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Coding Self-Audits Uncover Compliance Risks, Reimbursement Opportunities

In this age of automation, it’s tempting to rely on technology solutions alone to ease the burden of coding operations. And that’s OK; making coding easier is the primary purpose behind many of the coding and documentation tools available from leading EMR applications.

However, I’d like to offer a caveat: please don’t allow confidence in technology to detract from the value of self-audits. Technological aids don’t render coding and billing audits obsolete. As advantageous as some coding tools are, ongoing self-evaluation remains the single best way to ensure optimal coding practices – those that garner appropriate reimbursement while also protecting against payer investigations.

Take, for instance, evaluation and management visits (otherwise known as E/M services). They are the lifeblood of many practices, yet E/M services still account for a significant portion of the errors found in Medicare’s Comprehensive Error Rate Testing (CERT) audits. Perhaps that accounts for certain E/M services remaining on the Office of Inspector General (OIG) Work Plan for 2010.

Granted, a properly-constructed self-audit takes time and a degree of analytical savvy. But it’s the most reliable way to pinpoint your compliance risks, as well as potential reimbursement opportunities. It serves two proactive functions: 1) identify and correct coding errors and 2) support justifiable outliers.

The provider who consistently bills 99213 for every patient “just to be safe,” for example, in reality may open your practice to risk of payer audit. Payers often evaluate bell-curve data, which places “flat-liners” in the crosshairs. (Not to mention, a self-audit may reveal the provider’s services truly warrant higher-level, higher-paying codes.)

Conversely, you may be able to solidly defend the seemly risky provider who often bills the highest level visit codes. Your self-audit may show that this particular provider sees only high-complexity patients.

A good self-audit requires you to review your standards and procedures, as well as your claims submissions.  Here are some key guidelines to keep in mind:

  • Medical necessity is the “overarching criterion” for payment of any service. It is a compulsory element, in addition to the specific requirements of any CPT code.
  • The documentation itself – not the volume of documentation – supports the level of service reported.
  • Documentation of established patient office visits only needs to contain two of the three “key components” of the applicable code. However, it still must provide evidence to support the medical necessity of the visit.

Have coding and billing audits helped your practice?  What have you uncovered that you never expected?  What tips would you offer your peers?  Share any thoughts in the comments below.