Pediatric Coding Alert

Use all of the resources at your fingertips, including audit score sheets.

In last month's Pediatric Coding Alert, you learned the steps you should take to prepare for your first selfaudit-- but do you know what to do next? As part of our continuing series on auditing, check out the following tips to start your self-audit process.

Involve the whole staff. Let every member of your practice know what you're doing and why, and remind them that you aren't trying to get anyone in trouble. Instead, you want to determine whether they're helping to bring in the right amount of payments and cutting out denials.

Select the charts. Most auditing specialists recommend that you review 10 to 15 records per physician during your audit.

Examine documentation. Read 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.

Pay special attention to difficult services. When examiningphysicians' records, review not only the procedures, but also the E/M services. Some records are trickier to code, such as consults or time-based E/M records.

Time-based pitfall: You must have a believable reason to justify providing the majority of the service on counseling/coordination of care to justify basing your E/M level on time. "Bronchitis taking a lot of time to explain to a 20-year-old" is not a supportable reason.

The official recommendation is that the documentation should include the start and end time of the counseling/ coordination of care. For time to count in the outpatient setting, it must be face-to-face, with the patient and/or family.

It's better to have this written from the physician, rather than just from an EMR time stamp. Without seeing how a system's time stamp works, it's hard to say if the 'start' time indicates the time the exam started or the time that the patient came into the room. Auditors will look at having time in documentation when reviewing your records.

Use a score sheet. Some insurers or physician associations offer audit tool score sheet templates that can help you when auditing documentation. If you'd like to see a sample audit score sheet used by a pediatric practice, email editor Torrey Kim, CPC, CGSC attorreyk@codinginstitute.com.

The audit tool helps the auditor document the findings so that by the end of the record review, the documented information can be totaled to finalize the E/M key elements and come up with the appropriate level of E/M.

Tip: Be sure that the tool is compliant with the documentation guidelines. A record of the review should be kept as proof of the internal audit.

Educate your staff about your findings. After the audit, show your practitioners, coders, and billers what the outcome was so you can positively address any problem areas. For instance, if one of your physicians bills all 99213s, you might make him a card that explains the details of each E/M code.