The word "audit" provokes fear and anxiety to some providers, but once audits have been developed and refined for a practice, these fears seem to dissipate. Once everyone has a clear and concise understanding of the auditing process, the anxiety is diminished.
Auditing is important to evaluate the physician processes to make sure their compliance plan is operating correctly and to identify any inappropriate documentation, coding, and/or billing practices. One of the most important reasons for auditing is to identify any potential areas of concern that could put the physician or practice at a risk for audits.
OIG recommends two types of reviews:
1. Standards and procedures review — Are the standards current, complete, or need updated to reflect any government changes in regulations
2. Claims submission audits — Is coding, billing, and documentation in compliance with payer and government contractors. Are services performed reasonable and support medical necessity?
OIG states self-audits can be used to determine:
• bills are accurately coded and accurately reflect the services provided
• documentation is being completed and correct
• services or items provided are reasonable and necessary
• any incentives for unnecessary services exist.
It is recommended to start with a “baseline” audit after the first three months of implementation. This will identify areas that need improvement, education, and a basis for future audits.
The following are areas to build your foundation for future audits.
1. What documentation needs improvement
• Detail and specificity needed
• Medical necessity
• Components of chief complaint, history, examination, or medical decision making
• 95/97 examination guidelines
2. Possible coding/billing problems with EHR system
• CPT, ICD-9, and HCPCS codes
• CCI edits and LCDs
• Interpretation of grey areas
• New verses established patients
• Medicare guidelines
• Others — front desk, managers, etc.
• Problems identified — How are they resolved?
• How future problems will be identified and reported
• How often will audits will be performed?
• Hire external auditor
Once you have completed the baseline audits, I recommend developing an auditing compliance plan for everyone to follow as a blueprint for documentation, coding, and billing.
Our most important goal as coders is to protect our physicians from any potential fraud or abuse; however, this is a team effort and requires the entire office to follow the necessary steps of a compliance plan to be successful.
Here is a link for more information on OIG Compliance Guidelines.
Melody S. Irvine, CPC, CPMA, CEMC, CFPC, CPC-I, CCS-P, CMRS, has over 30 years of experience in the medical profession. She specializes in physician auditing, education, curriculum development, and consulting services. She is the CEO and founder of Career Coders online medical billing and coding school. Irvine is an approved Professional Medical Coding Curriculum (PMCC) instructor with AAPC. She is also a member of the AAPC’s National Advisory Board. E-mail her here.