Seven internal coding audits your medical practice needs now
We’ve all heard the old adage, “It’s not a problem until it’s a problem.” Those car repairs you keep delaying? They’re not a problem until your car breaks down on the side of the road. That data on your computer you keep forgetting to back up to the cloud? It’s not a problem until your computer crashes. That generator you know you need to buy but keep postponing? It’s not a problem until the next hurricane, and you lose power for a week.
In healthcare, medical coding errors may not be a problem until there’s a problem — in other words, until a payer starts denying claims or recouping payment. Proactive revenue cycle management is paramount. This includes quarterly — or even monthly or weekly — medical coding audits based on your practice’s medical coding audit policy.
Medical coding audits help practices correct errors in provider documentation, avoid incorrect or invalid codes, identify intentional or unintentional billing fraud, prevent over- and under-coding, and mitigate payer and auditor scrutiny. It’s about reducing claim denials and promoting revenue integrity (i.e., ensuring you’re paid accurately for the services you provide).
Following are seven medical coding audits that should be on your radar in 2022:
1. Telemedicine. If your medical practice provides services via telehealth, this is a great place to start with your auditing efforts. Why? The Office of Inspector General (OIG) continues to review telehealth claims to determine whether providers billing telehealth met Medicare requirements. The agency is conducting a series of audits of Medicare Part B telehealth services, the first phase of which focuses on whether services such as evaluation and management (E/M), opioid use disorder, end-stage renal disease, and psychotherapy met telehealth billing requirements. The second phase focuses on Medicare Part B telehealth services related to distant and originating site locations, virtual check-ins, electronic visits, remote patient monitoring, and annual wellness visits. Creating a telehealth auditing checklist can help streamline efforts.
2. E/M services. Effective January 1, 2021, physicians began using new E/M guidelines that permit them to bill based on total time spent on the date of the encounter or medical decision making (MDM) — whichever is most financially advantageous. Has your medical practice complied with the new guidelines? A medical coding audit can help identify potential problems such as using outdated time thresholds for each code, counting total time incorrectly, incorrectly interpreting and applying the newly-revised MDM table, and more. Consider creating a medical coding audit template to ensure consistency across auditors.
3. Modifier -25. Modifier -25 signals to a payer that a physician performed a significant, separately identifiable E/M service on the same day of a minor procedure or other service. It also signals that the payer should pay for both services separately. Modifier -25 has been an OIG target for quite some time, which is why it makes sense for you to audit it internally. Does physician documentation truly depict whether a separate E/M service was warranted, and if so, why it went beyond what’s normally associated with the procedure?
4. Chronic care management (CCM). Although CCM is not currently on the OIG’s Work Plan, it continues to be a target for commercial payers, which is why it makes sense to add it to your auditing list. Here’s what to look for when auditing CCM services: Does the patient have two or more significant chronic conditions that place them at significant risk of death, acute exacerbation/decompensation, or functional decline? Do you anticipate these conditions to last at least 12 months or until the patient’s death? Can you ensure that you didn’t bill CCM and certain other services (i.e., transitional care management, home healthcare supervision/hospice care, or certain end-stage rental disease services) during the same service period?
5. Incident-to services. When non-physician providers bill their services ‘incident-to’ a physician, they receive 100% of the physician’s fee schedule amount. Medical practices should audit these services regularly to ensure compliance. During a medical coding audit, ask these questions: Does the payer permit or forbid incident-to billing? Is the supervising physician present in the office suite and immediately available to provide assistance and direction? Does the medical practice bill incident-to services for new patients? (Note: Medicare does not permit it). Does the medical practice bill incident-to services for established patients when there’s a change to the plan of care? (Note: Medicare doesn’t permit this either.)
6. Podiatry services. Medicare Part B payments for podiatry and ancillary services are on the OIG’s 2022 Work Plan. If your medical practice provides these services, you’ll want to focus your audit on determining whether documentation of routine foot-care services (e.g., cutting or removing corns and calluses or trimming, cutting, clipping, or debriding toenails) clearly indicates that the services are necessary and integral to an otherwise covered service, performed to treat warts on the foot, performed in the presence of a systemic condition(s), or performed to treat infected toenails. It’s also important to ensure documentation reflects medical necessity for treating any foot injuries, diseases, or other medical conditions affecting the foot, ankle, or lower leg.
7. Place of service. Place of service has been a source of noncompliance and overpayments for many years. Most recently, the OIG added place of service codes to its Work Plan as well. The OIG is looking to determine the accuracy of these codes on Medicare Part B claims for physician services when beneficiaries are inpatients under Medicare Part A. Here’s the central question to ask during an internal medical coding audit: When a beneficiary is a registered inpatient at a hospital or SNF, did the physician code their services with a facility place-of-service code? They should use a facility code regardless of where the patient actually received the face-to-face encounter.
Conclusion
When it comes to internal medical coding audits, there are many areas on which medical practices can focus. Audits provide invaluable insights into potential revenue cycle management problems so you can ensure corrective action, reduce claim denials, promote revenue integrity, and avoid payer and OIG scrutiny. Leveraging your claims scrubber can also mitigate risk with many of these areas of vulnerability. Learn how edgeMED can help and be sure to visit the Healthy Snacks Blog for more expert insights, best practices and industry trends.
