What is the goal of your auditing efforts?

“Day-to-day operations in a medical practice involve significant amounts of clinical documentation and medical claims information. Ensuring accuracy of that information via regular audits — to ensure all processes and transactions are functioning appropriately — is an imperative for both risk mitigation and revenue cycle management.”

Veronica Bradley CPC, CPMA, Insight Article, MGMA, March 2, 2020

The Value and Purpose of Medical Coding Audits

Beyond identifying accidental or unknown “fraudulent” billing, there are other benefits to conducting an audit of your billing procedures.

Audit for education

As Veronica states and we’ve observed, encounter/chart reviews (“audits”) often provide a base for education – for providers, coders, billers, and practice managers. Proper coding for billing purposes has many potential points of failure. These “pain” points impact both compliance risk and revenue. These failure points can include: 

  • Insufficient clinical or procedural documentation
  • Improper use of CPT and ICD-10-CM codes
  • Lack of modifiers
  • Unbundling
  • Missed billing opportunities

Audit to improve your reimbursements

The article also lists audit topics that impact your practice’s revenue stream.

Audit topics that impact your practice’s financial health can include:

  • Inefficient payer reimbursement
  • Payer rules that limit, delay, or reject your billing
  • Payer downcoding
  • Errors in claims scrubbing
  • Trends in denials

Audit to reduce risk of payer audits

Performing your own documentation, coding, and risk audits will also provide you a view of the possible areas of risk if you were visited by a Recovery Audit Contractor (RAC) or any type of payer audit.

Resources from the OIG

For more compliance resources, here is a list from the Office of the Inspector General (OIG).

OIG Compliance Resources

If you need audit software or audit services, contact us at swiftaudit.com

We will be happy to help you with your compliance and revenue improvement needs.

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