Avoid Provider Chart Audits by Conducting In-House Self Audits
Published on Fri May 01, 1998
The increasing scrutiny from third-party payers of coding in general, and Evaluation and Management (E/M) Services in particular, make the possibility of an outside audit an uncomfortable reality. Physicians, coders and practice managers all will rest easier knowing they can pass an audit, and one of the best ways to achieve this peace of mind is by conducting regular self audits. But beyond alleviating fear, regular self audits also may improve your collection rate, according to Jan Rasmussen, CPC, a coding consultant and instructor for Med Learn, a medical practice management training and consulting firm. Many coding consultants believe physicians often undercode rather than overcode. Regular self audits can help you identify when you might ethically be entitled to greater reimbursement. Here are some tips to help you conduct an efficient self-audit to prepare your practice in the event you are ever formally audited.
1. Review Productivity and Utilization Reports. Most coding software allows you to print out reports that show which codes are being used by each physician. Rasmussen recommends going back six months if you havent done an audit in a while, and thereafter running reports and conducting a mini-audit every month. Once you have printed out reports for the time period you are auditing, examine the reports for each physician. Take a look at what codes are being used and at what frequencies, and look for red flags that will guide you into deeper investigation.
2. Search for "Red Flags."
As you look at the utilization reports for each caregiver (physician, CNM, PA, NP, etc.) take note of anything that stands out. Compare the reports to each other.
You want to notice "spikes" in frequency or codes that are being overused. For example, if you discover that nearly all office visits by a certain physician are being coded at level 2 and for another physician there is a spike in the use of level 4s and 5s, you may have a case where one is undercoding and the other is overcoding. Typically, you will see higher levels of coding in specialties such as ob/gyn, but a consistent run of the high levels of services warrants a look to be sure that those codes are justified.
Look for the frequencies of the use of consultation codes (99241-99245) vs. new patient codes (99201-99205). According to Rasmussen, this is an area where E/M service codes are being misunderstood and misused and one that might raise the attention of an outside auditor. (See article on page 9 on correctly utilizing consultation codes.)
Take note of whether or not Preventive Medicine Codes (99381-99397) are being used. This is especially important in gyn practices, because many women are coming in primarily [...]
