MPM Publications
When The Auditors Call...Are You Ready?
Whether you have FBI agents asking your employees to "please step away from your computer" or you have just received a friendly letter from a third-party payor requesting backup documentation for charges that you have submitted, an audit can be a stressful event. How can you take the worry out of a potential audit? The standard answer is to address all of your health care risks with a compliance plan and make certain all of your employees (including physicians) follow the plan. The answer is easy; getting there is the challenge.
When we think about an external audit the following questions come to mind: What are they looking for? How can I be prepared? What is my liability? During an audit, the key question in an auditor's mind is: Does the chart justify the bill? The patient's chart (report) should be the beginning and the end of the audit trail. Never make the auditor look elsewhere for pertinent information used to justify the medical codes assigned. The key element is documentation. If it wasn't documented, it didn't happen; therefore, it is crucial that only items clearly documented are billed to the payors.
Coding risks include acuity based coding, unbundling/fragmented billing, upcoding (assumption coding), improper use of interfaces, incorrect modifier usage, improper use of encoders, utilization of outdated codes, utilization of "cheat sheets," improper use of payable diagnosis lists and not assigning diagnosis codes to their highest degree of specificity.
When auditors evaluate anesthesia practices they are looking to ensure that the medical direction of concurrent cases do not overlap inappropriately. The incorrect "rounding" of time units also is an area of concern. Other areas that are audited to ensure that a practice is coding and billing for these services correctly are epidurals for delivery, ventilation management, critical care, special monitoring (e.g. central line, Swan-Ganz) and post-op pain management. As will all coding issues, it is important that the payor guidelines be met and that the documentation is complete in the patient's medical record to support the charges.
Every physician practice should have a compliance plan that addresses the coding risks for their organization. Policies and procedures are the foundation of a compliance plan. These policies should address all coding and billing risks for the organization and must be realistic and followed at implementation. Examples of key coding policies include ICD-9, CPT-4, Modifiers and Locum Tenens.
It is crucial that the persons performing medical coding for the practice have appropriate training. To ensure a consistent level of training, many organizations have chosen to employ nationally certified coders such as Certified Professional Coders (CPCs) and Certified Coding Specialists-Physician (CCS-P). Both credentials focus exclusively on coding for physician services.
Since outside organizations are already taking a closer look at your coding patterns, it is important that you perform regular self-examinations. Internal audits are a vital tool in determining your risks before an external audit happens. You are more in control of a situation when an external auditor brings a problem to your attention and you are able to respond with a "yes, that was a problem last year but we corrected that on a go-forward basis nine months ago." Correcting a problem does not necessarily relieve you of all responsibility associated with the original problem, but it does show a good faith effort to perform correct coding and a willingness to correct your problems.
For internal audits, the current trend is to perform pre-submission audits before the claim is sent to the third-party payor. Pre-submission audits allow you to discover problems and fix them without an incorrect submission. Post-submission audits also are a valuable tool but they should always be performed with care and with the assistance of your regulatory counsel. To ensure that all of your potential problems are uncovered and addressed, it is helpful to bring in outside organizations that specialize in physician coding audits. Valuable information such as payor trends across the country for specific areas of concern and payor contacts are very useful.
While the thought of an audit by a third-party payor is stressful, there are many proactive steps you can take to protect your practice. Identify your risks, implement relevant policies and procedures, and examine your practice patterns through internal and external audits on an ongoing basis. Even though there is no magic formula to ensure that your practice does not get audited, you are in greater control if you know where your potential problems lie.
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