Otolaryngology Coding Alert

Answer: An audit’s scope — the amount of time and documents involved in an audit — sets the agenda and, ultimately, establishes how deeply an audit is performed. Your scope will become a little more apparent as you answer questions such as “What’s the goal?” “What do I want from this?” “Who started or requested it?” Some scenarios that may prompt an audit include a new provider, a new procedure, or an issue with a payer.

For example, if you’re conducting an audit to figure out an issue with Medicare payments, you’ll need to know which Medicare Administrative Contractor (MAC) applies (which depends on the provider’s location) because you may need to take into account local coverage determinations (LCDs), as well as the Centers for Medicare & Medicaid Services’ (CMS’) Medicare Claims Processing Manual.

Part of determining the scope means choosing which “universe” you’re exploring with the audit. If you’re auditing an internal billing system, your report may focus on certain providers and/or certain services within certain dates for these payers. You could instead focus on auditing a particular department or generating your audit reports per provider — whatever your system will allow — but you want that report to give you your total universe.

If you’re doing reports per provider, you should look at a specific element, such as a date of service, a patient diagnosis, and/or a CPT^® code. You want, and need, everything, so when it comes down to selecting your sample, you have good information. Make sure you’re on the lookout for any internal billing policies, too.

It’s imperative that you know who all your players are; you don’t want there to be any confusion. You want an understanding that “this is what we have agreed is going to get done; this is what we’ve agreed is not going to get done.” Ironing out these details is important regardless of who’s conducting the audit because the boundaries can help everyone involved feel better respected and even more accountable.