Welcome to the new Outpatient Surgery website! Check out our login FAQs.
Coding & Billing
Self-Audits Made Easy
Torrey Kim
Publish Date: October 27, 2008   |  Tags:   Financial Management

We're going to show you how to set up a sound internal auditing system so that all your chart reviews run smoothly. Depending on the size of your facility, the number of physicians who operate there and the types of surgeries performed, the specifics of your self-audit will vary. Here are five guideposts to follow.

1. Choose your audit team. Involve your medical director, billing staff, office manager, administrator and anyone else who has access to billing data. Reassure those who consider the audit a witch hunt to find errors and to target problem employees that the audit is educational, not punitive, says Chris Felthauser, CPC, CPC-H, ACS-OH, ACS-OR, a coding consultant with The Coding Source.

2. Collect your resources. Set aside your CPT, ICD-9-CM and HCPCS Level II code books, as well as the most recent CCI edits and carrier coverage guidelines. Gather a random sampling of your records so that you vary the type of records that you'll audit. If your center bills 15 percent of its procedures for ophthalmology services, 15 percent for orthopedics, 15 percent for ob-gyn and 55 percent for podiatry, your sampling should reflect that.

3. Examine the documentation. You can perform a prospective audit (review charts that haven't yet been submitted to the insurer), or a retrospective audit (examine claims that have already been paid). There are advantages to both types. Prospective audits ensure that you'll submit accurate claims, whereas retrospective audits let you demonstrate how much money you forfeited due to inaccurate documentation (or how much inappropriate additional documentation you collected that you'll have to refund the payor). Review these items on your claims during the audit.

  • Verify that the correct patient health insurance claim number was submitted on the claim.
  • Verify that the surgical procedure was actually performed on the date submitted.
  • Validate the location where the surgical procedure was performed and verify the correct designation, outpatient or ASC.
  • Verify that all the surgical services submitted are reflected in the patient's medical records and operative report.

For retrospective audits, review the chart without first checking which codes were billed on the claim. Instead, ascertain what you believe to be the appropriate ICD-9-CM and CPT codes, then check the claim to determine which codes were billed. This is the most unbiased way to review charts for coding errors.

Another type of audit that you might find helpful is a comparison audit. "We sometimes compare our billing to that of the surgeon," says Ms. Felthauser. "If I find a discrepancy between what I want to bill for the facility fee and what the surgeon billed, I'll talk to the surgeon's coder. If we can't agree, we'll call an outside party to audit the claim to determine who is billing properly."

4. Report your findings. After the self-audit is complete, put together a presentation that discusses the audit findings. Call a staff meeting to review the errors you found and hand out documentation showing how you determined your findings.

If you found frequent documentation errors from the physicians who do cases at your center, alert them to your findings. Suppose you billed several meniscectomy claims based on an orthopedic surgeon's documentation. At the top of his operative report in his "Findings" section, he noted a lateral meniscectomy and a medial chondroplasty. Based on those findings, on your original claim you billed both 29881 (Arthroscopy, knee, surgical; with meniscectomy [medial OR lateral, including any meniscal shaving]) and G0289 (Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage [chondroplasty] at the time of other surgical knee arthroscopy in a different compartment of the same knee).

On closer inspection during your self-audit, you note that the physician didn't discuss the separate compartments in the body of his operative note. He only mentions work in the lateral compartment. Because you can only report G0289 when the procedures are performed in separate compartments, you realize that you submitted an erroneous claim and collected too much. Let the physician know that you plan to refund the facility's portion of the G0289 reimbursement to the carrier.

If you find a particular coding error that you want to share with all your surgeons, carve out time during a board meeting to discuss those findings, says Ms. Felthauser.

5. Retain the audit documentation. Always hang on to the records from your self-audit. This way, you can demonstrate what you reviewed and how you changed your coding practices to fit the audit results.