Wiki HELP: What is # of charts needed for audit?

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LauraNewYork

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My practice is changing the way internal audits are done. We will now be completing audits post billing. For unknown reasons, 20 charts has been chosen as the number to be audited per provider and this will be completed 2x/year/provider. I think this is overkill. We are already understaffed and this will be very onerous.

My vague memory is that the following is true:
5 charts / year is minimum and is equal to a 90% confidence interval (CI)
10 charts / year is normal and is equal to a 95% CI
15 charts / year is uncommon, but is equal to a 99% CI
Can someone provide guidance on the typical number of charts audited? If so, can you provide the reason why?

All replies appreciated very much!
 
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Internal audits are just that - an internal policy about who/what/how/when auditing will be done.
For example, as a manager, I personally audit my coders much more frequently than once per year. In fact, we do audits of each other of 10/month for E&M and 5/month for surgeries. So each coder spends about 1 hour per month doing auditing. We discuss those findings together as an educational tool within my coding team.
Official internal provider audits by another department are done once per year of 10 charts unless a provider fails the initial audit.
To me, audits are best completed PRE-billing. If you are performing post billing, you must ensure that any findings are corrected with the carriers which is certainly more work than findings corrected before claim submission.
I suppose it depends on why audits are being done. If it is to educate providers about potential errors, 20 charts twice a year does not seem like overkill. If it is to catch errors before claim submission, post audit doesn't do that. When you think about how many visits/year the providers are doing, and how many are being audited, it's probably 0.5% of the charts. If it is just for compliance reasons, and you consistently hit very high accuracy, then 20 2x/year might be more than is necessary.
In large healthcare systems, there are entire departments just doing audits. If you are concerned about the workload of your department, you should start with a discussion of this with your supervisor or manager.
 
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I agree with Christine, there is much more to this than just the "number" of charts or encounters. It depends on the scope and reason for the audit. Who is being audited? Is it for provider education or coder audit? In a group with that number 20 is actually low to me if it is for provider audit/education. What type of specialty is it, are you talking only single E/Ms or surgeries and procedures? Are staff/production coders being asked to do the audits too? That is a bit much, I agree. Especially if you have to meet production goals. Do your coders code "from scratch" or just edits, what else do your coders do, appeals, rejections, denials, A/R?

A practice needs an audit plan for this. How will it be carried out, what is the scope, what will you do with the results, what if there are errors and repayment is needed (if post pay)? Who will educate the providers on the results? Will this create tension between the staff coder and the provider(s) they code for? You have to have thick skin and be very calm, professional and know your topic when it comes to reporting audit results and educating providers, it can get heated if the results were not as expected or poor.
This is a pretty big undertaking, especially if it has not been done before or was outsourced prior and you are bringing it in-house. Like Christine mentioned, large systems and groups have separate departments headed by the Chief Compliance Officer (usually) for this because there are so many facets and implications.

There is boundless info out there to learn:
MGMA has a lot of info on it and benchmarks: https://www.mgma.com/mgma-stats/the...audits-following-the-2021-e-m-and-mdm-changes
 
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Appreciate the reply and references.
The providers are being audited.
We are a hem/onc group with associated radiology oncology and thoracic surgery. Our emr is OncoEMR. The lone compliance officer (located in HR) has only been involved in HIPPA, never billing. Up to now, the staff coders have been responsible for reviewing/modifying the MD/APP assigned E/M levels and ICD codes, adding modifiers, and adding HCCs (only since 4/2023) before the charge is sent out; we also work denials of E/Ms, labs and some radiology; we work all inpatient charges prior to billing which includes reviewing/modifying E/M levels assigned by MD/APP and assigning correct ICDs. The staff coders also make sure the correct provider(s) are listed on the inpatient and outpatient charges. 1 staff coder was assigned to provide prebilling audits starting in 2021 of only the MDs and providing email education of the results in addition to the above duties. One staff coder works with thoracic surgery reviewing/modifying the MD/APP assigned E/Ms and procedures as well as the above duties.

The new process is that the 4 staff coders will NOT change the E/M levels as assigned by MDs/APPs; however, the coders will still review every chart to correct or add ICD codes, add HCCs and then send charge out; all other duties remain.
New duties include reviewing new patient charts one week prior to appointment and adding diagnosis and potential HCCs diagnoses from new patient records. After appointment, the coder enters the RMD into the system.

While I am a staff coder, I have been advising on the development of the audit plan as per AAPC Webinars and other courses. Suggestions for what to do with the audit results have been provided to billing manager.
 
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Depending how busy/productive the clinicians are, 4 coders for 50 providers with the duties you listed does seem a bit understaffed. If their visits are time consuming and only see a handful of patients per day, and coders do not code/review surgeries or treatments (chemo and/or radiation), then maybe not so much. I would be curious why you used to review/modify levels and are now no longer doing so. Was it that you were changing only 1 E/M per week so the organization decided it wasn't worth the time? If you were changing levels frequently and the organization is aware of this, I would be concerned unless there was additional provider education recently.
IMHO, if an experienced coder is looking at a chart, it's a minimal amount of additional time to review the level if you are already reviewing to determine HCC, ICD10, and modifiers. What is the policy if you incidentally notice an incorrect level while reviewing and coding the other information?
And while I've never done HCC coding, a coder reviewing any chart PRIOR to being seen seems like a waste of time. I imagine you will need to re-review it again AFTER patient is seen, as relevant diagnoses should be determined by your provider's documentation.

Since the audit focuses on the providers, I imagine these audits are then only directed at the E/M level. The remaining code information is being done/reviewed by a coder.

My outsider's personal opinion about the situation is:
1) Coders do not review anything prior to visit.
2) If providers are coding, and a coder is reviewing, then the coder should review everything.
3) Post-submission audits are problems waiting to happen.
4) Maybe there should simply be a better system in place to make providers aware of incorrect coding during item 2 with provider education.
5) If auditing providers, the audit should be done before the coder reviews and before submission. If auditing the coders, the audit should be done after the coder reviews and before submission.
 
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