Practice Management Alert

Hint: The easiest way to gain experience may be off the clock.

Hear what three experts had to say during a 2022 AAPC AUDITCON Panel session about the differences between coding and auditing. Find out how to navigate any transitions you may want to make between the two specialties.

“An auditor’s role primarily should be to discover opportunities, or how can we make the best better? Also, we want to make sure that we are looking to mitigate any possible problems that we might see,” said Christine Hall, CPC, CPB, CPMA, CRC, CEMC, AAPC Approved Instructor.

What’s the difference between an auditor and a coder?

Angela Clements, CPC, CPMA, CEMC, CGSC, COSC, AAPC Approved Instructor: In reality, coders and auditors are similar. When you look at the foundation of what they’re doing: coders read the documentation, extract the information, and apply a code to it. You’re doing that from the start as an auditor, you’re reviewing the documentation, and you’re making sure that what was coded is supported by the documentation.

A big thing to remember when you’re auditing is that a lot of people are focused on what the provider is doing wrong.

It’s important because you know nobody wants to hear what they’re doing wrong.

But tell the providers what they’re doing right as well and also look for those opportunities. Maybe they coded their E/M [evaluation and management services coding] levels correctly, and they got the right diagnosis codes.

But you can see with the note that there was an opportunity, had they coded XYZ, they could have supported a higher level of E/M, or they could have possibly had some additional diagnosis codes. Or, if you’re coding from a fee-for-service basis — some companies are still getting that risk score. If the provider just said that the patient had diabetes, there’s a huge difference when it comes to risk scoring between diabetes and the patient who has diabetes with a complication or multiple complications. This may be the one time in an entire year that the provider gets any education, so you want to look for any opportunities to educate the provider.

What’s an example of an educational opportunity an auditor can show a provider?

Hall: I did an audit the other day and I made it a point to let the provider know: “You had such great documentation! But you documented that, during this visit, you did a pap smear and a pelvic exam, but you never reported it! So, although you had great documentation, we found opportunities of areas that you were not reporting for additional services.”

As an auditor, we kind of focus in on quality, and we also focus on those areas that may have been missed. Maybe that wasn’t captured by the coder, especially when you have physician coders who are coding their own visits, their own encounters.

How do I get experience auditing so I can get a job as an auditor?

Clements: Usually, experience is where people have trouble. I highly recommend that, even if you’re not in an auditing role and you’re in a coding role somewhere, work with your team and find out if you can just review records and get that practice with auditing. If they let you go and audit the physician, get the practice there, or if you can sit in while your auditor audits the physician, maybe you can audit a record at the same time and then go with them to get the education.

While you may not be an auditor by job description, you’re at least getting that experience as a coder to say, “Hey, I’m a coder, but I have experiences with auditing.” You have to remember you might have productivity to meet as a coder, so there might be things you have to do off the clock. But if you want to be an auditor badly enough, those are some things that you may want to commit to.

Which roles in a practice or organization should be audited?

Hall: Auditing is full circle. You would have an auditor that goes and audits coders, working to be able to provide opportunity and education to those coders in those areas that maybe they’re missing something.

You would audit providers because we’re looking at documentation and looking for those opportunities.

I audit the billing cycle to see where in the billing cycle things are missing. I had an office that called and said, “We’re getting a lot of demographic denials.” So we went in and audited the front desk, and the first thing we found out was that the front desk person was dyslexic, and so they were transposing all the numbers, so we would never have found that out without investigating where there’s either an issue or high volume.