Question Code Changes by Auditor


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Hi, We are starting a new coding & compliance department. During a pre bill audit; if you find that the documentation doesn't support the level billed; do your auditors change the code? If so, do you ask the provider first or inform (educate) after?

Same question for ICD10 codes that may be more appropriate or remove those that are not supported before sending the claim?


True Blue
Salt Lake City, UT
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It sounds like you are allowing the medical staff do the initial coding and having a CPC audit before billing. Not an uncommon practice. If the codes are not supported, they do need to be changed by the CPC, but providers need to be educated on why the change. Frequently you will see documentation that needs correction or additions made. Those get sent back to have the providers correct the documentation before billing. As a caveat, I would never want codes billed that were chosen by the clinical staff without being reviewed by a CPC first.


True Blue
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Yes, agree with the above here. Most organizations that allow providers to choose their own codes will require that the maintain a certain accuracy level which is monitored periodically. During the audit process, codes that are not supported by the records should be corrected, but depending on your organization and work flow, you may wish to give providers the option to rebut any errors that the auditors cite.

One thing I'd suggest considering as part of your audit plan is to rank the severity of coding errors - I've seen organizations that have done this with a point system assigned to types of errors and I think it makes a lot of sense. For example, a code that is not supported and shouldn't be billed at all is a more serious error than a code that is just upcoded by a level due to a minor detail in documentation, which in turn is more severe than a technically incorrect choice of diagnosis code which has no impact on reimbursement. This way you're not just assessing 'right vs. wrong' codes, but rather are looking at the overall picture of the risk that the types of errors are presenting to the organization.