auditing your facility’s services can help you uncover incorrect coding patterns or compliance issues among providers. Although going through the process can be daunting, working the steps internally can uncover problems – and allow you to correct any issues – before an outside auditor from the OIG or private insurer steps in your door.

What you do: When you perform a self-audit, you compare a physician’s billing records, claims, and medical records to verify the expected treatment outcomes and ensure the medical necessity of services. In addition, you’ll look for appropriate documentation to support fees and reasonable charges for services your physicians rendered.

Checklist: If you don’t know quite where to begin when you perform your first self-audit, keep this handy reference as a guide to remind you what types of questions you should be asking yourself. You’ll know you’ve done a thorough job is you can answer each of the following questions for each chart you check:

·         Does the documentation support the level of service billed?

·         Does the documentation support the CPT^® and/or HCPCS codes billed?

·         If the physician coded a consult, does documentation of a request from a third party exist in the chart?

·         Does the chart contain a written consult report back to the third party?

·         Did the physician use modifiers correctly?

·         Does the documentation support the ICD-9 codes the practice reported?

·         Did the physicians sign and date all entries?

·         Is the chart legible?

·         Is the name and identification number of the patient and provider on each page of the medical record and claim form?

·         Does the patient identification sheet include completed biographical data, including the patient's address, employer, home and work telephone numbers, and marital status?