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Tips to Avoid a Coding Audit: Use SOAP, Don’t Use Paste

AuditCopying and pasting: it’s a harmless task when snagging free clip art from a favorite website or sending 10 slightly customized emails to favorite relatives. But when you copy and paste notes from a patient chart into an EHR, you could leave yourself vulnerable to a coding audit.

Patient notes that are copied and pasted do not always accurately reflect what happened during a patient visit, which can flag auditors to an inaccurately billed claim, according to in an MGMA In Practice Blog post. As a result, office visits that were billed at a level 4 or 5 could be reclassified as “less severe” — with providers having to pay back the difference — or the claim could be denied, says Nancy Enos, FACMPE, CPC-I, CEMC, CPMA, principal, MGMA Health Care Consulting Group.

The “3 Ways to Help Avoid a Coding Audit” blog notes that this minor detail can make a big difference in claims management — and in the quest to avoid an audit. In MGMA’s 2014 Virtual Compliance Academy, Enos, warns that other details can prove just as critical.

For instance, the word “routine” used to describe the reason for a patient visit can be interpreted to mean the appointment was unnecessary. Rather than stating “routine visit,” Enos recommends being specific about why a patient made the appointment, using phrases such as, “here to establish care,” or “here for radiology results.”

Next, it is essential to document and justify excess time with patients. Sometimes patient needs consume the entire visit, which prevents providers from fully documenting the visit during the appointment. That’s OK, Enos says, as long as a provider documents the time he or she spent speaking with a patient in the service range area of the chart.

In addition to these tips, Enos recommends using the SOAP (subjective, objective, assessment and plan) notes approach to guide effective clinical documentation.

For more information on medical practice compliance, download the on-demand MGMA 2014 Compliance Virtual Academy.

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About the author: Susan Schooleman is a staff writer at MGMA.