Is Self-Auditing Really Necessary?

Posted on 6 Dec, 2017 |comments_icon 4|By Elizabeth

Yes, yes, and yes—self-auditing is essential.

Given the federal government’s focus on ferreting out health care fraud and abuse, practices that don’t implement compliance programs are putting themselves at risk. A vital part of an effective compliance program is implementing a method to monitor your practice’s coding and documentation.

The Pivotal Role of Self-Audits

Medical auditing is a critical component in any compliance plan and is essential to each part of the revenue cycle as a starting point to ensure accurate coding, documentation, and reimbursement. There are many reasons why a practice would want to conduct periodic medical record audits:

  • To detect cases of fraudulent billing practices
  • To identify outliers within the practice (example: a provider that generates unusually high E/M levels)
  • To decrease the chances of a Recovery Audit Contractor (RAC) audit
  • To pinpoint inaccuracies in procedure coding, weak coding habits, and the undercoding and overcoding of E/M and diagnosis coding
  • To ensure quality patient care

Challenged with meeting compliance standards, you can protect your medical practice from falling into poor coding, billing, and documentation traps by learning how to perform self-audits.

An effective medical record audit will help you spot inconsistencies between coding and chart documentation. And knowledge is power. As you begin to recognize your weaknesses and inaccuracies, you open the door to training and improvement.

What is medical auditing?

Medical auditing consists of an assessment and evaluation of documentation, coding accuracy, and policies and procedures to ensure compliance and efficiency. An audit reviews the documentation and claims information to determine if a claim has been coded appropriately. It also reviews documentation to determine if procedures and guidelines have been performed in accordance to standard medical practice and CMS guidelines. Documentation reviews will involve both the clinical staff, medical providers, and physicians.

Medical record auditing is one of the best ways to improve documentation and ensure the longevity of your organization. Quality healthcare is amplified by compliant medical record documentation. Audits are essential to identifying areas that may require improvement and correction. The outcome of medical record auditing should be providing the best care to your patients, and maintaining and improving the overall financial health of the organization.

Education of providers and staff

You can use audits to educate providers on how to improve their clinical documentation. You can also use audits to educate coders and billers on the proper coding and billing of CPT® codes, ICD-10-CM codes, HCPCS codes and modifiers. Educate all parties involved in the process, and ensure that regular ongoing training is provided to staff.

In addition to coding updates, policies and procedures should be reviewed periodically. Regular training ensures that expectations are in the forefront of the minds of all staff members. If documentation inaccuracies are found, clarify information with the provider and ancillary staff. As improvements are made at each level, the risk of noncompliance should decrease.

Hot Topics and Targets

Federal entities provide updates on different errors that have been identified. A good auditor will be aware of these errors and take action to ensure that their practice is not guilty of the same mistakes. The goal is not to instill fear in others simply by hearing the word “audit.” As an auditor, you are a resource — not someone who is aiming to get others in trouble. Once others recognize this function, your work will be more appreciated and your co-workers will be more receptive to guidance.

Bottom line

Regular audits will ensure that your practice is prepared. A solid audit plan can ensure proper documentation and make it easier to identify vulnerabilities before RAC, or a private payer finds a problem.

Learn More

Are you too muddled by compliance regulations to even figure out the self-auditing process?

Master Auditing Basics is an excellent resource that lays out in-depth guidance for effective review of medical documentation. The experts at TCI show you how to conduct internal and external reviews of coding accuracy, policies, and procedures to ensure you’re running an efficient and liability-free practice.



Elizabeth works on an array of projects at TCI, researching and writing about modern reimbursement challenges. Since joining TCI in 2017, she has also covered the nuts and bolts of cybersecurity, compliance with federal laws, and how to tap into the advantages of telehealth services.

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