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Code at the Correct Level: Answers for Effective E/M Audits

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Evaluation and Management (E/M) coding is far from an exact science. But whether you consider it an art or a science doesn’t change the fact that your practice must be in compliance with coding and documentation rules. That’s why it’s so crucial for practices to conduct periodic E/M audits to help verify that you’re coding accurately based on appropriate documentation.

To get the most out of your E/M audits, here are some answers to commonly asked questions:

Question #1: How often should I audit, and how many records?

Answer: You should perform an audit on every provider in your practice at least once a year to get the most comprehensive, practice-wide picture. The ideal number of records to review per provider will vary depending on the practice, but 10-15 randomly selected records generally are sufficient.

Question #2: Who should I target?

Answer: In addition to annual reviews of all providers, consider targeting physicians who’ve recently joined your practice to make sure they’re documenting and coding effectively. You may even want to conduct proactive audits for a short time, reviewing their code selection and providing feedback before billing any charges. Although this approach can delay the claims submission process, it can be valuable for helping a new provider fully acclimate to your practice’s coding approach.

Question #3: What should I look for?

Answer: Look through your reports to identify any claims issues, then use your E/M audits to help get to the bottom of them. For example, if your practice is experiencing an increase in the number of Medicare denials or an increase in the number of Medicaid claims, you could focus on reviewing charts that tie back to those payers.

Question #4: How do I know if our coding is on-target?

Answer: One simple way is to look at published bell curves. Available from many state, federal and commercial sources—as well as many professional organizations—bell curves help compare how a specific physician uses E/M codes versus his or her peers. Practices can use bell curves to compare physicians internally, by specialty, by region, by payer, and more. If any of your physicians appear to be outliers, check to see whether they are coding correctly based on the documentation. The results may highlight the need for focused education and training. On the other hand, they may just show an unusual case mix. Just be sure the documentation justifies the codes billed because being a consistent outlier may raise the possibility of payer audit.

To ensure both your coding process and your auditing approach are effective, consider having a third party audit your practice periodically—perhaps every few years. Whether a consultant or someone from a larger affiliated organization, an outside auditor can offer a fresh perspective.

Using this strategy and the answers above, you can turn your E/M audits into an effective compliance tool for your practice.