E/M Coding Alert - 2019 Issue 4
Compliance: 3 Tips Lead to Perfect Self-Audits
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Article Overview
This article explains practical themes in audit preparation for emergency department practices and other providers. It summarizes how to think about internal review planning, how Medicare and other payers evaluate claims at a high level, and which broad audit focus areas tend to draw attention. The piece is intended for coders, compliance staff, and practice leaders who want to assess whether their records and billing patterns are ready for scrutiny.
Why This Topic Matters
Strong self-audits can help practices identify documentation and billing risks before external reviewers do. Understanding common audit themes is important for compliance planning and for organizing internal review workflows.
Article Sections
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Tip 1: Know Most Essential Factor in Your Compliance Program
Explains why internal audit planning is central to a compliance program and describes general approaches to reviewing utilization patterns and selecting records for review. It also introduces the idea of using results over time to monitor training and performance.
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Tip 2: Know How CMS Evaluates Practices
Summarizes broad CMS audit approaches and the types of claim-review issues that may be examined. The section discusses general categories of claim problems, including basic errors, inefficiencies, abuse concerns, and fraud-related issues.
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Tip 3: Evaluate the Big Four Focus Areas
Describes four broad audit focus areas that can influence review risk in provider claims analysis. It covers frequency, procedure-code utilization by work relative value, modifier utilization, and time-based review concerns at a general level.
What You Will Learn
- How to think about building an internal audit plan
- How Medicare review programs may evaluate claims at a high level
- Which broad categories of audit focus areas are commonly discussed in compliance planning
- How utilization, frequency, modifiers, and time can factor into audit preparedness
Who Should Read This
- Emergency department practices
- Medical coders
- Compliance officers
- Revenue cycle staff
- Physician practice administrators
Modifiers Discussed
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