TOPIC: Suggestions for internal audits
HIM Connection, November 17, 2003
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TOPIC: Suggestions for what to audit internally
Use a "finders and fixers" plan to review and correct your biggest compliance issues. People inside of an organization are best at knowing how systems work and what steps are required to fix incorrect claims, but they may not know what to look for or how to find it. That is where outside help can help you find your compliance vulnerabilities. But, internal audits can also help your staff begin to uncover problems on their own. The list below is a starting point for some of the key areas to audit internally:
1. All areas of risk as identified in the OIG work plan
2. Do you have a compliance monitoring plan extended to outpatient services, including education and training for coding and billing?
3. Audit the UB-92 and CDM for new codes, old codes, and deleted codes.
4. Review your denial management process; are back-end fixes being made?
5. Review billing of pass-through items, especially from 2001 and 2002.
6. Review units of service reporting especially for drugs; determine if rebilling opportunities exist.
7. Review the charge capture process in the ED, as well as other departments, including the cardiac cath lab, interventional radiology, and in your clinics
8. Modifier usage; especially -25, -52, 59, 73, and 74
9. E/M guidelines created, and distribution of code levels
10. Use of observation, including all criteria being met before billing
11. Charges reported in high-volume APCs, APCs generating a high volume of outlier payments, or both.
12. Highest OCE edits internally point to problem areas
By fixing the issues yourself, your staff learns what the problems are, how they were uncovered, and how they can be avoided in the future.
This week's HIM Connection was adapted from the book, Compliance troubleshooter: Tackling the top 10 compliance challenges, by Joseph T. Gatewood Esq., Janet Hall, Leslie H. Kamil, MS, JD, James A. Kopf, et al. Click here for more information or order now and save $14.90 off the regular price.
Check out the Editor's Choice section below for solutions to your records completion problems.
Sincerely,
Kate Alvarez
Editorial Assistant
kalvarez@hcpro.com
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