The audit of 494 medical records found issues in billing and coding accuracy. Only 63.16% of records were accurately coded, below the target 95% accuracy rate. Financial errors resulted in $1,925 undercoding and $5,375 overcoding. Documentation was insufficient in 31 claims. Providers lacked documentation to support billed E/M levels and diagnoses. Opportunities included preventative medicine billing, E/M level documentation, and implementing coding reviews.

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