Whenever the word audit is used it usually causes some anxiety. This is especially true with some physicians who feel keeping up with the latest coding changes and still trying to manage a busy patient schedule can be an impossible task. At MTBC, our coders have to continually educate to stay abreast of new coding changes. If you do not have access to coding resources an audit of your current coding practices could be very beneficial. To maximize the benefit of a coding audit a physician should have a representative sampling of his or her work. For primary care physicians, the focus will be mainly on E & M encounters but if the physician is doing additional diagnostics or procedures in the office it is important to include these in the review. Many specialists will also include diagnostics and procedures in the encounters that are audited in addition to their E & M encounters. To get a good review, all documentation relating to the encounter needs to be included in the audit, including office notes and op reports when appropriate.
Although gathering a good sample of encounters with supporting documentation is critical to a good audit, the real benefit is in the review. To maximize the outcome of the audit the physician will want to set aside uninterrupted time to review and discuss the findings with the auditor. Reviewing the patient encounters in detail allows the physician to understand the auditor’s coding rationale and how the provider’s coding compares to other providers. Much of our coding reviews are focused on the supporting documentation. Issues with documentation or the verbiage used to document often leads to down coding an encounter. The review process is invaluable as an educational tool to address these types of opportunities. Reviewing examples of issues and solutions will greatly improve your coding. Conducting your review as a group of providers can also provide additional benefit as more encounters are reviewed addressing scenarios that may not have been included in one providers encounter sample. Reviewing as a group also helps the providers discuss opportunities to standardize encounter documentation and discuss any office changes that may enhance the documentation function.
As CMS increases its frequency of RAC audits, providers can use an internal audit to address coding issues in advance and hopefully avoid future RAC audit repercussions. Accurate coding is worth the time and effort. Taking steps now to identify and correct coding issues through an audit will optimize reimbursement and help minimize issues that may result from a future RAC audit.