Sample size and selection for a coding audit
March 30th, 2009 - Codapedia Editor
In 2001, the OIG published a compliance plan recommendation for physician practices. This is one in its series of compliance plans: hospitals, labs, billing services, etc had already been published. A copy of it from the Federal Register is attached in the resource page.
In it, the OIG recommended an annual audit of each practitioner's claims of either ten encounters selected randomly or 2-5 encounters per government payer. Government payers include Medicare, Medicaid, TriCare and Federal BCBS. Many groups find it simpler to select ten notes, randomly, without regard to patient insurance.
The OIG did not say how to select those services for audit. One option is to print a detailed list of patient encounters for a one or three month period. Note the total number of encounters. Use a random number generator (available at numerous websites, for free) to generate 10 random numbers. Apply those numbers to the list, and you have randomnly selected ten encounters.
A second option is to focus on high volume or high risk services. This might include claims with certain modifiers. For a primary care provider, it might be services billed as 99213 or 99214, since those are high volume services for primary care. For a hospitalist, it might be focusing on 99233, since CMS finds a high error rate for level three subsequent hospital visits.
Another method to select an audit focus is to review the OIG Work Plan for this year. If the OIG is focusing on a service that is performed at a high frequency in your practice, include those services in your audit.
Feel free to change your audit focus from year to year. If you find that your group is accurate in their established patient visit coding, select another focus for audit. This gives you the opportunity to educate your physicians while checking for compliance.
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)Artificial Intelligence in Healthcare - A Medical Coder's PerspectiveDecember 26th, 2023 - Aimee Wilcox
We constantly hear how AI is creeping into every aspect of healthcare but what does that mean for medical coders and how can we better understand the language used in the codeset? Will AI take my place or will I learn with it and become an integral part of the process that uses AI to enhance my abilities? Specialization: Your Advantage as a Medical Coding ContractorDecember 22nd, 2023 - Find-A-Code
Medical coding contractors offer a valuable service to healthcare providers who would rather outsource coding and billing rather than handling things in-house. Some contractors are better than others, but there is one thing they all have in common: the need to present some sort of value proposition in order to land new clients. As a contractor, your value proposition is the advantage you offer. And that advantage is specialization.ICD-10-CM Coding of Chronic Obstructive Pulmonary Disease (COPD)December 19th, 2023 - Aimee Wilcox
Chronic respiratory disease is on the top 10 chronic disease list published by the National Institutes of Health (NIH). Although it is a chronic condition, it may be stable for some time and then suddenly become exacerbated and even impacted by another acute respiratory illness, such as bronchitis, RSV, or COVID-19. Understanding the nuances associated with the condition and how to properly assign ICD-10-CM codes is beneficial.Changes to COVID-19 Vaccines Strike AgainDecember 12th, 2023 - Aimee Wilcox
According to the FDA, CDC, and other alphabet soup entities, the old COVID-19 vaccines are no longer able to treat the variants experienced today so new vaccines have been given the emergency use authorization to take the place of the old vaccines. No sooner was the updated 2024 CPT codebook published when 50 of the codes in it were deleted, some of which were being newly added for 2024.Updated ICD-10-CM Codes for AppendicitisNovember 14th, 2023 - Aimee Wilcox
With approximately 250,000 cases of acute appendicitis diagnosed annually in the United States, coding updates were made to ensure high-specificity coding could be achieved when reporting these diagnoses. While appendicitis almost equally affects both men and women, the type of appendicitis varies, as dose the risk of infection, sepsis, and perforation.COVID Vaccine Coding Changes as of November 1, 2023October 26th, 2023 - Wyn Staheli
COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.Medicare Guidance Changes for E/M ServicesOctober 11th, 2023 - Wyn Staheli
2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....