As new technologies progress more and more payers are actively deploying AI capable systems. This shift is now producing more audits of physicians than ever before and directly contributing to higher rates of denials. Audits take time and resources that you don’t have. You want to be compensated fairly for the work that you are performing and do what you do best – providing quality care for your patients.
When it comes to avoiding an audit there is a lot to consider and every situation is unique. However, here are 10 tips that can help keep you doing what you do best.
Understand your data
Are you an outlier? Don’t be afraid to ask your coding and billing company to run a report to compare you to other providers of your specialty.
Differences between your billing and that of national averages can be due to inappropriate coding and/or insufficient documentation. This could cause a loss of revenue in the future, if it hasn’t already.
Know your denial rate
What is your rate of denials? If you don’t know, this could be problematic. You can learn a lot by looking at the rate that your claims are or more importantly, aren’t, getting paid.
Overuse of modifiers
A common misconception is that your claims won’t get paid unless you append certain modifiers on them all the time, such as modifiers 25 and 59. However, these should only be used if certain criteria is met, and unnecessary use of these may land you in an audit.
Time is money
Time-based codes are scrutinized – heavily. Did you submit claims for an excessive number of hours in a day, not just to one payer, but cumulatively?
Do it right the first time
Don’t try to experiment when you are sending in documentation and billing to see what gets paid and what doesn’t. This can easily end up setting off red flags with payers.
Document it, all of it
Most important is your documentation. Remember, if it wasn’t documented, it wasn’t done. You could end up not getting paid for the service. Everything from the completeness of whats documented and how its phrased to simple things like signatures
Where the patient is vs. where you are
Billing for services that are considered “incident-to” still have certain requirements. If you are on vacation, making rounds at the hospital across town, or somewhere other than physically in the office space, this is an issue.
Under & over-coding
Undercoding (code billed for is less expensive than services documented) and Overcoding (code billed for is more expensive than services documented) are both improper representations of rendered services and could flag you for an audit, whether you’re billing all Level 2 codes or all Level 5s.
You may find it more lucrative to bill for multiple CPT codes, even when a single, more appropriate, code would suffice. However, this typically is a red flag that points to intentional forms of over-coding. Staying abreast of the latest codes used by your specialty helps.
Coding and billing professionals are responsible for keeping up-to-date with the changes of code sets such as international classification of diseases (ICD) from the World Health Organization, current procedural terminology (CPT) codes from the American Medical Association and Healthcare Common Procedure Coding System (HCPCS) from the Centers for Medicare and Medicaid Services. Most of these are changed annually.