Orthopedic Coding Alert

Question: Do you have any tips for performing a coding self-audit?

Mississippi Subscriber

Answer: Performing your own audit is a great way to catch services your practice isn't coding but should be getting paid for. You'll also be able to correct compliance issues before the HHS Office of Inspector General (OIG) comes calling.

Try this: Gather your current CPT, ICD-9 and HCPCS code manuals, along with the most recent Correct Coding Initiative (CCI) edits, local coverage determinations, E/M guidelines, and a medical dictionary for reference during the audit.

Experts suggest auditing at least 10 to 15 records per physician if you're in an outpatient practice, or 5 to 10 percent of the records if you're at a freestanding facility.

For each chart, make sure you can answer the following questions correctly, and you'll know you've done a thorough job:

- Does the documentation support the level of service you reported?

- Does the documentation support the CPT, HCPCS and ICD-9 codes reported?

- Are units billed correctly?

- If the physician coded a consult, does documentation of a request from a third party exist in the chart? Does the chart contain a written consult report sent to the third party? Is there a transfer of care for the condition?

- Did the physician use modifiers correctly?

- Did the physician sign and date all entries?

- Is each service billed in the name of the physician who performed and/or supervised it?

- Is the chart legible?

- Is the name and identification number of the patient and provider on each medical record and claim form page?

- Does the patient identification sheet include completed biographical data,
including the patient's address, employer, home and work telephone numbers, and marital status?

Follow up: If your audit shows a 90 percent or better compliance rate, you should perform a self-audit once a year, experts say. If the compliance rate is 70 to 89 percent, perform another audit in six months. When compliance is lower than 70 percent, you should perform repeat audits quarterly until the percentage improves to 90 percent or above (some providers won't accept less than 98 percent).

Remember: If you're under a corporate integrity agreement, you may need to follow a different auditing timeframe.