Ambulatory surgery centers can't afford to leave money on the table and have little time to spare for internal claims audits.
Here are 10 keys to optimize claims auditing:
1. Establish a goal for internal audits and appoint a qualified internal auditor. This can be the coding manager/supervisor, lead coder or someone from the compliance department with the appropriate credentials and qualifications.
2. Determine how frequently to audit — high-volume centers may warrant more frequent audits and randomly auditing problematic specialties or areas could help improve accuracy. However, the best practice for internal audits is on a quarterly basis; external audits are typically performed annually, says Cristina Bentin, CCS-P, CPC-H, CMA, Founder and President, Coding Compliance Management.
3. When auditing the claims, look for:
• Accuracy of CPTs
• Need for additional CPTs
• Accuracy of diagnosis codes
• Need for additional/different diagnosis codes
• Accuracy of modifiers
• Need for additional/different modifiers
4. Random audit of a claims sample — not every claim — can detect problematic patterns without taking the time to examine every claim. However, make sure the sample size is big enough; a recommended sample size is 10 percent of the case volume, says Ms. Bentin.
5. The most important cases to focus on are high-volume cases that impact the center more heavily than others and high complexity cases that have the most room for error. Cases that present multiple code choices are also important to audit for accuracy.
6. Conduct prospective audits as well to review claims prior to submission for appropriate coding, documentation and adherence to insurance carrier guidelines. Prospective audits catch the mistakes before billing out and save time in rebilling if the mistakes are found after the fact.
7. Use credible audit tools such as current editions of coding manuals, AMA guidelines, specialty guidelines, NCCI edits and carrier policies.
8. When auditing collections, look for:
• First follow-up within 15-30 days
• Additional follow up every 30 days
• Detailed follow-up notes
• Appeal done properly
• Claim/patient statement generated as needed
• Appropriate pre-collection efforts made
9. Keep track of audit dates, due dates and findings in a database to understand overarching trends. There are software systems to help capture and store this information.
10. Develop a report around each audit and follow up with problem areas within 90 days. Make sure coders are told exactly what's wrong and educated about how to fix it.
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