Radiology Coding Alert

Performing an audit can help your practice correct documentation errors before your claims are even submitted. Being proactive instead of reactive to an audit will improve your claims’ chances for reimbursement.

Learn the most common documentation errors auditors find and how to correct them.

Understand an Audit’s Importance

The word “audit” may initially illicit fear, but the process isn’t necessarily a bad thing. “Audit is normally one of those scary words, right? We don’t want anyone to come in and audit our records because we honestly feel like they’re trying to find something that we haven’t done right,” said Amy Pritchett, BSHA, CCS, CPC, CPC-I, CANPC, CPMA, CASCC, CDEO, CRC, CPMP, CMPM, CMRS, CEDC, C-AHI, Approved ICD-10-CM/PCS Trainer, AAPC Fellow, senior consultant at Pinnacle Enterprise Risk Consulting Services LLC, during AAPC’s AUDITCON 2022 session, “Why We Audit — Identifying Risk and Opportunity.”

While audits are sometimes necessary to review improper payments or incorrect billing, you can also perform audits to review factors that are affecting your practice’s bottom line. A practice may perform an audit to understand why their revenue has decreased, identify why medical necessity edits have increased, or ascertain why they’re receiving more denials than usual.

Identify Insufficient Documentation Errors

One of the most common errors auditors find is the lack of sufficient information. “These are going to be errors that are located in the medical documentation and are determined to have inadequate information to support a payment for those services,” Pritchett said.

The U.S. Department of Health and Human Services (HHS) Office of the Inspector General (OIG) sees similar errors each year regarding insufficient documentation. These mistakes include:

• Inadequate information to support payment
• Inconclusive evidence that some allowed services were provided
• Inconclusive evidence that services billed were provided at the level billed
• Inconclusive evidence that services billed were medically necessary

Correction: These errors can be corrected by querying the provider when you notice the documentation is missing the crucial information that you’ll need to submit the claim.

Spot CERT Documentation Errors

Medicare’s Comprehensive Error Rate Testing (CERT) program aims to approximate the Medicare Fee-for-Service (FFS) program’s accuracy. In the program, Medicare collects a random selection of claims and medical records, reviews the claims, assigns the claims to any of the five improper payment categories, and then a Statistical Contractor calculates the Medicare FFS improper payment rate.

One of the CERT documentation errors that Medicare has discovered involves incomplete progress notes. Auditors have discovered that some progress notes aren’t dated, aren’t signed, and may contain insufficient information to warrant reimbursement.

Another CERT documentation error involves unauthenticated medical records. Errors involving signatures (or lack thereof) account for several of the unauthenticated medical record errors. For example, the documentation may be missing a provider’s signature or the supervising physician’s signature. At the same time, a record may have an electronic signature, but the practice doesn’t yet have an official electronic record policy in place.

The medical record could also be missing the physician’s intent to order services or procedures. “The intent must be included within the creation of the documentation of the encounter, and this is simply going to accurately define the medical necessity. When that provider can transfer exactly what happened in that room to the patient documentation in the medical record, the intent is going to be the most valuable portion of your documentation,” Pritchett added.

Correction: To correct this error, the physician needs to supply a complete and signed order or progress note that explains the intent of the services to be provided.

For example, a patient visits their primary care physician (PCP) after the patient injured their knee during a basketball game. The PCP performs a physical evaluation of the patient’s knee and orders magnetic resonance imaging (MRI) of the knee with intrathecal contrast for further evaluation. By ordering the knee MRI, the PCP is showing intent to continue patient care and the initial knee examination exhibits the medical necessity for 73722 (Magnetic resonance (eg, proton) imaging, any joint of lower extremity; with contrast material(s)).

Support Common Procedures With Sufficient Documentation

If a patient’s medical record doesn’t include recorded images or indication that images were captured, that constitutes insufficient documentation. Insufficient documentation errors apply to common procedures, as well.

For example, you have a medical report showing that a patient presented to their PCP with complaints of stomach pains. The PCP documented that the patient is being referred for a laparoscopic cholecystectomy, but the medical record doesn’t list imaging studies nor does the record include the images that should’ve been recorded. Without an X-ray, computed tomography (CT) scan, or MRI, there isn’t any evidence to support the medical necessity for removing the patient’s gallbladder.

“CT scans are one of the major OIG audits in 2023, and they’re looking for three things. They’re looking for intent to order, insufficient documentation in the medical records, [and documentation] that supports medical necessity for the CT scan being done,” Pritchett said.

Correction: Double-check the documentation and the medical record for information and images related to the radiological studies. Query the provider if any of the required materials are missing that can help back up the claim.