Orthopedic Coding Alert

What you do before your audit will lay the framework for your compliance plan
 
With all the attention lately on fraud and abuse issues, many practices are ready to plan for their first self-audit but aren't sure where they should begin. Before you start your first self-audit, you need to ask yourself a few important questions and identify exactly what you hope to achieve. Get to Know the Basics of Self-Audits What it means: When you perform a self-audit, you-re comparing your physician's billing records, claims, and medical records to verify expected treatment outcomes and medical necessity of services. In addition, you-ll look for appropriate documentation to support fees and reasonable charges for services your surgeons rendered. 

Why you audit: When you audit your physician's services, you can uncover incorrect coding patterns or compliance issues. The plus here is that you-ll discover any problems before an outside auditor (such as one from the OIG or a private insurer) does.

What steps you should take: If your practice has a compliance manual or a policy and procedure manual, it may include a written policy that documents exactly how your audit should flow. If not, you should develop such a policy and add it to your manual. 

The OIG Compliance Guidance for Individual and Small Group Physician Practices can be found at http://oig.hhs.gov/authorities/docs/physician.pdf, and the OIG Compliance Program Guidance for Third-Party Medical Billing Parties is at http://oig.hhs.gov/fraud/docs/complianceguidance/thirdparty.pdf. You can also obtain this information from consulting firms as well, or from your fiscal intermediary.

If you-re still developing your audit procedure guide, the following tips should help you plan your first self-audit. 1. Decide Which Staff Members to Involve You should involve every member of your practice in your audit. In particular, you-ll want to hold a staff meeting before the audit to explain what you-re doing and why, and to remind staff members that you-re not trying to get anyone in trouble. Instead, you-re hoping to help them figure out what they-re doing right and determine what they should work to improve that will help the practice ethically bring in more reimbursement and decrease denials.

Following the audit, you should hold another staff meeting so you can share your results with the rest of the staff members. You can educate the physicians about the relationship between clear documentation and accurate coding; you can help the receptionist understand that when she makes an appointment, she should get the insurance information; you can explain to the nurses about collecting family histories, and so on.  2. Determine How Many Records You Should Audit If your practice has never performed an audit, you should consider the following factors so you can determine how many records to [...]