Part B Insider (Multispecialty) Coding Alert

AUDITS:

Get To The Bottom Of Audits--And Come Out On Top

Published on Sun Apr 23, 2006

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Why do bad audits happen to good coders?

Asking why your carrier has decided to put your evaluation and management (E/M) claims on prepayment audits isn't a waste of time. In fact, it may help you get off prepayment review more quickly, say experts.

Ask yourself, Why was the physician put under a prepayment audit in the first place? What was the red flag? Was she billing too many high-level codes? Too many consults?advises Suzan Hvizdash, medical auditor with University of Pittsburgh Physicians department of surgery.

If you can't answer those questions yourself by running reports and going through your charts, then you should schedule a meeting with the carrier, Hvizdash adds. Some carriers may be able to provide you with some valuable insights into the reasons for your audits.

Each Medicare carrier may have its own guidelines for which claims require a prepayment review, notes consultant Cindy Parman with Coding Strategies in Powder Springs, GA. Usually you'll find yourself on prepayment review if your claims appear to be outliers because you bill more visits or higher-level visits than average. NHIC has a good summary of its policies at www.medicarenhic.com/cal_prov/med_review.shtml.

You may not be able to tell in advance whether your claims will be audited by looking at each individual claim, notes Parman. But you might get a clue as to whether you're a target by running a report to look at your E/M bell curve and comparing this to the national data that the Centers for Medicare & Medicaid Services publishes on its Web site.

3 Red Flags

There are some red flags bound to attract an auditor's attention--scan your charts for the following:

A laundry list of diagnoses won't wash. If most of the diagnoses on your claim don't seem relevant to the E/M visit, then the carrier will suspect you've upcoded, says Young.

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Detailed or comprehensive exams for a simple problem. A patient with a runny nose and cough doesn't need a neurological exam, psychiatric evaluation and gastrointestinal workup, notes Young.

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Worksheets or EHRs. If the doctor checks off a lot of boxes showing that various body systems are normal without expanding on that finding at all, it may look suspicious to auditors, says Young. You should make sure your doctor only checks off boxes for areas he or she actually examined or did a review of systems (ROS) on.

Watch Out: Pay attention to other factors that may increase your E/M level. When your physician performs a history on a patient, she is looking for other conditions that may play into the main diagnosis, says Barbara Cobuzzi, president of CRN Healthcare Solutions in Tinton Falls, NJ.

Example: If a patient comes in with an upper respiratory infection (URI), that's probably a pretty simple problem, explains Cobuzzi. But suppose a patient comes in with a URI and has a history of URI, is immune compromised or has diabetes or cystic fibrosis. All of a sudden the URI is no longer straightforward, says Cobuzzi. You should look for these sorts of factors in your charts that may appear upcoded but are actually coded correctly.