Question Outpatient auditing

mojisola

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I was given some facility outpatient claims to audit without the procedure codes. I was made to understand that facility claims may not necessarily contain procedure codes. How do I do an audit without the procedures.
 

thomas7331

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What were you asked to audit? If it's not clear, I guess I would go back to whomever asked you to do the audit and get clarification. You're correct that some facility claims may not have CPT/HCPCS codes, so you would not be able to audit those entries from a correct coding perspective, but facilities do report their charges and costs, so there can also be a financial and/or payer audit of those claims for accuracy of reporting that information. Any kind of audit requires structure and guidelines - so I would ask if they just want you to verify the accuracy of any CPT/HCPCS codes against physician documentation, or if they want you to get into the other reporting aspects based on the facility's own guidelines or their payer contracts.
 

mojisola

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Thanks for your swift response. Basically I will be auditing outpatient hospital claims for overpayment/underpayment based on the charges, payment and rev code for the payer..
 

thomas7331

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Coding audits just compare documentation against code selection, and incorrect code selection may or may not cause a payment error on a facility claim. If you're doing a payment auditing, though, there's a wide range of things you can look at in addition to documentation, namely ensuring that payment was made according to the terms of the contract and also that claims are billed and paid appropriately in adherence to the payer's policies. I have some experience in the area - feel free to send me a private message if I can help with any specifics.
 
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