Health Information Compliance Alert

Presentation is everything when talking to staffers.

How many ticking time bombs are waiting in your medical records?

If you don't audit your charts regularly, you'll never know. But even the most thorough set of audits could come to nothing if your staffers believe they'll lose their jobs if you uncover a problem in an audit.

Reality: "Internal audits (or those conducted by the practice using an outside resource) are the main thing that will protect providers," says Stephanie Fiedler, CPC, ACS-EM with Loeb & Troper, LLP, in New York City. "Auditing is a method of determining which providers need education related to documentation and proper code selection," she says.

In fact, a large percentage of the audit focuses on the doctor's documentation, not how the coders and their managers are doing their jobs.

"If staff members are having a fear of losing their jobs, they are misinformed," says Susan Vogelberger, CPC, CPC-H, CPC-I, CMBS, CCP-P, president of Healthcare Consulting & Coding Education, LLC in Erie, Penn. "Physicians are happy to improve documentation because it keeps them from a government audit by not raising flags, and it often brings in more revenue."

Give staff heads up: When it comes to suggesting a self-audit to your practice members, "presentation is everything," Fiedler says. Introduce internal auditing so that staff understand the following, Fiedler advises:

• Staff members have no control over Medicare rules, and you're only auditing based on Medicare and CPT regulations.

• Self-auditing is a method of ensuring that not if, but when you are audited, you will fare better.

• Being proactive is better than reactive regarding chart reviews.

Tip: "I also find that bringing the provider into the conversation by asking questions, starting with positive points, works better than starting off with what they 'did wrong,'" Fiedler suggests.

"The OIG highly recommends monitoring as well as auditing, which is pulling a few charts weekly for a quick check," Vogelberger says. "If you perform an internal audit, it is imperative to follow up to ensure that not only what was being done incorrectly has been corrected, but also continues to be done correctly."