Part B Insider (Multispecialty) Coding Alert

Published on Sat Sep 18, 2010 PDF

Does your auditor know the score? Find out before it's too late.

Myth: Any coder can perform a chart audit.

Reality: Your auditor should be someone who understands the clinical scenarios your physicians are dealing with. An auditor should also be aware that different carriers may use different audit tools.

Your coder or biller should have a good working knowledge of Medicare's documentation and coding guidelines, especially for evaluation and management visits, experts say.

An auditor also needs to know the difference between the 1995 and 1997 E/M guidelines, and understand the ins and outs of common procedures in your office. Coding staff often believe that there is only one way to audit and that only the auditors' criteria are correct. In fact, however, there are many different audit tools, and the auditor isn't always right.

This is especially true when the auditor doesn't understand clinical issues. If the auditor has not spent time using the documentation criteria from the clinician's perspective, then the result could lead to inappropriate upcoding or downcoding.

When it comes to E/M visits, your auditor should always use the tool your local carrier has identified as appropriate. That way, you'll be sure your auditor is auditing the same documentation and using the same tool structure as the carrier. Plus, some carriers mix the 1995 and 1997 E/M documentation guidelines.

For surgeries, the auditor should be knowledgeable about the procedure and be able to interpret the operative report. Plus, the auditor should have a good working knowledge of auditing both E/M and surgery claims.

Your auditor should also know how to compile the audit's results and how to educate providers if needed.

Tip: Physicians should use audit results as a tool and shouldn't accept the recommendations of an audit without reviewing them personally.