Audit Sample
- 1. Billing and Coding Audit Results Date Facility
- 2. Audit Results • Medical Records Audited: 494 • Accurately Coded: 312 (63.16%) – Accuracy Rate should be 95% • Financial Impact: – Undercoded---$1,925.00 (6.07%) – Upcoded---$5,375.00 (30.77%) – Wrong Category---31 claims (6.28%) • Documentation must support what is billed – Financial Errors---7.37% SAMPLE AUDIT 2
- 3. Errors by Provider SAMPLE AUDIT 3
- 4. Graft of Errors SAMPLE AUDIT 4
- 5. Errors by Provider SAMPLE AUDIT 5
- 6. Audit Report and Documentation Example of: Incorrect Diagnosis Code Hearing Test Documentation Missing Codes: 90716, 90472, 90472 Incorrect Modifier Financial Impact: 1 unbilled vaccination code and 2 administration codes SAMPLE AUDIT 6
- 7. Audit Report and Documentation Example of: Incorrect Diagnosis Code Hearing Test Documentation Missing Codes: 90716, 90472, 90472 Incorrect Modifier Financial Impact: 1 unbilled vaccination code and 2 administration codes SAMPLE AUDIT 7
- 8. Audit Report and Documentation Example of: Incorrect Primary Diagnosis Code Charges were billed on the siblings account 115685, but it should have been billed to 115686 Financial Impact: New patient was billed as an established patient SAMPLE AUDIT 8
- 9. Audit Report and Documentation Example of: Incorrect Primary Diagnosis Code Charges were billed on the siblings account 115685, but it should have been billed to 115686 Financial Impact: New patient was billed as an established patient SAMPLE AUDIT 9
- 10. Audit Report and Documentation Example of: Primary Diagnosis Code can be more specific Modifiers should not be attached to the E/M code, it should be attached to the procedure code Financial Impact: Specimen handling fee not billed SAMPLE AUDIT 10
- 11. Audit Report and Documentation Example of: Primary Diagnosis Code can be more specific Modifiers should not be attached to the E/M code, it should be attached to the procedure code Financial Impact: Specimen handling fee not billed SAMPLE AUDIT 11
- 12. Audit Report and Documentation Example of: Incorrect Primary Diagnosis Code Primary Diagnosis is not supported by documentation Financial Impact: Billed as an E/M, but it is a Preventative Medicine Visit SAMPLE AUDIT 12
- 13. Audit Report and Documentation Example of: Incorrect Primary Diagnosis Code Primary Diagnosis is not supported by documentation Financial Impact: Billed as an E/M, but it is a Preventative Medicine Visit SAMPLE AUDIT 13
- 14. Audit Report and Documentation Example of: Documentation does not support E/M level Incorrect Procedure Code Financial Impact: Code 69205 (includes general anesthesia), it should have been billed as 69200 SAMPLE AUDIT 14
- 15. Audit Report and Documentation Example of: Documentation does not support E/M level Incorrect Procedure Code Financial Impact: Code 69205 (includes general anesthesia), it should have been billed as 69200 SAMPLE AUDIT 15
- 16. Maximize Your E/M Visits SAMPLE AUDIT 16
- 17. Maximize Your E/M Visits SAMPLE AUDIT 17
- 18. Overall Findings for Office Visits • Preventative Medicine Services • Evaluation and Management have excellent documentation codes are billed by levels and and are billed by the age of the must have supporting patient. documentation in specific areas – Bill vaccination codes to include, to maximize reimbursement. procedure and administration – If it was not documented, it was code, as well as J codes as not done. applicable. – Identify patients as new or – Do not bill an E/M and a established. preventative medicine code – Code external causes for accidents, together, because one will be adverse reactions, injuries and late denied, usually. effects. – Document at least 3 vital signs for – Do not place modifiers on an E/M credit. code. – Use vaccination combination codes as applicable. – Utilize specimen handling codes as applicable. SAMPLE AUDIT 18
- 19. Opportunities for Improvement • Complete a baseline audit for all • Implement Retrospective Billing providers, in order to identify the Reviews most common errors. – Review a sample of claims that – Establish a training program based have been billed for compliance on the data collected from the and possible rebilling and provide audits. ongoing training as needed to • Evaluation and Management training providers • Shadow your doctors to make sure all • Implement Quarterly Audits services are documented in the medical record – Hire a third party to audit a sample of medical records on a quarterly • Implement Concurrent Coding basis to establish any patterns of Reviews noncompliance with billing or – Review a sample of claims coding practices. concurrently for compliance and provide ongoing training as needed to providers SAMPLE AUDIT 19
- 20. QUESTIONS?? SAMPLE AUDIT 20