Pediatric Coding Alert

The same audit process and timeline won't work for every office -- identify your practice's needs.

As you read in last month's Pediatric Coding Alert, government payers are not the only insurers who perform audits. Private insurance companies also audit practices, and you should make sure that your pediatric office has nothing to worry about if an auditor does pay a visit. As part of our continuing series on auditing, check out the following tips to start your self-audit process.

What's the Point?

If your pediatric practice doesn't conduct regular internal audits, you're likely losing money and overlooking billing mistakes that could result in missed billing opportunities 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 regulation and coding guidelines, by learning how, when, and why to perform internal audits.

Ensure Everyone Knows Why an Audit Is Important

Before beginning your audits, you need to get your office staff, including the physicians and non-physician practitioners, on board. Explain to everyone in your practice why an internal audit will benefit your practice.

"Internal audits are a way to make sure you are on track and nothing has gone awry," says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. "By doing internal audits, you can identify opportunities for education, opportunities for the development of better forms, and opportunities to tune up the practice."

Additionally: Internal chart audits make it possible to find and correct coding errors and self report, rather than letting the payer find them. If your staff members seem reluctant to participate, let them know that the point of the audit isn't toferret out errors and get people into trouble " it's to improve coding down the line.

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."

Choose Prospective vs. Retrospective Auditing

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

• rospective audit -- Your practice examines new claims before you file them.
• Retrospective audit -- Your practice examines paid claims.

A prospective audit helps you identify and correct problems before sending the claim, 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, however.

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

Best bet: 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.

Determine Your Audit Schedule and Process

How often your practice performs an internal audit will depend on the size and type of your practice. 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 twice a year, 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: "There are multiple ways of selecting charts ... it depends on what you are trying to find out," Cobuzzi explains. Your internal audit should deal chiefly with procedures and services that your office most frequently provides. Keep in mind that a practice's top-20 high-volume codes typically account for 80 percent of its reimbursement. So focusing on these 20 services is a good place to start.

Final thought: "Remember an audit is much more than coding, it involves documentation, coding, billing and data input, denials management, and office process following policies and procedures," Cobuzzi says.