Keep Practice out of Auditor Targets by Knowing These Triggers

Posted on 19 Jan, 2016 |comments_icon 1|By Chris Boucher

Pay attention to this coding hotspot quintet to minimize audit chances.

Most medical practices live in fear of the audit. Even with the most robust policies in place, there’s always that feeling that the practice could be doing more in case a payer wants to check your books.

Luckily, you can count on advice from experts like Frank Cohen, MPA, MBB, principal and senior analyst for The Frank Cohen Group in Clearwater, Fla.

Check out what Cohen had to say about can spark an audit in his January 7 Webinar, “Is Your Practice a Government Target? Pre-Audit Risk Analysis.”

Look Out for Audits from Government, Private Payers

Cohen reports that an audit is a review of medical claims, and the auditor could be either a government or a private payer. A payer might opt to audit your practice for several reasons; a random event that created an anomaly in your coding/billing, a benchmarking event, etc.

In all actuality, however, “it may be impossible to determine what triggered an audit,” says Cohen. “But you must always be prepared for one.”

Focus on These Audit Hotspots

According to Cohen, payers decide to audit most frequently due to concerns in the following areas, which he defined as “The Big 5”:

  1. Evaluation and Management codes (99201-99215, etc.)
  2. CPT® procedure code utilization by frequency
  3. CPT® procedure code utilization by relative value units (RVUs)
  4. Modifier utilization (modifiers 25, 57, 59 [or the new ‘X’ modifiers], etc.)
  5. Time (total provider work hours your practice bills for)

Best bet: Be sure to keep compliant with all payer rules on all issues — but take extra care to ensure that you have no compliance holes in Cohen’s aforementioned “Big 5” areas.

Eliminate Reasons for Audits

Within Cohen’s “Big 5” of audit hotspots, there are several specific missteps that could drive auditors to your front door. According to Cohen, practices are frequently penalized for these reasons:

  • No documentation: The provider doesn’t submit any medical records to support the claim.
  • Insufficient documentation: The provider’s documentation lacks certain patient facts that the payer deems vital (e.g., the patient’s overall condition, diagnosis, services the provider performed, etc.).
  • Medically unnecessary service: The payer’s claim review staff identifies information in the medical record that leads them to decide that services the provider reported “were not medically necessary based on Medicare coverage policies,” Cohen reports.
  • Incorrect coding: The provider submits documentation that does not line up with the choice of code. This is often a result of overcoding, but undercoding could also spur a payer’s auditing ears.

Best bet: Strive to bulwark the documentation, ICD-10 and CPT® coding on all of your claims to reduce the risk of an audit.


Chris Boucher

Chris Boucher has nearly 10 years of experience writing various newsletters and other products for The Coding Institute. His blog will cover several areas of coding and compliance, including CPT® coding, modifiers, HIPAA compliance and ICD-10 coding.

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