Avoid Mistakes That Trigger Audits

Avoid Mistakes That Trigger Audits

Using the correct coding for medical diagnoses and procedures is most critical in order to get reimbursed and avoiding audits by payer sources like Medicare. Certain errors become red flags for payers and an audit will most likely come about because of it. Both Medicare and the private payers are looking into coding errors more closely. The Medicaid program has what is called an integrity program that addresses faulty billing. Medicare has several private contractors that audit for them. And these audits are not random. They are looking at high risk triggers such as referrals, complaints, and data analysis.

Below are common ways that providers run into problems and are at high risk for an external audit:

1.    A physician collects the wrong category of code.

2.    The physician selects a new code when the patient is established.

medical billing service3.    A physician selects a consult when the payer does not recognize the consultation codes and the claim is denied, then it is appealed.

4.    Doing all services at one level

5.     Billing all visits and other services at a high level.

6.    Getting too comfortable with a code and use it to bill frequently.

7.    Trying to increase revenue by coding for a higher level of service.

8.    EMRs can produce false information on a patient’s visit. A normal exam can be chosen on the system, but it is questionable whether a doctor performed whole exam or not.

9.    Also, there can be discrepancies within the exam documentation. A review of body systems could be checked with no gastric issues noted, but an entry of “complaining of abdominal pain” would be found elsewhere in the EMR.

By being diligent and mindful of coding correctly, many of the mistakes mentioned can be avoided. Trying to add codes where they are not applicable will not only trigger an audit, you will need to pay back the funds as well. Here are some techniques to utilize in your practice to avoid an external audit from a payer:

– Self-audit your documents. Go to the OIG Work plan where you will find a pdf file of the Office of Inspector General that give you a roadmap of areas you need to address.

– Do your auditing in areas where you have the highest volume of services that appear on the OIG Workplan.

– You may be able to go on your payers’ website and find the audit sheet that they use.

– Have your own worksheet to work from so that everyone can see things in the same way and see the same points.

– Compare coding to actual clinical documentation that has been previously recorded in the chart. This coding audit can help in revealing any variations from the national averages. Analyze whether the variations are due to inappropriate coding or frequent higher level coding.

– Physicians should understand coding and take it upon themselves to learn it.

– Always make sure that the code used really describes the service provided.


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