5 Questions about Coding Compliance- Chart Audits
What are the core elements of an effective coding compliance program?
The basic elements of coding compliance are auditing and education. A well-structured program includes a robust process of chart reviews that are followed by result-based education. This auditing process should be a continuous one, with emphasis on those providers demonstrating continued non-compliance and/or poor audit scores.
Education should also be delivered to new providers entering the group, as well as all staff who are involved in the claim submission process. It’s also important to provide annual updates to review coding changes, plus periodic updates to review any relevant legislative/policy changes which may impact the group.
What are the main triggers for a payer audit?
The main catalyst for an audit are aberrant billing patterns, as compared to providers of the same specialty in the same geographic area. These aberrations could include significant E/M coding level variances, overuse of modifiers, and “impossible days” (i.e. cumulative typical times associated with billed codes that exceed reasonable thresholds).
Does a complex patient encounter reduce or eliminate the need to meet other documentation requirements, such as review of systems, family history, or physical exams?
No. All documentation requirements associated with the billed code must be met. The only exception is when visits are predominantly focused on counseling. However, medical decision-making must still be inherent to the encounter.
Is it okay if we intentionally undercode?
The rules of coding state that the provider must code to the highest specificity and accuracy supported by documentation. In the event of a payer audit, the financial repercussions of such errors do not rise to the same level as overcoding.
However, an inflated error rate can be used to perpetuate additional auditing and higher scrutiny. Prepayment audits (which occur when a payer requires your notes before paying the claim) are particularly impacted by error rates, as the provider must usually achieve and maintain an acceptable level of accuracy for a predetermined length of time.
How often does an audit reveal underbilling or uncaptured revenue?
Chart reviews, either conducted internally, outsourced, or both are a very effective way of identifying specific services and/or providers who may not be billing for work performed or are undercoding office visits.
An ongoing process of auditing and monitoring typically reveals some degree of revenue opportunities, while at the same time identifying those providers in need of education or reinforcement of key concepts/guidelines associated with complete and accurate documentation to support billing.
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