Radiology Coding Alert

Question: Do you have any tips for performing a coding self-audit?


Mississippi Subscriber

Answer: A self-audit catches services your practice isn't coding but should be getting paid for and lets you correct compliance issues before the OIG comes calling.

Gather current CPT, ICD-9, and HCPCS books, NCCI edits, local coverage determinations, and E/M guidelines, along with a medical dictionary for reference. 

Audit at least 10 to 15 records per physician if you're in an outpatient practice or 5 to 10 percent of records if you're at a facility. Perform the audit as a team and include physicians familiar with the coded services.

For each chart, answer the following questions:

• Does the documentation support the level of service reported? Is the documentation complete relative to the provided services?
• Does the documentation support the CPT, HCPCS, and ICD-9 codes reported?
• Are units billed correctly?
• If the physician coded a consult, does documentation of a request from a third party exist in the chart? Does the chart contain a written consult report that was sent to the third party? Is there a transfer of care for the condition?
• Did the physician use modifiers correctly?
• Did the physician sign and date all entries?
• Is the chart legible?
• Is the name and identification number of the patient and provider on each medical record and claim form page?
• Does the patient identification sheet include completed biographical data, including the patient's address, employer, home and work telephone numbers, and marital status?