Pulmonology Coding Alert

Question: We recently got a letter asking us to submit some records for review. We don’t see Medicare patients and the letter is from Blue Cross Blue Shield. Is this a mistake?

Massachusetts Subscriber

Answer: A payer’s review of records doesn’t necessarily mean you’re being audited. In some cases, these types of letters are routinely sent in response to specific codes. For example, if you submitted an unlisted code without any description of the service that the doctor provided, chances are that the insurer will need to see the documentation without proceeding.

Having said that, it’s still possible that you are being audited, because Medicare is not the only insurer that performs audits. According to the Blue Cross Blue Shield of Massachusetts website, “Blue Cross Blue Shield of Massachusetts conducts provider audits of paid, professional provider claims to verify the accuracy of claims reimbursement in accordance with the plan’s agreements and the National Healthcare Billing Audit guidelines.”

Your best bet is to comply with the documentation request, and provide the information in a timely fashion. If you have reason to believe the audit is more extensive than a typical focused review of services, you may want to contact your legal team, a health care attorney or consultant for assistance.