Ambulatory Self Audits

The Problem

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Hard facts

• $33 difference in reimbursement between codes 99213 and 99214 = Loss of $165 per day or approximately $40,000 in a year/ physician if improper E/M coding or insufficient documentation
• Recouped payments for claims that don ' t meet medical necessity or medical record discordances
• Illegible notes and unsigned, undated and untimed notes

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CMS

• The 2010 CERT study also reported that approximately 42% of the error rate was due to payment on claims where the documentation did not support the medical necessity of a service or procedure
• Nearly 50% of the error rate was for claims reported as having insufficient documentation to report the service

Results

  • Internal inconsistencies with nursing note and progress note discordances were the highest ranking findings in 48% of the audited cases — “Bilateral rhonchi” versus “clear to auscultation” — “Lower extremity swelling versus no edema” — “Acute diverticulitis” versus “Abdominal pain”
  • 36% of the cases did not have “Chief complaint” in the progress note- an essential part of the note that can invalidate a billing claim

Aerolib Services

• Retrospective ambulatory and procedure case audits for primary care and specialists - orthopedics, surgery and cardiology elective procedures
• Review of coding and documentation with validation of correct OPPS reimbursement.
• Documentation and E/M audit risk reduction strategies on audited patient records
• Contact us today for discussion with your medical staff on audit reduction strategies

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