Otolaryngology Coding Alert

What does scheduling and scrutinizing documentation have to do with your success?

Self audit is a process. Before you jump in and take on the job, you need to prepare yourself and your staff for it. As you may probably know, government payers are not the only insurers who perform audits. Private insurance companies also audit practices, so you should make sure that your otolaryngology office will be left hassle-free should an auditor pay a visit.

Sense of purpose: If your otolaryngology practice doesn't conduct regular internal audits, you're likely losing money and overlooking billing mistakes that could result in missed billing opportunities, improper payer processing and erroneous coding. Identify areas where your practice's inefficiencies may be delaying payment or allowing for missed charges, while also evaluating your compliance with payer regulations and coding guidelines, by learning how, when, and why to perform internal audits.

Demythologize some essential elements of self audit that are embedded within the following fabrications.

Myth 1: Internal Audits Get Staff In Dire Straits

Internal audits are a way to make sure you are on track and nothing has gone awry, so you need to let every member of your practice --" including physicians and non-physician practitioners -- know why you're doing an internal audit. Because of the stigma that the word "audit" brings to most people, you would probably have to remind them that you aren't trying to get anyone in trouble. Instead, you want to determine if there are gaps in knowledge and opportunities within the practice which will assist in bringing in the right amount of payments, optimize income, reducing denials, and improving patient care.

Everyone in your practice should realize that there's light at the end of the tunnel: Internal audits can spawn opportunities for education, opportunities for the development of better forms, and opportunities to tune up the practice. In addition, internal chart audits make it possible to find and correct coding errors and self report, rather than letting the payer find them in a punishable event. A practice audit is similar to the accounting check-up most businesses perform at least annually.

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, ACSEM, a consultant 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, CCPP, CEO of Healthcare Consulting & Coding Education, LLC. "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."

Denials audits are an often missed opportunity, notes Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. They tell the practice when the payers are shorting the practice and where there are opportunities for appeals and the resultant increased income, she explains.

Myth 2: All Audits Have The Same Approach

In fact, there are two types of internal chart audits your practice needs to look at before determining which will work best in your office:

• Prospective audit -- Your practice examines the documentation and resultant coding before the claims are filed..
• Retrospective audit -- Your practice examines the documentation and resultant coding after the claims have been submitted.

A prospective audit helps you identify and correct problems before sending the claim to the payer, which could mean you'll discover incorrect coding or charges that would otherwise have been missed. Keep in mind that this type of chart audit can potentially delay billing and the resultant payments, however.

Alternative: Retrospective chart audits do not delay billing and payment, but causes your office to be reactive by refiling claims with corrections based on the audit findings, rather than proactive in finding problems before you submit the claim.

Your practice must determine for itself what types of audits your staff can reasonably complete and what effects on claim submission timing and cash flow the practice can handle. When reviewing charts -- most auditing specialists recommend that you review 10 to 15 records per physician during your audit -- you should examine the documentation and determine which ICD-9 and CPT codes you think apply to the chart, then check which codes were actually assigned to the services.

Myth 3: End and Begin Audits Whenever You Please

Schedule gives life to the whole internal audit process, without it, all your efforts might go to waste. Depending on the size and type of your practice, you should decide how often your practice performs an internal audit. Consider the amount of resources the practice can devote to the audit while simultaneously conducting day-to-day office business.

Pointer: Remember that the more often you can audit, the cleaner your claims will continue. At a minimum, you should conduct an internal audit at least annually for each physician and for denials, experts advise. After you've prepared your staff for the auditing process and determined when you'll perform an audit, you'll need to define the focus of the audit. Ask: "What do we want to accomplish?" Then focus on the following points:

• Determine the audit's scope. Which providers, services, date range, and payers will it address?
• Determine how to select charts. Will you fix this process for each provider, or will you randomize the chart selection? Pull charts and organize supporting documentation, such as a printout of physician notes, account billing history, CMS 1500 forms, and explanations of benefits (EOBs).

Tip: Think about using a score sheet to collect the data and demonstrate the audit results. Some insurers or physician associations offer audit tool score sheet templates that can help you when auditing documentation for E/M services. There are also software products which can assist your auditors perform E/M audits such as E/M Manager or Intellicode. The advantage of a software product is that it assists in the reporting. (For a sample audit score sheet used by a otolaryngology practice, and Otolaryngology 1997 exam form, email editor Claire Gamboa at cgamboa@codinginstitute.com.)