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Physicians on 100% audit review

  1. Default Physicians on 100% audit review
    Medical Coding Books
    If you have a physician who is on 100% audit review for a previously failed E/M audit (less than 25% accuracy), do you assess any type of disciplinary measures (for lack of a better term) such as holding all charges including procedures until a marked improvement is seen in his coding? Do you make the physician responsible for reimbursing the Coding/Compliance Department for the additional coder resources required for the 100% review?

    Along those same lines - what about one-level difference? We currently refund all differences whether one level or more. I have heard that some entities use a one level difference as an educational opportunity for the physician and do not refund the payor in that instance. The monies are only refunded when a 2 level difference or greater is identified.

    I am looking for input to see if what we are currently doing is in line with others are doing.


  2. #2
    Columbia, MO
    In my opinion, and maybe not popular, but if there is a less than 25% accuracy rate then it is the coding departments fault as well. Even though the physician marks(assigns) the codes it is the responsibility of the coder to read ALL documentation and verify the accuracy of the codes BEFORE assigning codes to a claim. To do anything less means you are not coding you are performing data entry. If you find on post audit that incorrect codes were submitted and paid resulting in an overpayment then you have a requirement to refund the monies to the carrier regarless of the amount.

    Debra A. Mitchell, MSPH, CPC-H

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