June 25, 2021 | By Stephanie Allard, CPC, CEMA, RHIT
When I ask practices if they have been through an external audit recently, they typically will state “no” or let me know if recent requests for a larger number encounter notes have been received. Through these conversations, I realize that they are not noticing that when a request for one patient at a time or one date of service at a time comes through it is an indication that the payer wants to take a closer look to verify whether they should be paying the claim, issuing a denial or maybe even asking for a refund. While the request may not jump out as a large external audit, it is still an indication that the note is going to be reviewed for appropriateness of code selection based on supporting documentation.
An audit review is not always going to be a large request for multiple notes per provider. Is your organization aware of the number of requests, types of requests, and trends or patterns seen through the requests? At times the requests get lost, are not reviewed timely, or notes are sent back to the payers with no tracking of the information being requested. Without reading and tracking the information, you are potentially missing education opportunities, which in turn can heighten the level of compliance risk in the group. It is important to understand that each time a payer requests documentation, the purpose of that is review the service for accuracy of documentation, coding, and to ensure medical necessity is supported. It may also be an indication that they have noticed a trend or pattern in the way that a provider is coding and billing.
In working with some of my clients on their requests for documentation and denial tracking, I have found that, as stated above, many of the requests are limited to a very small number of encounters. The majority of the requests that I have seen are related to higher dollar claims, E/M services with a 25 modifier, or providers who are billing a higher number of a particular E/M service than others in their group or region. Having a tracking process in place has allowed us to review documentation prior to submitting to the payers for external review. In the event that the coding is incorrect, the billing staff is able to send a correction along with the request for notes, and then education feedback is given to the provider. This type of process along with a compliance plan and regular audits has not only ensured a higher level of compliance throughout the organization, but it has also given the providers the confidence they need to become more comfortable with the documentation requirements and with their code selection.
In the past, I have spoken about the fact that external audits are not avoidable. It is a common misconception for some to think that a practice is within compliance simply because their claims get paid with a low volume of denials. As a result, they feel their risk of audit is very low. It is not a matter of prevention but ensuring documentation and coding compliance to lessen overall risk at the time that an external audit does occur.