Two “Do’s”, Two “Don’ts” for Handling a Medical Coding Audit

Find out four pointers for making it through your medical audit successfully.

The most recent GAO report concerning money the U.S. government improperly paid,  estimates Medicare Fee-for-Service spent about $36 million it shouldn’t have in FY 2017.

While that figure represents a 2.5% decrease—the lowest rate since 2013, in fact—it’s still an awful lot of money.

But what does this situation mean for you as a professional healthcare provider and not just a taxpayer? It means medical coding audits aren’t going away anytime soon.

What is the role of coding auditing in today’s healthcare system? The government audits providers to recoup lost money. But audits can also benefit medical practices like yours when approached the right way. They can help ensure your coding is as accurate as possible, which contributes to not only better patient outcomes but also less lost revenue for you.

How to Handle a Medical Coding Audit

At MDCodePro, our focus is equipping you to maximize your medical coding regulatory compliance all the time—not just when it’s too late and an audit is on the horizon. There are several proactive steps you should take to prepare for audits. But we do want to offer some “do’s” and “dont’s” for handling them in ways that can lead to the best result for you.

DO Respond to the Audit Notice Right Away.

Medical-Coding-Audit An audit notification is no reason to panic, but you also don’t want to ignore the importance of a medical coding audit. As Barbara Rubel of Management Services Network told Diagnostic Imaging, if you don’t respond within the short time frame allowed, “there’s the automatic assumption that the RAC [Recovery Audit Contractor] is correct and they start taking your money back.”

Responding quickly works to your advantage. Section 935 of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 keeps Medicare from recouping payments when providers request redetermination or reconsideration. “If you respond to the initial audit/overpayment request within the first 20 days to 30 days,” Angela Miller of Medical Auditing Solutions told Physicians Practice, “that will prevent the requirement for payments on extrapolation until the appeal process is complete.”

DO Retain Professional Legal Counsel.

Don’t face an audit without the guidance of a healthcare law expert. Attorneys with experience in this field can not only help you ensure you are complying with the law, but also may identify potential errors or oversights in the auditor’s determination.

According to Angela Miller, providers should use attorneys and consultants because Medicare payers “are becoming very tenacious, so hoping for the best in an audit is ‘naive.’” Legal professionals’ outside perspectives may also  spark “ideas for corrective action that would benefit the provider that could be implemented prior to submitting the first level audit.”

DON’T Assume the Auditor is Correct.

“If you think there is an error with the payer’s findings,” Dr. Dennis Mihale and colleagues write for the AAPC, “you have a right to appeal the decision and should do so, as appropriate.” If you think the auditor’s initial determination is incorrect, it may be in your best interests to say so.

As Sharon Easterling points out for AHIMA, “A provider who is clear, factual, and has documented evidence supporting its original claim can often use [the discussion] period to its benefit.” After the discussion period, the more formal, five-level Medicare Appeals Process may still be an option.

Auditors can be intimidating, but they can also be wrong—and often are, according to the Physicians Advocacy Institute. That organization cites an HSS OIG finding that “approximately 44% of all appealed RAC contractors’ [sic] findings of alleged overpayments are overturned at the third level of appeal.”

DON’T Submit More Information Than Asked For.

When an auditor’s request for documentation from your practice arrives, comply with it, but don’t go above and beyond. As Kimberly Huey writes for the AAPC, “it’s not generally a good idea to send more than what was specifically requested.”

Make sure what you provide during a medical record audit is not only complete but also legible; many auditors won’t bother trying to read illegible records, and that will hurt your cause. In addition, don’t alter the records you send. Innocent attempts at clarification could be seen as deliberate falsifications, as healthcare law attorney Abby Pendleton told Diagnostic Imaging, and could lead to license revocation.

Increase Accurate Documentation Before Audits with MDCodePro

One last “do” is a step you can take right now, before any audit notice ever comes: Strengthen your documentation, and consequently your medical coding, by making MDCodePro your go-to resource for finding the optimal CPT® code for each patient visit.

With a methodology validated in countless audits and proven to have increased hundreds of physicians’ annual revenue by an average of $30,000, the MDCodePro app combines a streamlined, straightforward education in CMS E/M coding essentials with a powerful but easy-to-use code generator. You’ll learn and apply your new understanding of the Medicare coding guidelines with confidence, achieving greater regulatory compliance, more comprehensive and accurate record-keeping, and receiving more of the reimbursement you’ve legitimately earned and documented.

Fill out this online form to get more information about how MDCodePro can support your efforts to get your documentation and coding right, so you emerge from medical coding audits with your records and revenue intact.

Leave a Comment