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Insurance Q & A
Does Your Facility Need an Audit?";
Lolita Jones
Publish Date: June 9, 2008   |  Tags:   Financial Management
Whether you handle your billing and coding in-house or outsource it, whether your coder has tons of experience or is just starting, every facility can benefit from periodic coding audits. The Office of Inspector General recommends performing "regular, periodic compliance audits?to address?compliance with laws governing kickback arrangements, the physician self-referral prohibition, CPT/HCPCS, ICD-9-CM coding, claim development and submission, reimbursement, cost reporting and marketing." Audits are a good way to catch random errors and pick up patterns of inappropriate coding practices.

Frequent in-house audits are always a good idea, but it may also be helpful to periodically hire a coding consultant to perform a thorough, unbiased audit and provide some fresh perspective.

Many of the consulting firms that audit ASC cases can be found in the handouts for ASC-related conferences/conventions and some of them are exhibitors at these meetings as well. An audit can take anywhere from two to five days (on-site) depending on the case mix of your ASC. It may cost you several thousand dollars depending on the number of days that the consultant is on-site and whether you request that the consultant prepare a formal final report of his/her findings. I would recommend having an audit performed at least once a year.

In addition to spot-checking cases that you've already billed for, have the coding consultant review cases that you haven't yet submitted for payment to catch and correct mistakes before you submit them for reimbursement.

Ask the coding consultant to identify, in writing, the medical records with missing or inappropriate modifiers, ICD-9-CM diagnosis and procedure codes, CPT codes, and HCPCS Level II codes (as reported by the ASC staff for facility component billing). Also ask her to provide official coding guidelines and/or clinical references for any changes she recommends. Have the consultant spend time with your coders to teach them better ways of coding and develop a plan for resolving issues.

Catching mistakes early could save you from major trouble down the road. To give you an idea of what you might find, here are some sample findings from concurrent pre-bill coding audits that I recently conducted at three ASCs. These cases represent cases that could be found in most multi-specialty ASCs, and there are lessons that can be learned from each of these.

Record 1:
Integumentary System
The Blue Cross/Blue Shield patient was seen for re-excision of forehead basal cell carcinoma with advancement flap closure of the defect site. Per the operative report, the advancement flap was used to close a defect site measuring 5 x 2.5 cm (12.5 sq cm).

This case was inappropriately coded as 14040 (Advancement Flap Closure, Forehead, 10 sq cm or less). To be corrected, the 14040 designation should be deleted and 14041 (Advancement Flap Closure, Forehead, 10.1 sq cm to 30.0 sq cm) assigned instead. Code 14041 classifies the 12.5 sq cm defect site dimension.

In cases such as these, remember to assign adjacent tissue transfer codes based on the dimensions of the wound/defect in square centimeters.

Record 2:
Musculoskeletal System
The Blue Cross/Blue Shield patient was seen for right arthroscopic acromioplasty and arthroscopic rotator cuff repair. The coder inappropriately assigned code 23420 (Open Rotator Cuff Repair).

To be correct, the coder should delete 23420 and report 29826 (Arthroscopic Acromioplasty) and unlisted arthroscopy code 29999 for the arthroscopic rotator cuff repair. As per the "CPT Symposium 2002" handout (prepared by the American Medical Association), remember that there is currently no CPT code for arthroscopic rotator cuff repair and as such the CPT code 29999 for unlisted arthroscopy procedure should be reported.

Record 3:
Digestive System
The Medicare patient was seen for a colonoscopy due to a family history of colonic neoplasia. The physician does not state that this is a "screening colonoscopy" in the medical record; however, the Coder assigned a screening diagnosis code of V82.89. In addition, the procedure was not coded as a screening colonoscopy (G0105 or G0121); rather, it was coded as a diagnostic colonoscopy.

This record should have been reviewed with the attending physician. If the patient was seen for a screening colonoscopy, this must be documented, and the CPT code 45378 should be changed to G0105 (high -risk patient) or G0121 (non-high risk patient). If the patient was seen for a diagnostic colonoscopy, the diagnosis code must be changed from the screening diagnosis code, to a more appropriate code (depending on the physician's clarification).

Remember to educate your physicians on the need to document whether their colorectal cancer screening patients are high risk.

Record 4:
Female Genital System
The commercial patient was seen for a diagnostic hysteroscopy and a laparoscopic left salpingectomy, which was correctly coded. However, no CPT code was assigned to classify the laparoscopic lysis of adhesions. Per the operative report: "... extremely retroverted fixed uterus with adhesions holding it to the posterior cul-de-sac... The left fallopian tube was dilated, was completely wrapped and encased the left ovary. It was also attached to bowel and to the left pelvic cul-de-sac."

The code that would need to be assigned is 58660 (Laparoscopic Lysis of Ovarian/Tubal Adhesions), as this is supported by the operative report documentation. Per the CPT Assistant, January 1996, AMA, lysis of adhesions should be reported if the following are documented in the medical record: adhesions are multiple or dense, cover the primary operative site, or add considerable time to the operative procedure and increase the risk to the patient.

This case demonstrates the need to educate your physicians on the documentation needed to support the additional coding and payment of lysis of adhesions and to use the documentation to accurately code the procedure.

Record 5: