Retrospective audits

March 29th, 2009 - Codapedia Editor
Categories:   Coding   Compliance  
0 Votes - Sign in to vote or comment.

Many physician practices took the OIG recommendation to heart, and do annual compliance audits.  There are many questions to answer about audits:  how many, how often, internal or external auditor, doing the work under attorney client privilege and whether to do the audits prospectively or retrospectively.

Retrospective audits are audits performed in a physician practice after the claims are submitted to the payer.  There are some advantages to this.  The practice or auditor can select from a large sample of claims submitted, and use a random number technique to select the claims.  This typically results in a large variety of codes selected to audit.  The claims have been submitted, so the group doesn't need to hold the claims and delay payment.  This type of audit is typically less time sensitive (because claims aren't held) and can be scheduled more easily.

The auditor reviews the medical record and assigns CPT® and ICD-9 codes and modifiers and reviews that the claim is submitted according to coding rules and government regulations.  If the audited code differs from the code submitted and that results in the group collecting additional funds, the group must correct and re-submit the claim, refunding the money to the government payer.

Some groups elect to do these audits through their attorney, giving the work product attorney-client privilege.

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

How to Search Find-A-Code for Medicare Policies and Guidelines — LCDs, NCDs and Articles —
November 18th, 2020 - Raquel Shumway
Help for Searching Find-A-Code when searching for Medicare Policies and Guidelines — LCDs, NCDs and/or Articles.
Cross-A-Code Instructions in Find-A-Code
November 18th, 2020 - Raquel Shumway
Cross-A-Codeis a toll found in Find-A-Code which helps you to locate codes in other code sets that help you when submitting a claim.
COVID Vaccine Codes Announced
November 11th, 2020 - Wyn Staheli, Director of Research
On November 10, 2020, the American Medical Association (AMA) announced the addition of two new codes which will be used for the new COVID-19 vaccines along with 4 new administration codes to be used when reporting the administration of these vaccines.
Are You Aware of the 2021 Star Rating System Updates?
November 5th, 2020 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Each year the Centers for Medicare & Medicaid Services (CMS) publishes the Star Ratings System Updates for Medicare Advantage (Part C) and Medicare Prescription (Part D). This rating system was developed to help beneficiaries identify and select the health plans that best meet their needs, specifically addressing main issues:  Quality of ...
Special Needs Plans Help Beneficiaries and Risk Adjustment Reporting
October 22nd, 2020 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
It is no secret that Medicare and Medicaid are steadily moving towards their goal of value-based health care. Medicare Part C (Medicare Advantage) identifies and rewards payers, and subsequently their providers, for increasing the efficiency and quality of care they provide to Medicare...
CMS Expands Telehealth Again
October 20th, 2020 - Wyn Staheli, Director of Research
On October 14, 2020, CMS announced further changes to expand telehealth coverage. Eleven (11) new codes have been added to their list of covered services bringing the current total to 144 services. The new services include some neurostimulator analysis and programming services as well as some cardiac and pulmonary rehabilitation services.
Significant COVID-19 Code Changes as of October 6
October 8th, 2020 - Wyn Staheli, Director of Research
Significan COVID-19 Code Changes as of October 6



Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2020 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association