Tips to perform a successful self-audit

Try to engage the whole staff: See to it that every member of your practice know what you are doing and why. Also, remind them that you are not trying to get anyone in a tight spot. Instead, you want to find out whether they are helping to bring in the right amount of payments and minimizing denials.

Choose the charts: Most auditing specialists recommend that you review 10 to 15 records per physician during your audit.

Examine documentation: Go through the documentation and find out which ICD-9 codes(http://www.supercoder.com/icd9-codes/) and CPT codes you think apply to the chart. Then see which codes were actually assigned to the services.

Focus on difficult services: While examining physicians'records, review not only the procedures but also the E/M services. Some records such as consults or time-based E/M records are trickier to code.

Time-based pitfall: You must have a credible reason to justify providing the majority of the service on counseling/ coordination of care to justify basing your E/M level on time. Bronchitis taking a lot of time to explain to a 20-year-old is not a supportable reason.

The official recommendation is that the documentation should have the start and end time of the counseling/coordination of care. For time to count in the outpatient setting, it must be face-to-face with the patient and/or family.

It is better to have this written from the physician, rather than just from an EMR time stamp. Without seeing how a system's time stamp works, it is difficult to say if the ‘start' time indicates the time the exam started or the time that the patient came into the room. Auditors will look at having time in documentation when reviewing your records.

Score sheet: Some insurers or physician associations offer audit tool score sheet templates that can aid you while auditing documentation.

The audit tool helps the auditor document the findings so that by the end of the record review, the documented information can be totalled to finalize the E/M key elements and come up with the proper level of E/M.

Tip: See to it that the tool is compliant with the documentation guidelines. A record of the review should be kept as proof of the internal audit.

After the audit, show your practitioners, coders and billers what the outcome was so you can positively address any problem areas.