Urology Coding Alert

Find errors and compliance issues before an outside auditor does. 

Are you confident that your urology coding and billing would hold up to scrutiny from a payer auditor? You can ease your stress and stop worrying when an auditor will knock on your door by performing internal reviews of your urologist’s coding and billing.

Review advice from the experts on how you can use internal chart reviews to evaluate your practice’s compliance and billing processes – before someone else does.

Know the Reasons for Auditing

Performing internal audits can help you ensure billing and coding compliance and may also help you find money you’ve been leaving on the table. Finding problems early helps alleviate risk. Audits will also uncover inconsistencies in documentation and coding so you can focus your staff education. For example, maybe something conveyed was misunderstood, or confusing, and that will come out in the audit.

“Internal audits are a way to make sure you are on track and nothing has gone awry,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. “By doing internal audits, you can identify opportunities for education, opportunities for the development of better forms, and opportunities to tune up the practice in terms of its processes visa vie the compliance commitments made by the practice.”

“Maybe something conveyed was misunderstood, or confusing, and that will come out in the audits,” says Suzan Berman, CPC, CEMC, CEDC, manager of physician auditing compliance at West Penn Allegheny Health Systems in Pittsburgh, Penn. “Without regular internal audits you would have no idea how the practice is doing with regard to its compliance of the regulations and guidelines.”

“It is better to do an internal audit to identify any opportunities the practice has to improve in the areas of documentation, coding, process, and compliance without anyone from the outside coming in and imposing it on them, while taking monies from the practice, accusing them of fraud and/or abuse, civilly or criminally,” Cobuzzi adds.

Tip: Refer to these internal audits as reviews if being done as an educational exercise, Berman suggests. “That way they are not as threatening as the word audit may convey,” she explains. Some people equate an “audit” with finding mistakes, but “reviews” are considered check-ups of your coding practices and using the term “reviews” seems less confrontational and accusatory.

Choose Prospective vs. Retrospective Auditing

There are two types of internal chart audits your practice needs to look at before determining which will work best in your office:

·         Prospective audit — Your practice examines new claims before you file them.

·         Retrospective audit — Your practice examines paid claims.

A prospective audit helps you identify and correct problems before sending the claim, which could mean you’ll discover incorrect coding or charges that would otherwise have been missed. However, keep in mind that this type of chart audit can potentially delay billing.

Alternative: Retrospective chart audits do not delay billing, but cause your office to be reactive by refilling claims, rather than proactive in finding problems before you submit the claim.

“Prospective audits for coding and billing are always better than retrospective audits because, if an error is found, you don’t have to pay the money back and bring to light to the payer that an error took place,” Cobuzzi says. “But if it is not possible to do prospective audits, retrospective audits can take their place. Just remember, that any errors in billing or coding must be corrected, this includes under and over payments.”

Best bet: Your practice must determine for itself what types of audit your staff can reasonably complete, and what effects on claim submission timing and cash flow the practice can handle.

Set Your Audit Schedule and Process

How often your practice performs an internal audit will depend on the size and type of your practice. Consider the amount of resources the practice can devote to the audit while simultaneously conducting day-to-day office business.

Pointer: Remember that the more often you can audit, the cleaner your claims will continue. At a minimum, you should conduct an internal audit at least twice a year, experts advise.

Determine your focus: Most offices should concentrate on their evaluation and management code levels during an audit, because “they are always looked at carefully by many payers. However, if your office does more procedures or lab services, you should concentrate your efforts there,” Berman says.

“Remember an audit is much more than coding, it involves, documentation, coding, billing and data input, denials management, and office process following policies and procedures,” Cobuzzi says.

Start with a baseline: You should begin your audit efforts by performing a baseline audit — the first comprehensive audit your practice undergoes. With the information gleaned from a baseline audit, you’ll be able to streamline future auditing efforts and focus on the most important areas to your insurers. The baseline will help you decide how frequently you need to perform future audits and also help you determine the areas for improvement that your practice should focus on between audits.

Going forward: How often you perform internal reviews after the baseline audit depends on several factors, including your time and staff resources, the baseline audit’s results and your practice’s size. In most cases, plan to perform an internal audit at least once per year, and more often if you find high error rates.

Plan to perform an internal audit at least once per year and more often if you uncover low compliance rates, Berman suggests. “If the size of the practice or auditing staff permits, every six months or quarterly could certainly be advantageous,” she adds.

Without regular auditing, you could be making regular billing mistakes over and over again. And if an outside auditor finds those problems, the practice might have to refund thousands of dollars and face further penalties and fines, Berman says. “You never want to be surprised [in an audit],” Berman says.

Act on Your Findings

Following the audit, you should develop some tools within your practice to make documentation easier. For instance, if your audit reveals that one physician in particular bills all 99213s (Office or other outpatient visit for the evaluation and management of an established patient ...), make him a card that explains the details of each E/M code, or write up a template that shows him exactly how many elements in each section must be examined before he can bill 99214. Then he’ll be more inclined to select the right code.

Some experts recommend that each physician memorize the requirements of the E/M code that he bills most frequently. Then, if he performs more or less than what that code requires, he’ll know to bill a different code, and he can look up the requirements of the others.

Or you might want to make up a list of the top-50 diagnosis codes that your urology practice reports so the physician can easily reach for the right ICD-9 code every time, rather than writing nonspecific diagnosis statements such as “incontinence,” which often leaves questions about the type of incontinence or cause.