by Michelle West, CPC, CEMC, CPMA, CRC
August 11th, 2017
In the new year, have you found yourself in the new role of performing internal chart audits for your organization? Are you often finding yourself saying "Now What?!" First, take a deep breath and start with the basics. In this week's tip, I will review the very basic tips and principles to help you in your new role.
First, begin by gathering reliable resources. Also, look for proper training from industry experts or those who were in the role prior. Once you have determined the type of audits that you will be performing (Medicare, commercial carrier, etc.), begin by researching the guidelines. It's best to begin with the CMS 1995 and 1997 Documentation Guidelines as well as the CMS Claims Processing Manual, and AMA CPT Guidelines.
Next, don't forget that you're not alone! Tap into the resources and training available to you, such as those offered through a NAMAS membership to receive ongoing education, certification and support. The next thing you'll need is a good auditing tool. When choosing an audit tool (or two), be sure that it'll work best for your role in your organization, and is most conducive to your practice's specialty.
To continue, determine your audit sample. A good idea is to do a utilization review to determine any potential areas of risk for your first audit sample. A utilization review determines which codes are most used by your organization. This will help you to review for accuracy, identify any potential areas of risk, and help you identify any billing irregularities, etc. If you do not have a billing system analyst within your organization who can assist you with a utilization review, consider enlisting the help of a good source.
Using random sampling when selecting your audit sample will help eliminate bias in terms of units. Be sure that you are choosing an amount of charts for review that best minimizes sampling errors (if too large), or so small that it doesn't accurately portray the code population being reviewed. A good beginning number may be 20 charts per provider.
Before you begin auditing, you should review your organization's audit policy or compliance plan. This should outline all internal policies, methodologies, how grey areas are addressed, etc. I wish you best of luck in your new role!