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BILLING & COMPLIANCE: An Audit a Day Keeps the OIG Away

No matter how skilled your coding staff, errors sneak into the bills you drop but with the recent outlier controversy attracting government eyes, it pays to know the ins and outs of your coding and billing system before the Office of the Inspector General (OIG) sends you a hefty bill. While audits require considerable resources and know-how, an ounce of preventative evaluation now will spare you countless legal and financial woes later.
Use Your Time Wisely
For the cleanest system operation, a concurrent audit is best, says Laura Siniscalchi, RHIA, CCS, CCS-P, CPC, senior health care consultant at Deloitte & Touche in Boston, though retrospective audits are more common because concurrent audits must vie with hospital submission deadlines. To combat this dilemma, many facilities have added in-house staff to check a batch of samples for errors at the end of each day. Not only does daily review let you catch mistakes before you drop the bills, but it also ensures the efficiency of the chargemaster and helps address coding problems before they become widespread.
"It is best to identify clinical departments with possible APC problems through a high-level review of sample claims from all departments," says Siniscalchi, because "just by looking at claim information, an individual knowledgeable in APC issues can identify areas that need a closer look." Take random samples first to identify trouble spots, because they'll give you a comprehensive overview. Then take focused samples to approach those issues in greater depth. While focused samples skew your results, they'll enable to concentrate on issues specific to your hospital.
Expose the Problem
While the ideal audit covers all outpatient services, it may behoove you to narrow your facility's focus and spend your time looking at the most common recipients of APC reimbursement: the emergency department, ambulatory service centers, hospital-based clinics, and the radiology and interventional radiology departments. Within these units, you'll need to review both the "soft-coded" records transcribed by coders and the "hard-coded" ones generated by the charge description master (CDM). Keep your eyes peeled for three types of errors:

Clerical errors are sporadic, careless mistakes in transferring written information that occur randomly and infrequently.


Judgmental errors are mistakes in critical decision-making that can often be prevented through education of coders and physicians.


Systemic errors are hard-coded into the CDM and the most important, expensive, and widespread of the three.

Awareness of current CMS regulations and CCI and OCE edits and correspondent upkeep of your CDM will save you headaches down the road by [...]

- Published on 2003-04-01