One of the most effective tools a practice can use to ensure compliance is conducting internal medical record audits. Regularly performing chart audits should be fundamental to any practice’s ongoing compliance program.

Why conduct a self-audit?

The Office of Inspector General (OIG) released updated compliance guidelines in 2023.¹ Of the seven elements of an effective compliance plan, number six is Risk Assessment, Auditing and Monitoring. The OIG advises, “Health care providers and other industry stakeholders should take proactive measures to ensure compliance with program rules, including regular reviews to keep billing and coding practices up-to-date as well as regular internal billing and coding audits.” In addition, the Centers for Medicare & Medicaid Services’ (CMS’) compliance program guidelines indicate that it helps to have an external firm audit the practice on a regular basis (every 1 or 2 years).

What should be audited?

Auditing high-dollar procedures, most-performed services, billing modifier use, diagnostic testing, and multiple procedures are some common auditing areas. CMS publishes Local Coverage Determinations and Local Coverage Articles to provide guidance for indications, coverage, and documentation requirements for certain procedures, which are also prime areas to assess compliance. The OIG Work Plan is also a good resource to review for additional audit focus areas.²

Each billed claim is tied to specific documentation within the medical record. By billing a particular CPT code, the practice asserts that all required criteria for that code have been met. In a chart audit, you review CPT, HCPCS (eg, those for intravitreal drugs or optical services) and diagnosis codes (ICD-10) to ensure alignment with the documentation. An audit answers key questions such as these:

• Does the chart note support the billed service?
• Are signed insurance authorizations, HIPAA privacy notices, consents, and operative reports for treatments, injections, or minor procedures present?
• If applicable, are there signed Advanced Beneficiary Notices?
• Are orders and interpretations for diagnostic tests complete, and is there sufficient documentation of medical necessity for visits, tests, and procedures?

How should the results be used?

Recognizing a problem does not guarantee a solution. Once internal audits and reviews have been performed, the practice administrator or compliance officer should determine which issues require immediate attention. Evaluating which problems represent the costliest financial or compliance impact is specific to an administrator’s role. Analyze trends to get an overall measurement of the audit’s effectiveness for eliminating problem areas. For example, are there recurring issues for a specific service or provider? After identifying the right priorities for your practice, begin implementation of corrective actions.

For example, develop and assign targeted training sessions based on practice staff roles and responsibilities, and any compliance risks specific to those roles and responsibilities. Base the training on the internal audit results around billing, coding, documentation, and medical necessity, and include references to Medicare and other appropriate payer guidance.

After corrective actions and training, the control process of circling back on the same issues will be essential to ensure any new processes are working. Follow-up audits are essential to confirm that new procedures effectively resolve previous compliance risks.

Conclusion

In summary, regular internal medical record audits are essential for maintaining compliance in health-care practices, aligning with the OIG’s 2023 guidelines and CMS. By examining high-priority areas such as high-dollar procedures, commonly used billing modifiers, diagnostic tests, and more, practices can ensure their billing and coding align with regulatory standards. Each audit should confirm that claims documentation supports the services billed, with all necessary consents and authorizations in place. Once issues are identified, they should be prioritized and resolved through targeted training and corrective actions. Periodic re-audits are vital to verifying that corrective measures are effective and that the practice maintains a robust compliance program over time. OP

References

1. U.S. Department of Health and Human Services Office of Inspector General. HHS-OIG General Compliance Program Guidance. 2023. https://oig.hhs.gov/documents/compliance-guidance/1135/HHS-OIG-GCPG-2023.pdf. Accessed Nov. 21, 2024.

2. U.S. Department of Health and Human Services Office of Inspector General. OIG Work Plan. https://www.oig.hhs.gov/reports-and-publications/workplan/index.asp. Accessed Nov. 21, 2024.

Laurie K. Brown, MBA, COMT, COE, CPC, CPMA, LSSYB, is a senior consultant with VMG Health in Tucson, Ariz. She has experience in the ophthalmic industry holding managerial, clinical, and surgical roles for more than 35 years.