medical coding audits


Medical Coding Audits:

Auditing physician charges and billing practices is debatable, but it’ll normally yield enhanced claims management procedures, cash flow and compliance with related laws and regulations.

An annual audit allows doctors and practice staff to recognize specific coding problems that may recur in comparable claims submissions. Careful pre-submission observation and review of these comparable claims may safeguard against errors that might cause a claim denial. All over-payments and charging mistakes identified during a retrospective audit should be managed with regard to the payer’s repayment instructions.

Who should carry out the audit?

Physicians and practice staff should take part in the audit procedure for best results. As a doctor, you are eligible to be compensated for the services you provide when they’re coded and recorded appropriately.

Physicians and clinic staff with a strong understanding of CPT codes and guidelines, the Resource Based Relative Value Scale, in addition to payer’s clinical payment policy, contracts, fee schedules and compensation guidelines are valuable to an effective audit.

Designate a practice staff individual to be answerable for the audit procedure and consider hiring a consultant specializing in charging and collections to help in specified audit jobs.
The consultants contract should ensure confidentiality and compliance with the Health Insurance Portability & Accountability Act of 1996.

What should be thought about throughout the auditing

  1. Determine who in the clinic will be answerable for auditing the health plan obligations.
  2. Assign staff, doctors and an outside consultant to perform the audit.
  3. Review the recommended OIG audit procedure previously referenced and adapt it to your clinic.
  4. Address concerns including: Will the audit be performed retrospectively or prospectively?
  5. What type and size of sample will be drawn: arbitrary, controlled, select payers, all payers?
  6. What audit tools may be utilized to determine the appropriateness of claims?
  7. What risk areas should be closely monitored? The OIG recommends auditing five or more medical records per federal payer, or five to 10 arbitrary medical records per physician.

In addition, the OIG suggests 3 methods of drawing an arbitrary sample: from compensated claims, claims by payer or claims containing one of the top 10 denials by payers. Utilize a claim analysis check-list to identify the adequacy of coding, documentation and completeness of a claim.

Sample check-list items include:

  1. Was the service performed and recorded appropriately?
  2. Are the correct doctor and clinic identification numbers listed on the claim?
  3. Is there a CPT code that would more accurately reflect the service performed?
  4. Is suitable modifier appended to the CPT code to precisely reflect the service performed?
  5. If this medical record was reviewed by an external auditor who doesn’t know the patient, does the record supports the CPT codes selected?

The medical record must show that each service provided by the doctor was medical necessity and reasonable.

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