Take a Closer Look at the Audit Process

By Jaci Johnson, CPC, CPC-H, CPMA, CPC-I, CEMC

AAPC offers a wide selection of specialty specific exams. These allow individuals to test their skills in one particular area where they feel they have a certain level of expertise. In addition to these specialty exams there is one that allows the individual to showcase their skills across multiple specialties. The Certified Professional Medical Auditor (CPMA®) exam tests one's ability to audit various specialties as well as understand how an audit is conducted from beginning to end. How do you know when you are ready to sit for this exam? What knowledge base is needed to understand the concepts? The easiest way to approach these questions is to consider how an audit is conducted in a medical practice. From the time someone in the practice decides to request an audit until the results are tabulated and presented, there are multiple steps in the process to consider. Let's take a closer look at the audit process. In essence, let's audit an audit. The first step is the decision to perform the audit. Is this audit being performed because there is a known compliance issue, did a provider request to have his records reviewed, or is it part of an annual compliance plan? Based on the answer to this question, the scope of the audit can be determined. The scope will outline the time frame for the selection of claims to be audited. The reason for the audit also will help in deciding how many claims should be reviewed. The number of claims will vary based on whether this is a focused review that is only concerned with a specific coding issue or a baseline audit that is conducted to determine if there are any potential risk issues. Often the request for the audit will require a statistically significant number of claims to be reviewed to ensure a measure of reliability in the results. The number for the statistical sample would be based on the total number of claims within a selected period of time. Once the scope is determined and the selection process has been completed, the actual review of the documentation can begin. In addition to the supporting documentation, auditors require the claims data to reflect what was actually billed. If the audit will include the review of Evaluation and Management (E/M) codes, then the auditor should have a sound knowledge of certain concepts and have certain tools available. The auditor should have a firm grasp of all the E/M guidelines in the CPT® manual and the Medicare Documentation Guidelines, both versions. The auditor also will require a thorough understanding of any modifiers associated with E/M codes. In addition to the fundamentals of auditing the documentation to ensure proper E/M code selection, the auditor should have knowledge of "incident to" guidelines, understand the guidelines associated with Physicians at Teaching Hospitals (PATH), and know how to identify in the documentation any misuse of the guidelines. If the audit will include reviewing any surgical services, the auditor is responsible for an even greater fund of knowledge. The auditor must be skilled in maneuvering through the National Correct Coding Initiative (NCCI) to determine any misuse of bundled codes. The auditor should also be aware of any Local Coverage Decisions (LCD) that may pertain to those procedures and National Coverage Issues as determined by the Centers for Medicare & Medicaid Services. As with any coding audit, an understanding of the CPT® manual coding rules for that service is mandatory. The auditor must also understand proper use of modifiers for various surgical coding scenarios and be able to determine if the documentation can support the need for that modifier. The PATH guidelines are often a part of a surgical audit as well, and it is important that the auditor be able to recognize who is performing the service. The medicine section of the CPT® manual presents the coder with a wide variety of procedures and services. From an audit perspective, this can pose a challenge. There are no set rules that cover all those services. The auditor needs to be as well-versed with infusions as with psychiatry services or physical therapy and all things in between. The NCCI and LCD can still be useful reference tools, along with any individual guidelines found within CPT®, and of course the use of modifiers. To complete an audit it is also necessary to assess the diagnosis codes that were billed to determine if the documentation can support their use. The documentation should be compared to the code billed for correct specificity. The Official Coding Guidelines found in the ICD-9 manual should be consulted for any questions concerning coding accuracy. In addition to all the coding guidelines and CMS requirements that have been noted above, the auditor should be familiar with signature requirements and also verify proper dates of service for all services reviewed. Once the audit has been completed, the results should reflect any variances in what codes and modifiers were billed versus what the auditor determined to be the codes and modifiers based on the documentation provided. The auditor should be able to provide the resources that were used in determining the findings of the audit. What is done with the audit and how the results or findings are communicated is often determined by management in the practice. Depending on the types and severity of the variances discovered in the audit process, a decision may be made to bring in legal counsel to help determine next steps. The auditor should be familiar with the information provided by the Office of Inspector General (OIG) concerning compliance and Corporate Integrity Agreements, even though the process may be handled by a lawyer. Sometimes the audit may begin at the request of a lawyer, and the whole process is considered under attorney client privilege. This concept should be clearly identified to the auditor so that the privacy of the audit can stay intact. Performing an audit can be quite a cumbersome endeavor and is a heavy responsibility. The steps outlined here are not a comprehensive list but provide an overview of some of the considerations during the audit process and should be used as a guide when deciding to sit for the CPMA® exam. Jaci Johnson is president of Practice Integrity, Richmond, Va. She has been working in the field of medical coding and auditing for 22 years and has been a CPC®since 1994. She teaches PMCC courses and manages a national client list, providing compliance monitoring for provider documentation. Johnson was recognized as Coder of the Year for the state of Virginia in 2006. She is the past president of her local AAPC chapter and currently serves on the AAPC National Advisory Board. She can be reached atjaci@practiceintegrity.com.