Orthopedic Coding Alert

Self-audits are well worth the time, experts say You-ve decided which type of audit you should perform and you-ve explained the process to your staff, so you-re ready to dig in and pull some charts. Get down to business with the following self-audit recommendations from our experts. Gather Your Resources Before you perform your first audit, you should make sure you have current CPT, ICD-9 and HCPCS code books available, says Jay Neal, an independent coding consultant in Atlanta. And keep the most recent National Correct Coding Initiative (NCCI) edits close at hand, along with local medical review policies, E/M guidelines, and a medical dictionary for reference during the audit.
 
Examine Documentation for Problems When you perform the self-audit, you should read the documentation and select which ICD-9 and CPT codes you think apply to the chart. Then check which codes the physician or coder actually assigned to find out whether they selected the right codes for the services that the physician documented.

Tip: Someone other than the original service provider should review the chart for accuracy, because the audit must be objective. Combat Problem Areas -You should develop some tools within your practice to make documentation easier,- says Angela Cassidy, an orthopedic coder in Los Angeles. For instance, if your audit reveals that one surgeon in particular always bills 99213 (level-three office visit), make him a card that explains the details of each E/M code or write up a template that shows him exactly how many elements in each section must be examined before he can bill 99214 (level-four office visit). Then he-ll be more inclined to select the right code.

Some coding experts recommend that each physician memorize the requirements of the E/M code that he bills most frequently. Then, if he performs more or less than what that code requires, he-ll know to bill a different code and he can look up the requirements of the others.

Or you can make a list of the top-50 diagnosis codes that your practice reports so the physician can easily reach for the right ICD-9 code every time, rather than writing nonspecific diagnosis statements such as -tibia fracture,- which often leaves questions about the type of fracture or cause. Save Documentation  You should retain all of the documentation from your self-audits in your office to demonstrate what you reviewed and what you changed.

Your records should indicate whether your audit was part of a regular compliance program, or whether you performed the audit because you had a problem  and you wanted to use prospective measures to avoid future inaccuracies.