Part B Insider (Multispecialty) Coding Alert

Published on Mon Feb 07, 2011 PDF

Accurate documentation will be the most important tool you have in fighting off accusations of incorrect coding and billing.

Want to know how to keep your cool during a Medicare audit? One MAC wants to make sure your documentation meets the muster and won't trigger any issues with auditors so you can breathe easily if you find out they'll be paying you a call.

NGS Medicare, a Part B MAC in four states, offered its "How to Survive A Medicare Audit" webinar on March 3, and reps from the payer shared information on preparing your practice so you're prepared if an auditor should knock on your door.

"Every practice should access the resources needed to be compliant," said NGS's Donna Pisani during the call. "Know what LCDs and/or NCDs apply to your practice, and how they impact your bottom line. Are you using the supplemental instruction articles (SIAs) that help with the billing and coding, and add vital information to the LCDs?" she asked, noting that the MAC's recent poll indicated that many practices don't use the SIAs.

Using the information in the documents, as well as your current ICD-9, CPT, and HCPCS coding books, you can perform a self-audit to ensure that your documentation looks pristine.

Button Up Your Documentation: Although you may have heard "if it wasn't documented, it wasn't done" many times during your coding career, it could be the most important advice you've ever learned. After all, that statement holds true from a legal standpoint if records are ever sent to a court, said NGS Medicare's Karen Drake, RN, during the call. "Supporting documents such as initial evaluation, diagnostic test results, notes from consulting physicians, admission information" can help you prove medical necessity for your services, Drake says.

In addition, if you're performing any type of therapy or other timed services, make sure you document the times of starting and finishing, Drake advises.

Bottom line: Your documentation will be the only thing standing between a glowing audit report and a potential problem, so make sure your practitioners are documenting perfectly.