Ms. Edelberg said the explosion of RACs, ZPICs, MFCUs and other programs designed to detect fraud and recapture unsupported payments means coders, billers and collectors must invest in an ongoing, robust audit program.
She said E/M services are the most significant financial and compliance risk to any practice because they encompass a range of services with unique documentation requirements, which may change based on individual payor rules, and E/M services are billed most frequently.
She said practices should invest in an educated auditor who considers all relevant guidelines and understands the common problem areas in E/M services coding. She said because many practices cannot afford to outsource auditing, in-house coders must perform audits in addition to their regular duties — a challenge since coders tend to audit with the same potentially incorrect information used to code.
She recommended that practices review in-house policies for Medicare, Medicaid and major payors for all provided E/M services and take a refresher course in the necessary E/M levels for the site of service. She said auditors should pay extra attention to the required key elements for each code set and educate themselves on proper auditing practice prior to conducting the audit.
Read the AAPC report on E/M auditing.
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