Radiology Coding Alert

Question: Do you have any tips for performing a coding self-audit?


Mississippi Subscriber
Answer: A self-audit catches services your practice isn't coding but should be getting paid for and lets you correct compliance issues before the OIG comes calling.

Gather current CPT, ICD-9, and HCPCS books, NCCI edits, local coverage determinations, and E/M guidelines, along with a medical dictionary for reference. 

Audit at least 10 to 15 records per physician if you're in an outpatient practice or 5 to 10 percent of records if you're at a facility. Perform the audit as a team and include physicians familiar with the coded services.

For each chart, answer the following questions:
Does the documentation support the level of service reported? Is the documentation complete relative to the provided services?Does the documentation support the CPT, HCPCS, and ICD-9 codes reported?Are units billed correctly?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 that was sent to the third party? Is there a transfer of care for the condition?Did the physician use modifiers correctly?Did the physician sign and date all entries? Is the chart legible?Is the name and identification number of the patient and provider on each medical record and claim form page?Does the patient identification sheet include completed biographical data, including the patient's address, employer, home and work telephone numbers, and marital status?
 
Follow up: Self-audit once a year if you have a 90-percent or better compliance rate, each six months if the rate is 70 to 89 percent, and quarterly if compliance is lower than 70 percent.

Keep records of the entire process, and document opportunities and plans for improvement. This documentation can show good faith if you face an external audit -- but only if you've followed through on your proposed plans, experts say.