Audit tools are essential to successfully completing an audit. Whether you utilize electronic tools or paper worksheets, you will need access to good auditing tools. Electronic audit tools are helpful because they not only assist with the process, but also aid in reporting.
While electronic audit tools can do a great deal of work for auditors, a knowledge of auditing is a must. Electronic tools do not apply the concept of medical necessity, and an auditor will need to apply their own knowledge while working in the tool. This will be very important when auditing E/M codes. Good audit tools will walk an auditor through the most important aspects of compliance.
Tip: Electronic tools cannot determine medical necessity!
CPT®, ICD-10-CM, and HCPCS Level II code books should always be at your disposal when auditing. Coding manuals are essential for the coding and documentation audit process. The guidelines should be reviewed to ensure proper application of codes.
Tip: Double check the date of service to ensure the correct manual is utilized.
Prior to beginning an audit, it is important to consider the payer specific guidelines for the cases that are being audited. If auditing Medicare claims, determine the MAC for the region or location that is being audited.
Some MACs provide specific information pertaining to documentation and coding guidelines that must be adhered to. Review the information for the specific MAC on their website to familiarize yourself with the various policies. Medicaid policies
are also important to review, especially if you provide services for Family Medicine, Internal Medicine, Pediatrics, or Obstetrics and Gynecology.
Note: Private payers will also have their own policies that are sometimes not aligned with CMS. So be sure to know a specific payer’s guidelines before beginning the audit!
Remember: Your payer contracts may also hold vital information that is needed to complete an audit.
Example: Smoking cessation counseling shows how payer contracts and policies will be utilized to determine if documentation guidelines have been met. These codes are timed codes, so not only will you rely on payer guidelines, but you will also rely on CPT® for guidance.
CMS outlines specific guidance on what is included in the documentation for this code. CMS states that the patient has used tobacco, must be competent and alert during the time that the counseling is being provided, and the counseling should be furnished by a qualified physician or Medicare recognized practitioner.
Some Medicaid programs have gone a bit further with the requirements and have specified that, in addition to the patient using some sort of tobacco product, you must also document the cessation techniques, the length of time spent during the counseling, intentions for follow up with the patient, and the resources provided (i.e., 1-800-QUIT-Now or cessation pamphlets).
Tip: Internet searches will be helpful to locate payer policies!
It is essential that you have all documentation guidelines at hand to refer to during the audit.
The type of auditing you are doing will dictate which type of documentation guidelines you need. For example, E/M auditing relies on 1995 and 1997 documentation guidelines, while procedure auditing will utilize documentation a bit differently.
An auditor may rely on the CPT® manual for documentation guidelines, but at times, specialty specific manuals like the manuals that The Coding Institute publishes, will be a better resource to inform you of documentation requirements for specific codes.
Timed codes, like those for physical therapy, require the documentation to include the time spent with the patient. There are also codes from the integumentary system, for example, skin excisions, that require the documentation to detail the location and size of the excision.
When conducting an audit, whether it is an internal or an external audit, it is important to know the policies of the organization, which may impact your audit. For example, Medicare does not accept consultation codes. Most coders and billers know that you must convert consultation codes for Medicare patients to either new or established visit E/M codes.
An auditor may audit a case and think that it should have been billed as a consultation, but the patient is covered by Medicare. It would be helpful for the auditor to know that even though the documentation supports a consultation and the practice bills out a new patient visit, it is not coded incorrectly. They need to know that the office converts their consultation codes.
When choosing 1995 versus 1997 E/M documentation guidelines, knowing interoffice policies is important. Although CMS takes a stance that a provider can use whichever set of guidelines is more advantageous to the provider, some organizations require that their providers use certain guidelines. Knowing which guidelines the provider applies will be helpful during the audit process. An auditor can always provide suggestions on code selection based on standard documentation, but make sure you are aware of the policies of the office.
It would be helpful for an auditor to know if a practice or provider uses templates, forms, or any other type of documentation that may be separate from their general note. Sometimes a provider will refer to these forms in their note (i.e., “See patient questionnaire for ROS”), so having access to additional documentation will be essential and may make the difference in code selection.
The encounter form, or superbill, shows the codes that the provider selected. These forms are typically used for prospective audits where the claim has not yet been billed to the payer and the auditor is auditing the provider. CMS-1500 or UB04 forms are needed to review retrospective audits. You will need to determine what was billed out to the payer to determine if any coding errors have occurred. You can find sample encounter forms or superbills by searching on the Internet under the terms superbill or encounter form. Figure 3-1 shows a CMS-1500 form.
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