5 Tips to Pass Medical Claim Audits for Physician Practice

Audits – whether internal or conducted by an outside consultant – are a reason for stress, but you can make the process as painless as possible by keeping your coding accurate and focusing on these key areas every day.

Medical Audit

1. Report the Most Appropriate Diagnosis

Procedures in the operation room don’t always happen the way the anesthesiologist (or the surgeon) planned, and there are numerous times when surgeons need to perform some unplanned surgical procedures. In such situations, you need to be able to think fast and accurately. When a postoperative diagnosis is more descriptive of or relevant to a procedure, coders should use it instead of the preoperative diagnosis. You may need more than one supporting diagnosis, depending on the situation and the carrier.

When looking up CPT® codes, you should choose the one that explains most clearly the service that your surgeon actually performed.

2. Double-Check Procedure Times

Time units are an extremely important part of the anesthesia billing equation, and, therefore, you must always remember to double-check the patient records to make sure that the times you reported in your claims are absolutely correct. It is also important to note the exact start and stop times for the procedure or service that your anesthesia provider performed. If you round off times up or down, it can lead to OIG scrutiny, decreased amount of reimbursement, and fine or punishment, and even cancellation of your physician’s license.

Apart from this, you must also make sure that the anesthesia provider must be present for any face-to-face time that is billed. It is important to also make sure that any “physician performance” modifiers, such as–AA, -AD, -QK, QS, QX, etc., are met and documented well.

3. Know the Patient’s History

Patient’s past medical-history can have a bearing on your anesthesia codes, and this information can be extremely important to a coder, even if the patient has completed the treatment.

4. Confirm the Physician’s Role

Always remember to double-check to make sure that each patient record correctly documents the physician’s level of involvement in the case.

5. Stop Any More Errors in the Future

The main purpose of an audit is to help check the accuracy of the patient records, and coding mistakes will definitely come up in them. It is a wonderful chance for you to correct them and prevent from happening in the future. You can take these simple steps to rectify the coding mistakes and make sure they don’t repeat in future:

  • Conduct internal audits each quarter. You can also hire a consultant to perform an audit annually.
  • Conduct post-audit checks, especially in the areas that you find have problems.
  • Follow up on the problem areas.
  • Motivate your coders and billers to participate in continuing-education programs to make sure they stay on top of coding updates.
  • Hold regular meetings with your coders and billers to keep them updated about changes in coding and billing rules and any changes in your practice’s rules.