BC Advantage - 2022 Issue 4
2022 Annual Audit Elements: What Should Be Reviewed
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Article Overview
This article explains how practices and health systems can build a relevant annual audit plan for coding and compliance review. It covers broad audit planning considerations, high-risk service selection, sample selection approaches, prospective versus retrospective review, and general focus areas such as evaluation and management services, modifiers, incident-to and split billing, Coumadin clinic visits, and medical necessity. It is intended for compliance staff, auditors, coders, and practice leaders who need a practical framework for deciding what to review and why the review matters.
Why This Topic Matters
Choosing the right services and review methods can help organizations support compliance efforts, align audits with their actual billing patterns, and respond more effectively to payer or government scrutiny.
Article Sections
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Audit planning considerations
Introduces the general approach to selecting audit topics for a practice or health system. It discusses broad compliance drivers, payer and government focus areas, and the need to tailor audits to organizational services.
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Sampling and review approach
Summarizes different ways an audit sample may be selected and the choice between prospective and retrospective review. It also addresses when organizations should seek guidance before using certain methodologies.
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Common high-risk service areas
Describes broad categories of services that may be prioritized in an audit plan. The discussion centers on evaluation and management, billing-related modifiers, incident-to and split billing, Coumadin clinic services, and medical necessity.
What You Will Learn
- How annual audit priorities are commonly determined for healthcare organizations.
- What broad factors can influence which services are selected for review.
- How audit sampling approaches and review timing are discussed at a high level.
- Which general service categories are often included in an audit focus list.
Who Should Read This
- Compliance officers
- Medical coders
- Billing and reimbursement staff
- Practice managers
- Health system administrators
- Auditors
Codes Discussed
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