Pediatric Coding Alert

Our experts offer insights, proven strategies for this important management tool.

Self-audits are a little like visits to the dentist — you know that they might turn out to be painful, but you also know that they are important for your well-being.

That’s why we prepared this two-part series on self-audits to give you a deeper understanding of why you need to regularly perform them in your practice. We reached out to two pediatric audit experts and asked them to lead you through the process using simple, proven techniques to arrive at insightful results that will benefit you and your providers.

So, if you need a reminder about why self-audits are a necessary evil, or if you’re looking for some guidance on how to streamline the process, look no further. We promise this won’t hurt a bit.

Why Perform a Self-Audit?

“Simply put, all practices should be concerned that they are coding to compliance and coding for proper reimbursement,” cautions Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

On the compliance end, self-audits can help your practice stay familiar with existing payer guidelines and keep you current with changes as they arise. Additionally, if the unthinkable happens and Medicaid or a private payer claims it has overpaid your practice, evidence that you have regularly conducted internal audits will go a long way to show the payer that your practice has established a culture of compliance and that you have been acting in good faith. That, in turn, may persuade the payer that the overpayment was the result of unintentional error rather than deliberate fraud.

But the most obvious reason for conducting an internal audit is financial. A successful audit can help you identify billing mistakes produced by inaccurate coding or workflow problems that can result in delayed or even missed payments. Regular audits can be opportunities for education on documentation and coding as well as for streamlining practice procedures and creating money-saving efficiencies.

Step 1: Determine Frequency, Scope of Audit

The first component of a successful self-audit is to determine its frequency and scope. For frequency, “you should perform an audit at least once a year, and preferably twice a year, to make it easier on your coding staff. This should be a continuous audit where a few providers are chosen every month if there are a large number of providers,” suggests Holle.

In addition to the frequency, you should also decide “which clinicians you’re going to examine, how far into past service dates you’re going to go, how many records per doctor, and so on,” recommends Jan Blanchard, CPC, CPMA, pediatric solutions consultant at Vermont-based PCC.

Step 2: Pull the Notes

For a broad examination of specific codes, you’ll need to pull “a bare minimum of five records per doctor,” Blanchard suggests.

Step 3: Analyze the Notes

This is where things can get a little complicated, as there are two schools of thought about how you should accomplish this.

To compare or not to compare: On the one hand, there are those who advocate comparing the frequency of procedures and services your pediatrician performs with national averages for pediatricians performing the same procedures and services. This requires comparing your data to national data such as the American Association of Professional Coders (AAPC) evaluation and management (E/M) Utilization Benchmarking Tool (www.aapc.com/resources/em_utilization.aspx) or the Medicare Provider Utilization and Payment Data (www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/medicare-provider-charge-data/physician-and-other-supplier.html).

The comparison requires you to look at the frequency with which you document a particular code with the national average. Then, “if you find yourself coding 99213 80 percent of the time, when nationally the percentage for 99213 is at, say, 45 percent, you know this is an important issue to address,” Holle argues. “This forces you to ask, ‘Why are so many of our visits at a lower level? Is it because of poor documentation or poor understanding of what is involved in a certain level of care?’” Holle continues.

In other words, this is a great opportunity for you to review whether you are coding, documenting, and billing the code correctly.

Some, however, question this approach and argue that you can ask the same questions without having to search for data outside of your own practice.

“Unless your carriers are holding you accountable as outliers, I don’t recommend these kinds of comparisons. And even then, their deviation should be defensible by your encounter notes,” Blanchard maintains.

In next month’s issue, we’ll continue to look at how you should analyze the data obtained from your self-audit, as well as providing advice on what to do with the results you obtain.