Is your Coding Compliance 95%?
Did you know the OIG has set the accuracy rate at 95%? In every setting, documentation begins and ends with the physician. Medical coding audits are a significant part of maintaining compliance. According to the recommended OIG Compliance Plan for Physician practices, auditing and monitoring are critical to ensuring compliance.
At a minimum, every medical practice should conduct an audit of its coding and documentation annually. Clinical documentation should be reviewed continuously to ensure accurate claim submission and improve revenue along with documentation and coding.
Medicare, Medicaid, and Commercial payors consistently audit physician claims for office and hospital visits, surgical procedures, and ancillary services. Did you know that payors are auditing E/M services with procedures on the same date when using Modifier 25? Payment recovery occurs when services that do not meet the Modifier 25 definition of “Significantly Separately Identifiable.” All payors are performing recovery audits on a routine basis.
Since the guidelines changed in 2021, we have seen an E/M shift, with a significant increase in new patient level 4s (99204) billed. This makes it even more important to audit and monitor, as the higher-level E/M codes have proven to be a red flag. Are your higher E/M levels supported in the documentation and medically necessary? If you don’t know, you need an audit to see where you stand.
Ask yourself these five questions:
Are you certain you are audit-proof?
When was the last time you had an audit?
If a payor audited your coding and documentation tomorrow, would it pass?
Will your documentation stand up to payor scrutiny?
What parameters has your practice implemented to ensure your coding and documentation are compliant?
An audit can identify:
Incorrect code selection
Unbundling issues
Missed billing opportunities (missed procedures or undercoding)
Services that were billed but not supported with accurate medical record documentation
Higher levels of E/M services billed incorrectly
Incorrect modifier usage
Diagnosis coding errors and incorrect linkage to the CPT/HCPCS codes
Documentation deficiencies or discrepancies
Healthcare reimbursement continues to operate under numerous regulations and compliance requirements that depend on good documentation and accurate coding. An audit will improve documentation, ensure compliance, and ensure your practice receives the appropriate reimbursement for services provided.
Now is the perfect time to seek an expert review. KZA consultants have a wealth of experience and have meticulously examined thousands of chart notes. Our extensive specialty coding expertise establishes KZA as a trusted partner for audit and education. We’re here to help you. Contact a Client Services representative at 312-642-5616 to schedule your audit today.