How to Prepare for an E/M Coding Guideline Audit Before It Happens

Don’t Wait Until an Audit Notice Arrives. Take These Proactive Steps Today.

U.S. healthcare spending continues to rise, and news about Medicare overpayments threatening the program’s integrity continues to grab headlines.

In March 2018, for example, the Office of the Inspector General’s (OIG) six-month audit of outpatient physical therapy services claims brought to light an estimated $367 million in improper payments.

Physical therapists don’t submit evaluation and management (E/M) codes to insurance payers as you do. But many physicians and other healthcare providers do worry their coding might not fare better when auditors scrutinize their compliance with Medicare documentation guidelines.

After all, Medicare inappropriately paid $6.7 billion for E/M claims in 2010, according to the HHS OIG’s major report on the subject—a full 21% of Medicare E/M payments that year. The agency has good reason to be looking for providers whose documentation and coding don’t comply with regulations.

Are you worried they’ll find mistakes in your charts and claims?

You do your best to use the 1995 or 1997 CMS documentation guidelines correctly, of course. But their extreme length and widely criticized complexity make your task challenging, at best. Even CMS’ recently announced plans to reform its auditing might not ease your understandable apprehension.

Using MDCodePro won’t help you avoid an audit. No reputable product or service can make you that guarantee. But adopting the MDCodePro app as your resource and primary tool for mastering medical record documentation’s general principles marks a significant step toward getting ready for audits before they occur.


3 Concrete Strategies to Prepare Your Practice for Audits

Here are three other things you can do, starting now, to make sure you’re ready well before any audit notice arrives:

  • Benchmark Your Billing
    Do you know whether your billing aligns with other physicians in your specialty, your region, or even your own practice? If not, find out now. CMS provides resources like the Part B National Summary Data File to help you compare how you use specific CPT® codes to the way other practitioners do. If you’re consistently over- or undercoding compared to your peers, you’ll want to review how you use the Medicare documentation guidelines. Maybe that’s where you’re making mistakes likely to attract auditors’ attention.Remember, you may not be making documentation mistakes. In fact, you may not be making mistakes anywhere. Variance with other practitioners’ billing doesn’t automatically mean you’re in the wrong. Digging into the issue prepares you to answer audit questions should they arise. “Physicians who do not conduct [a benchmarking] analysis are doing themselves a grave disservice,” cautions the Physicians Advocacy Institute and American College of Emergency Physicians.
  • Medicare Documentation GuidelinesConduct Your Own Audits
    You need to take the initiative and audit your records before an auditor decides to. Your practice can conduct in-house audits by pulling a random sample of charts on a regular basis for an unbiased team to review using auditors’ rules (as the American College of Physicians recommends). Or consider hiring a third-party medical coding company to double-check your coding.Why are internal audits so important? Discovering errors now gives you the chance to correct them. You’ll also find out what you’re doing right. Seeing how you already meet CMS’ medical record documentation guidelines will give you peace of mind and increase your confidence in coding patient visits going forward.
  • Implement a Compliance Plan
    Internal audits are only one key component of an effective compliance program as outlined by the OIG. Other important elements include a designated compliance officer or contact person, open lines of communication between practitioners and that individual, and well-publicized guidelines enforced with appropriate corrective action as needed.Developing a compliance plan requires significant time and energy, but the resulting culture of compliance will pay off for your practice in valuable ways. “Errors will happen,” Dr. Ranjan Sachdev wrote for Orthopedics Today. “What is expected from practices is that they… are trying to promote compliance. If they can show that, they are likely to get more lenient treatment… [Most] auditors are not out to get you. They want to make sure that the laws are followed and that you have good intent.”


Master the CMS E/M Coding Guidelines with MDCodePro

Whatever else you do to prepare yourself and your practice for possible audits, educating yourself about Medicare documentation guidelines is imperative. The Department of Health and Human Services reminds physicians that under the civil False Claims Act, “no specific intent to defraud [Medicare] is required” to find against a practitioner: “It is illegal to submit claims for payment… you know or should know are false or fraudulent.” Ignorance provides no excuse.

As a highly trained and conscientious provider, you don’t need the threat of legal consequences to motivate you to learn about E/M coding guidelines. You want to give your patients the best possible care, which includes documenting patient visits in the best possible way. The guidelines can help you do that. You also want to be reimbursed appropriately and fully under the Physician Fee Schedule for the work you do. The guidelines help you achieve that goal, too.

When you subscribe to MDCodePro, you’re investing in comprehensive and immediately relevant training in CMS documentation and coding guidelines. You’re also getting a powerful yet simple-to-use Code Generator to lead you to every visit’s optimal billing code.

Proven accurate in audit after audit, the MDCodePro methodology facilitates more accurate medical documentation, increased regulatory compliance, and more captured revenue for your practice.

Don’t keep worrying about how you’d fare in an audit. Take action to get ready. Make your next move today: Sign up for MDCodePro by clicking here.

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