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How to Complete a Coding Audit (Internal Medicine)

Correct coding by physicians is critical to getting paid for what you do and for avoiding external audits by Medicare and other payers. ACP has many resources on the issue.

Ultimately, however, the only way to determine whether coding is appropriate is to compare it against the actual clinical documentation you recorded in the chart. This coding audit can reveal whether any variation from national averages is due to inappropriate coding or to atypical levels of intensity among your patients.

This type of audit can help you make corrections before payers challenge any inappropriate coding, or it can give you the confidence to fully code the more intense encounters you conduct.

There are a few simple rules to consider to ensure the audit demonstrates what you intend it to demonstrate. For the internist, the issues of coding are generally related to evaluation and management so this guide refers to evaluation and management auditing.

Rule #1: Select charts randomly.
Do not select the charts yourself. Ask a staff member to pull a patient list for a week, and pull every 5th chart until reaching 10 charts. It does make sense to concentrate on visits that occured over a certain time period to observe trends. Merely pulling charts at random out of the racks will not accomplish this goal.

Rule #2: Don’t review your own charts.
It is virtually impossible to be unbiased when reviewing your own charts. The person in your practice chosen to review the charts should have knowledge of the coding rules, should be able to complete an auditing worksheet, and have a strong understanding of medical terminology. That person may be another physician, a nurse, a qualified coding specialist in the office, or a consultant hired for the purpose.

Rule #3: Use the same rules as the auditors.
Medicare and private insurer auditors may interpret guidelines in different ways, but they do usually adhere to a few simple rules. First, they are supposed to use whichever E/M documentation guidelines that are more beneficial to the physician when auditing – either the 1995 or the 1997 guidelines. It is best for internists to start with 1995 guidelines as they are much more likely to benefit the internist. See ACP’s basic coding guide for more information on the difference between the 1995 and 1997 guidelines.

Coding audit worksheets can be found here.

Rule #4: Keep coding audits results professional and educational.
Physicians should be given the opportunity to review and study the results of their coding audits and to openly discuss what can be improved. Improved coding is encouraged when everyone on staff is committed to the goal of complying with documentation guidelines in order to avoid potential adverse impact on the practice. Avoid a heavy-handed response to the chart audit results -- making coding audits punitive for the parties involved does not benefit the practice and can lead to defensive behaviors that are even more harmful than simple miscoding.

Rule #5: Work at correcting errors.
Completing a coding audit accomplishes very little unless a serious effort is undertaken to remedy the problems identified. Establishing an on-going reporting and feedback system to physicians is important. Error rates should be recorded, but trends in documentation should also be noted. If one physician is not documenting a thorough history, that should be noted. If another physician is not recording a chief complaint, that should be improved. If the practice or the physician can show improvement from one quarter to the next, that is an excellent sign of commitment to fixing errors. Remember, correcting any systematic under coding uncovered in an audit will enable you to collect the revenue to which you are entitled, and addressing over coding will minimize the likelihood that you will have to pay money back to Medicare or another payer if audited.

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