Documentation Audit It is common and recommended practice to conduct periodic audits of provider documentation. Not only is this type of audit expected as part of a Compliance Program, but audits often find areas where reimbursement can be increased. Plus, audits significantly reduce the risk that a Medicare or commercial payer audit will find discrepancies, which can lead to penalties and fines. An audit typically reviews a random sample of documentation from each physician and other provider: usually 10 to 20 charts per provider. The selection may be expanded to assure an adequate sample across modalities or locations, etc.  The typical timeframe is three to six weeks after receipt of the charts.  Costs are generally in the range of $20 to $40 per chart, depending on volume and specialty/complexity.  AdvantEdge guarantees that the audit will add value1. Often, a documentation audit is conducted in parallel with, or after, a compliance review. A compliance review looks at some or all aspects of the current compliance program and/or operations to identify compliance risks and areas for improvement. See this document for additional details about compliance reviews. The documentation audit typically includes the following: • Review of CPT/HCPCS Level II codes to ensure complete and accurate assignment. • Review of modifiers to ensure proper assignment and use. • Review of medical record documentation to ensure it substantiates the CPT/HCPCS procedure codes assigned and ICD-9/ICD-10 diagnosis codes assigned. • Review of code assignments to ensure no mismatches between medical record and bill. • Identify opportunities to improve compliance and reimbursement. • Identify system issues between HIM, clinical departments and patient accounting (if any). • Provide summary by case/modality type. • Onsite review of findings and recommendations with practice / department leadership. 1 If you don’t feel the review is worth the cost, when the invoice arrives, simply pay what you think it is worth. Example Audit Summary MEDICAL ASSOCIATES Procedure and Diagnosis Code Accuracy Compliance Issues Revenue Issues Missed billable services Order of services Unbundled 1 Billed but not performed 7 Wrong code or category 3 Modifier errors 6 Documentation deficiencies 9 Dx coding errors 8 Sample size: 143 encounters Total definitive coding errors: 25 “Clean claim” ratio: 82% Cases containing major errors: 15 of 143 or 10% Lost revenue per encounter: $8.17 CPT Procedure Codes Diagnosis Codes % Correct % Correct 93% 94% Common Errors: Downcoded: 99212/213/243 vs. 99214 99202/243 vs. 99203 99243/244 vs. 99245 Upcoded / Wrong Procedure Code: 99244/243 vs. 99203/202/214; wrong procedure code; no consult statement 99253 vs. 99252 99254 vs. 99253 Documentation Date of written report and dictated report don’t match “Family history noncontributory” not sufficiently documented Report not signed Recommended Actions  Update current documentation guidelines and training  More frequent feedback from coders to providers: at least monthly  Improve QA of coding including monthly reviews of each coder 5 0