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Stephanie Allard, CPC, CEMA, RHIT Senior Compliance Specialistnamas logo
This auditing and compliance “Tip of the Week” was originally published by the National Alliance for Medical Auditing Specialists (NAMAS), a division of DoctorsManagement. ICD-10 was officially implemented on October 1, 2015. One of the intents of moving to ICD-10 was to enable and encourage reporting diagnoses with a higher level of specificity. Many payers expect claims to contain specific codes to support the clinical indication for the procedures or services being rendered.

Over the years I have found that one of the main risks to an organization are employees who get comfortable in their positions to the point where the explanation for or response to an audit variance is “that is how we have always done it.”

If you have personally said this, or if you work in an organization where this refrain is commonly heard, I would challenge you to analyze your daily work to see if you are able to identify the source behind the coding and/or workflow processes that represent the way things were “always” done.

  • Is there a documented internal policy you are following?
  • Do the CPT guidelines direct you to code in a certain way?
  • Does CMS have specific guidance on the code category you are utilizing?

Internal policies are an important part of any organization as they offer clear guidance across the organization and bring everyone together, so all are on the same page to ensure consistency. The policies should always include clear citation of sources for the department to be able to reference in the future. A citable reference source also offers auditors documented support to back up the guidance they are teaching to providers or coders.
The AMA’s official CPT guidelines should be a resource that we as auditors look to often. When we have been in the field for a long time, we tend to get comfortable and reference our own memory of the guidelines when auditing. By doing this regularly, it is possible that we are completely forgetting a portion of the actual guidance or we are misinterpreting them. A good way to avoid getting comfortable is to review the guidelines for the CPT categories involved in a new audit before jumping in.

Most of the time, CMS and/or its administrative contractors publish specific guidance for code categories and coding scenarios. Whether you audit for one organization or for many, it is important that you are familiar with the CMS website and the different Medicare administrative contractor (MAC) websites. When auditing, we should look first to the MAC that has jurisdiction in the specific state we are doing the audit in. The MAC’s website will have local, state-specific guidance that supersedes national CMS guidelines, and if it turns out the MAC does not provide specific guidance, then we can fall back on national CMS guidance.

The field of medical coding changes on a regular basis and, as auditors, we are required to keep our knowledge bases up to date and hold ourselves accountable to ensuring that the information we are teaching is current and accurate. Organizations should also ensure that they are providing ongoing education to providers, coders and support staff so that day-to-day work is being done in as compliant a fashion as possible.
You can find a list of MACs and their jurisdictions by state at the link below.

This Week’s Audit Tip Written By:
Stephanie Allard, CPC, CEMA, RHIT
Stephanie is a Senior Compliance Consultant with our parent company, DoctorsManagement.

What to do next…

  1. Contact us to discuss your audit needs by calling (800) 635-4040 or email [email protected].
  2. Read more: What can you expect from a coding and compliance review?
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